Jesse M. Lewin

Surgical smoke and the dermatologist.

BACKGROUND The use of electrosurgery and lasers by dermatologists and dermatologic surgeons has increased in recent years with the growth of technology and procedures performed. These devices produce surgical smoke that has been demonstrated to harbor live viruses and bacteria in addition to hazardous chemicals. OBJECTIVE We sought to review the literature on surgical smoke, its effects on those exposed, and measures that may be used to protect dermatologists and their staff. METHODS We conducted a review of the literature on surgical smoke during the last 25 years. RESULTS The studies reviewed indicate the potential for infection, carcinogenesis, and pulmonary damage as a result of exposure to surgical plume. LIMITATIONS There is no inclusion of literature and subsequent findings published greater than 25 years prior. CONCLUSIONS It is evident from our review that surgical smoke poses potential health risks to dermatologists who perform procedures using electrocautery and lasers. We recommend diligent use of high-filtration masks in addition to smoke evacuation systems to dermatologists performing laser surgery and using electrocautery. Furthermore, we advocate investigation into quantifying the exposure of dermatologists to surgical smoke in the outpatient setting.

Advances in the management of basal cell carcinoma.

Basal cell carcinoma (BCC), a malignant neoplasm derived from non-keratinizing cells that originate in the basal layer of the epidermis, is the most common cancer in humans. Several factors such as anatomic location, histologic features, primary or recurrent tumors, and patient characteristics influence the choice of treatment modality for BCC. Mohs micrographic surgery (MMS) facilitates optimal margin control and conservation of normal tissue for the management of BCC; however, other treatment modalities may also be implemented in the correct clinical scenario. Other treatment modalities that will be reviewed include simple excision, electrodesiccation and curettage, cryotherapy, topical immunotherapy and chemotherapy, photodynamic therapy, and radiation therapy. In addition, targeted molecular therapeutic options for the treatment of advanced or metastatic BCC will be discussed in this informal review based on recent literature obtained by using PubMed with relevant search terms.

Use of Digitally Stained Multimodal Confocal Mosaic Images to Screen for Nonmelanoma Skin Cancer.

Importance Confocal microscopy has the potential to provide rapid bedside pathologic analysis, but clinical adoption has been limited in part by the need for physician retraining to interpret grayscale images. Digitally stained confocal mosaics (DSCMs) mimic the colors of routine histologic specimens and may increase adaptability of this technology. Objective To evaluate the accuracy and precision of 3 physicians using DSCMs before and after training to detect basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in Mohs micrographic surgery fresh-tissue specimens. Design This retrospective study used 133 DSCMs from 64 Mohs tissue excisions, which included clear margins, residual BCC, or residual SCC. Discarded tissue from Mohs surgical excisions from the dermatologic surgery units at Memorial Sloan Kettering Cancer Center and Oregon Health & Science University were collected for confocal imaging from 2006 to 2011. Final data analysis and interpretation took place between 2014 and 2016. Two Mohs surgeons and a Mohs fellow, who were blinded to the correlating gold standard frozen section diagnoses, independently reviewed the DSCMs for residual nonmelanoma skin cancer (NMSC) before and after a brief training session (about 5 minutes). The 2 assessments were separated by a 6-month washout period. Main Outcomes and Measures Diagnostic accuracy was characterized by sensitivity and specificity of detecting NMSC using DSCMs vs standard frozen histopathologic specimens. The diagnostic precision was calculated based on interobserver agreement and κ scores. Paired 2-sample t tests were used for comparative means analyses before and after training. Results The average respective sensitivities and specificities of detecting NMSC were 90% (95% CI, 89%-91%) and 79% (95% CI, 52%-100%) before training and 99% (95% CI, 99%-99%) (P = .001) and 93% (95% CI, 90%-96%) (P = .18) after training; for BCC, they were 83% (95% CI, 59%-100%) and 92% (95% CI, 81%-100%) before training and 98% (95% CI, 98%-98%) (P = .18) and 97% (95% CI, 95%-100%) (P = .15) after training; for SCC, they were 73% (95% CI, 65%-81%) and 89% (95% CI, 72%-100%) before training and 100% (P = .004) and 98% (95% CI, 95%-100%) (P = .21) after training. The pretraining interobserver agreement was 72% (κ = 0.58), and the posttraining interobserver agreement was 98% (κ = 0.97) (P = .04). Conclusions and Relevance Diagnostic use of DSCMs shows promising correlation to frozen histologic analysis, but image quality was affected by variations in image contrast and mosaic-stitching artifact. With training, physicians were able to read DSCMs with significantly improved accuracy and precision to detect NMSC.

An Inferiorly Based Rotation Flap for Defects Involving the Lower Eyelid and Medial Cheek.

We report a series of 20 patients who underwent inferiorly based rotation flaps for reconstruction of defects of the medial and infraorbital cheek and lower eyelid following Mohs micrographic surgery for nonmelanoma skin cancer. Defects ranged from 1.2 to 3.2 cm in longest diameter and patients ranged from 27 to 91 years of age. All 20 patients had excellent functional and cosmetic outcome with up to 2-year follow-up and no subsequent surgical or laser revision. There were no instances of partial or complete flap necrosis, hematoma, or ectropion. Our series includes defects that originated on the cheek as far laterally as directly below the lateral canthus, and terminated as far medially as the nasal sidewall. An inferiorly based rotation flap is a viable alternative to a laterally based rotation flap and should be in the armamentarium of reconstructive dermatologic and facial plastic surgeons.

Management of Aggressive Basal Cell Carcinoma

Basal cell carcinoma (BCC), a malignant neoplasm derived from nonkeratinizing cells that originate in the basal layer of the epidermis, is the most common cancer in humans. Several factors such as anatomic location, histologic features, primary versus recurrent tumors, and patient characteristics influence the treatment modality for basal cell carcinoma. Mohs micrographic surgery facilitates optimal margin control and conservation of normal tissue for the management of aggressive basal cell carcinoma, basal cell carcinoma on the head, neck, or genitals, recurrent basal cell carcinoma, those with infiltrative histology or perineural invasion, and those occurring in immunosuppressed hosts; however, other treatment modalities may also be appropriately implemented for more indolent BCCs on non-high-risk sites. For the treatment of aggressive or advanced BCCs, surgical clearance with margin assessment is preferable whenever feasible, and at times, a multidisciplinary approach with adjuvant or rarely neoadjuvant therapy with targeted molecular therapeutic agents or radiation therapy when indicated.

Line scanning, stage scanning confocal microscope (LSSSCM)

For rapid pathological assessment of large surgical tissue excisions with cellular resolution, we present a line scanning, stage scanning confocal microscope (LSSSCM). LSSSCM uses no scanning mirrors. Laser light is focused with a single cylindrical lens to a line of diffraction-limited width directly into the (Z) sample focal plane, which is parallel to and near the flattened specimen surface. Semi-confocal optical sections are derived from the linear array distribution (Y) and a single mechanical drive that moves the sample parallel to the focal plane and perpendicular to the focused line (X). LSSSCM demonstrates cellular resolution in the conditions of high nuclear density within micronodular basal cell carcinoma.

Papular eruption associated with palifermin

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Acute Syphilitic Balanitis and Gross Penile Edema in an HIV- Infected Man

Syphilis presenting with balanitis and penile edema is rare, and in most cases has been considered to be a manifestation of primary syphilis. We report the case of an HIV-infected man who presented with penile edema and balanitis concomitant with an eruption on his buttocks, lower abdomen and thighs. Histologic examination and serology were diagnostic of syphilis, and the patient was successfully treated with benzathine-penicillin. Our case represents an unusual, infrequently reported presentation of secondary syphilis.