Erica H. Lee

Procedural dermatology training during dermatology residency: A survey of third-year dermatology residents

BACKGROUND Given the expanding role of multiple surgical procedures in dermatology, resident training in procedural dermatology must be continually assessed to keep pace with changes in the specialty. OBJECTIVE We sought to assess the third-year resident experience in procedural dermatology during residency training. METHODS This survey study was mailed to third-year dermatology residents at 107 Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs in 2009. RESULTS A total of 240 residents responded (66%), representing 89% of programs surveyed. Residents assume the role of primary surgeon most commonly in excisional surgery (95%) and flap and graft reconstruction (49%) and least often in Mohs micrographic surgery (18%). In laser and cosmetic procedures, the resident role varies greatly. Residents believed they were most prepared in excisional surgery, botulinum toxin, and laser surgery. Residents believed it was sufficient to have only knowledge of less commonly performed procedures such as hair transplantation, tumescent liposuction, and ambulatory phlebectomy. Of responding residents, 55% were very satisfied with their procedural dermatology training during residency. LIMITATIONS Individual responses from residents may be biased. Neither residency program nor dermatologic surgery directors were surveyed. CONCLUSION This survey confirms dermatology residents received broad training in procedural dermatology in 2009, in keeping with ACGME/Residency Review Committee program guidelines. The results provide feedback to dermatology residency programs and are an invaluable tool for assessing, modifying, and strengthening the current procedural dermatology curriculum.

Melanoma of the lentigo maligna subtype: diagnostic challenges and current treatment paradigms.

Summary: Melanoma of the lentigo maligna subtype presents diagnostic and treatment challenges because of ill-defined clinical margins in cosmetically and functionally sensitive areas of the head and neck with extensive sun damage. This review highlights the natural history, varied clinical presentations, and pitfalls in histologic diagnosis. The focus is on the surgical management, comparing excision and pathologic tissue processing techniques of wide excision, Mohs micrographic surgery, and staged excision. Staged excision is recommended for optimal surgical margin control. Nonsurgical treatment modalities are also reviewed for the elderly or unresectable cases.

A systematic review of patient-reported outcome instruments of nonmelanoma skin cancer in the dermatologic population

BACKGROUND Treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) has traditionally focused on minimizing recurrence and complication rates. However, the assessment of patient satisfaction and quality of life (QOL) is also important. These outcomes are best assessed by patient-reported outcome (PRO) instruments. OBJECTIVES We sought to conduct a systematic review of published PRO instruments purporting to measure aspects associated with QOL and/or patient satisfaction in the dermatologic BCC/SCC population and evaluate their development, content, and psychometric properties. METHODS PubMed, Embase, Cochrane via Wiley, PsycINFO, CINAHL, and HaPI from inception to April 2011 were searched. Articles that discussed the instrument development and validation process were included. RESULTS A total of 2212 articles were identified. Twenty met our inclusion criteria resulting in 6 PRO instruments: 3 general dermatology (Skindex, Dermatology Life Quality Index, dermatology quality of life scales), 1 general plastic surgery (Patient Outcomes of Surgery-Head/Neck), and 2 skin cancer-specific (Skin Cancer Index, disease-specific questionnaire). The 6 instruments all underwent some degree of formal development and validation, however, only the Skin Cancer Index was developed and validated in the BCC/SCC population. LIMITATIONS The review may not have included all relevant PRO instruments. CONCLUSIONS The Skin Cancer Index demonstrates the most evidence of its usefulness in patients with BCC/SCC. The Skindex-16, Dermatology QOL Scales, and Dermatology Life Quality Index target different aspects of QOL and should be used depending on the specific question being investigated. The Patient Outcomes of Surgery-Head/Neck may be beneficial to assess perceptions in appearance before and after surgical intervention.

Clinical value of paraffin sections in association with Mohs micrographic surgery for nonmelanoma skin cancers.

BACKGROUND During Mohs micrographic surgery (MMS), situations can arise in which paraffin sections may be used in conjunction with frozen sections. OBJECTIVE To determine the clinical value of paraffin sections in association with MMS, including frequency, reasons, and information obtained. METHODS AND MATERIALS Single‐center retrospective cohort study at a cancer center. MMS cases for nonmelanoma skin cancers over a 5‐year period in which paraffin sections were used were identified. Reasons for submitting paraffin sections were reviewed. Initial biopsy, Mohs frozen section, and paraffin section diagnoses and histologic subtypes were compared. RESULTS In 258 (7.8%) cases, paraffin sections were used in association with MMS. The most common reasons were to further assess high‐risk histologic features or unusual frozen section findings, to complete tumor staging of cutaneous squamous cell carcinomas, and to assess perineural invasion (PNI). Initial biopsy diagnosis differed from the Mohs frozen and paraffin section diagnoses in 20% to 22% of cases. The initial biopsy histologic subtype changed from low or indeterminate to high risk in Mohs frozen and paraffin sections in 24% to 29% of cases. CONCLUSION In MMS for select high‐risk or unusual nonmelanoma skin cancers, paraffin sections are useful in more accurately documenting tumor histology, completing cutaneous squamous cell carcinoma staging, and detecting PNI.

Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification.

BACKGROUND Determining the biopsy site location of a skin cancer before treatment is often challenging. OBJECTIVE To study the implementation and effectiveness of biopsy site selfies as a quality improvement measure for correct surgical site identification. MATERIALS AND METHODS In the first phase, the ability of dermatologic surgeon and patient to definitively identify the biopsy site and whether photography was needed to ensure site agreement were recorded. In the second phase, patients were requested to take biopsy site selfies, and after implementation, similar data were collected including whether a biopsy site selfie was helpful for definitive site identification. RESULTS In the first phase, the physician and patient were unable to identify the biopsy site 17.6% (49/278) and 25.5% (71/278) of cases, respectively. A photograph was needed in 22.7% of cases (63/278). After implementation of biopsy site selfies, the physician and patient were unable to identify the biopsy site 17.4% (23/132) and 15.2% (20/132) of cases, respectively. Biopsy site selfies were available for 64.1% of cases for which no internal image was available and critical for site identification in 21.4% of these cases. CONCLUSION Biopsy site selfies has proven to be helpful for correct surgical site identification by both the physician and the patient and may also provide further reassurance and confidence for patients.

Correlation of Handheld Reflectance Confocal Microscopy With Radial Video Mosaicing for Margin Mapping of Lentigo Maligna and Lentigo Maligna Melanoma

Importance The management of lentigo maligna (LM) and LM melanoma (LMM) is challenging because of extensive subclinical spread and its occurrence on cosmetically sensitive areas. Reflectance confocal microscopy (RCM) improves diagnostic accuracy for LM and LMM and can be used to delineate their margins. Objectives To evaluate whether handheld RCM with radial video mosaicing (HRCM-RV) offers accurate presurgical assessment of LM and LMM margins. Design, Setting, and Participants This prospective study included consecutive patients with biopsy-proven LM and LMM located on the head and neck area who sought consultation for surgical management from March 1, 2016, through March 31, 2017, at the Dermatology Service of the Memorial Sloan Kettering Cancer Center. Thirty-two patients underwent imaging using HRCM-RV, and 22 patients with 23 LM or LMM lesions underwent staged surgery and contributed to the analysis. Main Outcomes and Measures Clinical lesion size and area, LM and LMM area based on HRCM-RV findings, surgical defect area estimated by HRCM-RV, and observed surgical defect area. In addition, the margins measured in millimeters estimated for tumor clearance in each quadrant based on HRCM-RV findings were calculated and compared with the surgical margins. Results Among the 22 patients (12 men and 10 women; mean [SD] age, 69.0 [8.6] years [range, 46-83 years]) with 23 lesions included in the final analysis, the mean (SD) surgical defect area estimated with HRCM-RV was 6.34 (4.02) cm2 and the mean (SD) area of surgical excision with clear margins was 7.74 (5.28) cm2. Overall, controlling for patient age and previous surgery, surgical margins were a mean of 0.76 mm (95% CI, 0.67-0.84 mm; P < .001) larger than the HRCM-RV estimate. Conclusions and Relevance Mapping of LM and LMM with HRCM-RV estimated defects that were similar to but slightly smaller than those found in staged excision. Thus, mapping of LM using HRCM-RV can help spare healthy tissue by reducing the number of biopsies needed in clinically uncertain areas and may be used to plan treatment of LM and LMM and counsel patients appropriately.

Desmoplastic melanoma presenting after laser treatment: a case report and tale of caution.

A 73-year-old woman with Fitzpatrick skin type II presented for management of a squamous cell carcinoma in situ (SCCIS) of the right cheek. She reported a brown sun spot was treated twice using a neodymium-doped yttrium aluminum garnet laser (type not known) in 2007 with near resolution of the brown pigment. One to two years later, the patient noted firmness in the area, and this was assumed to be a cyst. The lesion continued to increase in size and developed a pinkish hue. In 2010, she presented to a local dermatologist and was referred to a plastic surgeon for biopsy. Outside pathology showed a poorly oriented strip of skin with changes consistent with an actinic keratosis. Given the superficial nature of the biopsy, a second biopsy was recommended. A different dermatologist performed the second biopsy and submitted the tissue to exclude ‘‘morphea BCC or morpheaform basal cell carcinoma.’’ A board-certified dermatopathologist reported that biopsy as SCCIS. The patient, selfreferred, presented to our office for further management.

Benign and premalignant skin lesions.

LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Clinically describe various cutaneous neoplasms. 2. Identify the corresponding histopathologic findings. 3. Discuss the optimal treatment approach for each entity. SUMMARY Cutaneous neoplasms are broadly viewed as benign, premalignant, or malignant. In dermatology, lesions are classified based on the primary cell of origin or the component of the skin predominantly affected by the pathologic change (epidermis, dermis, or subcutaneous fat). The diagnosis and treatment of skin lesions rely on understanding the clinical presentation and corresponding histopathology. Surgical treatment is not always indicated and is dependent on multiple variables. This review discusses several benign and premalignant neoplasms frequently encountered by the plastic surgeon. The emphasis is on clinical presentation, histopathologic correlation, and management approach.

Comorbidity scores associated with limited life expectancy in the very elderly with nonmelanoma skin cancer

Background: There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined. Objective: Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC. Methods: A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation‐27 (ACE‐27) and age‐adjusted Charlson comorbidity index (ACCI). Dates of death, follow‐up, and overall survival were determined. Results: ACE‐27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not. Limitations: Retrospective study design and referral bias. Conclusions: ACE‐27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.

Comorbidity Assessment in Skin Cancer Patients: A Pilot Study Comparing Medical Interview with a Patient-Reported Questionnaire

Background. Comorbidities are conditions that occur simultaneously but independently of another disorder. Among skin cancer patients, comorbidities are common and may influence management. Objective. We compared comorbidity assessment by traditional medical interview (MI) and by standardized patient-reported questionnaire based on the Adult Comorbidity Evaluation-27 (ACE-27). Methods. Between September 2011 and October 2013, skin cancer patients underwent prospective comorbidity assessment by a Mohs surgeon (MI) and a radiation oncologist (using a standardized patient-reported questionnaire based on the ACE-27, the PRACE-27). Comorbidities were identified and graded according to the ACE-27 and compared for agreement. Results. Forty-four patients were evaluated. MI and PRACE-27 identified comorbidities in 79.5% and 88.6% (p = 0.12) of patients, respectively. Among 27 comorbid ailments, the MI identified 9.9% as being present, while the PRACE-27 identified 12.5%. When there were discordant observations, PRACE-27 was more likely than MI to identify the comorbidity (OR = 5.4, 95% CI = 2.4–14.4, p < 0.001). Overall comorbidity scores were moderate or severe in 43.2% (MI) versus 59.1% (PRACE-27) (p = 0.016). Limitations. Small sample size from a single institution. Conclusion. Comorbidities are common in skin cancer patients, and a standardized questionnaire may better identify and grade them. More accurate comorbidity assessments may help guide skin cancer management.