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1.
Dermatol Surg ; 2021 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-33625139

RESUMO

BACKGROUND: Extramammary Paget disease (EMPD) poses treatment challenges. Invasive and noninvasive treatment modalities exist with variable success reported. Reflectance confocal microscopy (RCM) is emerging as an adjuvant diagnostic tool. OBJECTIVE: To evaluate the treatment of EMPD patients and the role of RCM. METHODS: Prospective study. Demographic and tumor characteristics were recorded. Handheld-RCM was performed and correlated with histology. Treatment, clearance, pathology, and follow-up were all recorded. RESULTS: Thirty-six EMPD lesions in 33 patients were included. Mean age was 71.7 years, and 23 were men. Mean number of surgical stages needed to clear margins was 1.9 (SD, 0.9; 1.0-3.0 stages), and mean margin needed to clear was 1.8 cm. Reflectance confocal microscopy correlated well with scouting punch biopsies (kappa, 0.93; p < .001). Disruption of the dermoepidermal junction was associated with invasive EMPD versus in situ (83.3% vs 25.9%) on histology (p = .01). LIMITATIONS: Relatively small sample size. CONCLUSION: Extramammary Paget disease is challenging, and lesion demarcation is of the utmost importance. Using a staged surgical excision approach, the mean margins needed were 1.8 cm, less than previously reported. Nonsurgical modalities, including radiation therapy, imiquimod, or photodynamic therapy can be considered if surgery is not pursued. Reflectance confocal microscopy is a valuable noninvasive imaging modality for the management of EMPD.

2.
J Am Acad Dermatol ; 2020 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-33096134

RESUMO

BACKGROUND: There are no well-defined clinical factors to predict the risk of occult invasion in melanoma of the lentigo maligna type (LM) prior to complete histopathologic analysis. OBJECTIVE: To evaluate whether clinical size was a predictor of invasion in LM and subclinical extension. METHODS: Consecutive cases of LM were recorded in a prospectively maintained database from 2006 to 2019. Patient and tumor data were recorded during initial evaluation. 'LM clinical area' was calculated in square millimeters (length x width). All patients were treated with staged excision. RESULTS: We included 600 patients. Mean age was 65.9 years (SD 12.3; range 27 - 95 years); 62.8% (n=377) were males. The mean LM clinical area was 128.32 mm2 for in situ lesions vs 200.14 mm for invasive lesions (p=0.1). Based on quantile regression, the median margin required for complete removal increased with LM clinical area. LIMITATIONS: study performed in a tertiary cancer center with possible referral bias and more complex cases. CONCLUSIONS: LM can present with variable clinical size which may correlate with subclinical extension; however, the presence of invasion is not well estimated by LM clinical area.

3.
J Am Acad Dermatol ; 2020 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-32781177

RESUMO

Long-term survival of cancer patients has risen dramatically during the last few decades. Despite this remarkable success, the same treatments that have enabled cure or remission often secondarily affect the skin, hair, and nails. Conditions including scarring, striae distensae, persistent alopecia, pigmentary changes, nail alterations, chronic radiation dermatitis, and radiation fibrosis have been associated with anxiety, depression, decreased quality of life, and impaired function. These dermatologic changes are cosmetically disfiguring, may limit activities, and are a visual reminder of past illness. Interventions towards improving these untoward sequelae and restoring the appearance and function of skin and appendages are critical for normalization and may contribute to improved quality of life in cancer survivors. Herein, we outline dermatologic sequelae of cancer therapies with a review of medical and procedural treatment strategies to restore dermatologic health in the survivorship population.

8.
Dermatol Surg ; 45(4): 588-597, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30946699

RESUMO

BACKGROUND: Nonphysicians are expanding practice into specialty medicine. There are limited studies on patient and physician perspectives as well as safety outcomes regarding the nonphysician practice of cosmetic procedures. OBJECTIVE: To identify the patient (consumer) and physician perspective on preferences, adverse events, and outcomes following cosmetic dermatology procedures performed by physicians and nonphysicians. MATERIALS AND METHODS: Internet-based surveys were administered to consumers of cosmetic procedures and physician members of the American Society for Dermatologic Surgery. Descriptive statistics and graphical methods were used to assess responses. Comparisons between groups were based on contingency chi-square analyses and Fisher exact tests. RESULTS: Two thousand one hundred sixteen commenced the patient survey with 401 having had a cosmetic procedure performed. Fifty adverse events were reported. A higher number of burns and discoloration occurred in the nonphysician-treated group and took place more often in a spa setting. Individuals seeing nonphysicians cited motivating factors such as level of licensure (type) of nonphysician, a referral from a friend, price, and the location of the practitioner. Improper technique by the nonphysician was cited most as a reason for the adverse event. Both groups agree that more regulation should be placed on who can perform cosmetic procedures. Recall bias associated with survey data. CONCLUSION: Patients treated by nonphysicians experienced more burns and discoloration compared with physicians, and they are encountering these nonphysicians outside a traditional medical office, which are important from a patient safety and regulatory standpoint. Motivating factors for patients seeking cosmetic procedures may also factor into the choice of provider. KEY POINTS: Both patients and physicians think more regulation should be in place on who can perform cosmetic procedures. More adverse events such as burns and discolorations occurred with patients seeing nonphysicians compared with those seeing physicians. In addition, for those seeing nonphysicians, a majority of these encounters took place in spa settings. Patient safety is of utmost concern when it comes to elective cosmetic medical procedures. More adverse events and encounters occurring outside traditional medical settings when nonphysicians performed these procedures call into question the required training and oversight needed for such procedures.


Assuntos
Técnicas Cosméticas/normas , Dermatologia/normas , Pessoal de Saúde/normas , Atitude do Pessoal de Saúde , Competência Clínica , Técnicas Cosméticas/estatística & dados numéricos , Dermatologia/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/estatística & dados numéricos , Humanos , Estados Unidos/epidemiologia
10.
J Am Acad Dermatol ; 80(5): 1403-1409, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30654079

RESUMO

BACKGROUND: There is little evidence to guide surgical management of biopsies yielding the histologic descriptor atypical intraepidermal melanocytic proliferation (AIMP). OBJECTIVE: Determine frequency of and factors associated with melanoma and melanoma in-situ (MIS) diagnoses after excision of AIMP and evaluate margins used to completely excise AIMP. METHODS: Retrospective, cross-sectional study of 1127 biopsies reported as AIMP and subsequently excised within one academic institution. RESULTS: Melanoma (in situ, stage 1A) was diagnosed after excision in 8.2% (92/1127) of AIMP samples. Characteristics associated with melanoma/MIS diagnosis included age 60-79 years (odds ratio [OR] 8.1, 95% confidence interval [CI] 2.5-26.2), age ≥80 years (OR 7.2, 95% CI 1.7-31.5), head/neck location (OR 4.9, 95% CI 3.1-7.7), clinical lesion partially biopsied (OR 11.0, 95% CI 6.7-18.1), and lesion extending to deep biopsy margin (OR 15.1, 95% CI 1.7-136.0). Average ± standard deviation surgical margin used to excise AIMP lesions was 4.5 ± 1.8 mm. LIMITATIONS: Single-site, retrospective, observational study; interobserver variability across dermatopathologists. CONCLUSION: Dermatologists and pathologists can endeavor to avoid ambiguous melanocytic designations whenever possible through excisional biopsy technique, interdisciplinary communication, and ancillary studies. In the event of AIMP biopsy, physicians should consider the term a histologic description rather than a diagnosis, and, during surgical planning, use clinicopathologic correlation while bearing in mind factors that might predict true melanoma/MIS.


Assuntos
Neoplasias de Cabeça e Pescoço/diagnóstico , Melanoma/diagnóstico , Neoplasias Cutâneas/diagnóstico , Pele/patologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biópsia , Criança , Estudos Transversais , Procedimentos Cirúrgicos Dermatológicos , Diagnóstico Diferencial , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Margens de Excisão , Melanoma/patologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Neoplasias Cutâneas/patologia , Adulto Jovem
11.
J Am Acad Dermatol ; 80(2): 303-317, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29782900

RESUMO

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.


Assuntos
Carcinoma Basocelular/epidemiologia , Carcinoma Basocelular/patologia , Carcinoma de Células Escamosas/patologia , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/patologia , Raios Ultravioleta/efeitos adversos , Biópsia por Agulha , Carcinogênese/efeitos da radiação , Carcinoma Basocelular/fisiopatologia , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/fisiopatologia , Feminino , Humanos , Imuno-Histoquímica , Incidência , Masculino , Prognóstico , Medição de Risco , Neoplasias Cutâneas/fisiopatologia
12.
J Am Acad Dermatol ; 80(2): 321-339, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29782901

RESUMO

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.


Assuntos
Carcinoma Basocelular/diagnóstico , Carcinoma Basocelular/terapia , Cirurgia de Mohs/métodos , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/terapia , Idoso , Anilidas/uso terapêutico , Biópsia por Agulha , Carcinoma Basocelular/prevenção & controle , Dermoscopia/métodos , Detecção Precoce de Câncer , Educação Médica Continuada , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Fotoquimioterapia/métodos , Prognóstico , Piridinas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Neoplasias Cutâneas/prevenção & controle , Tomografia de Coerência Óptica/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
13.
J Am Acad Dermatol ; 2018 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-30227192

RESUMO

BACKGROUND: Non-physician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology. OBJECTIVE: To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the US. METHODS: Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary Master File, which reflects Part B carrier and durable medical equipment fee-for-service claims in the US. RESULTS: Over 4 million procedures were billed independently by NPs and PAs, which accounts for 11.51% of all. Injection, simple repair, and biopsy were the most commonly billed by non-physician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher in the East Coast, Midwest, and Mountain states. LIMITATIONS: Data is at the state level, limited to Medicare beneficiaries, and doesn't include billing incident-to physicians. CONCLUSIONS: This study demonstrated the increasing scope of practice of NPs and PAs in dermatology, despite limited training and lack of uniform regulations. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.

16.
Dermatol Surg ; 44(2): 159-174, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29059147

RESUMO

BACKGROUND: Ambiguous histopathologic diagnoses represent a challenge for clinicians because of a lack of definitive diagnosis and related uncertainty about management. OBJECTIVE: To review the literature on atypical melanocytic proliferations and detail synonymous terms, epidemiology, diagnostic work-up, histopathology, treatment, and prognosis. METHODS: Databases from PubMed and Web of Science were searched for articles related to atypical melanocytic proliferations. RESULTS: Intraepidermal melanocytic proliferations with features worrisome for possible melanoma in situ (MIS) are generally excised as for MIS. Reported rates of upstaging of such cases to invasive melanoma on review of the excision are very low. Because invasion, lymph node spread, and metastasis can occur in atypical melanocytic lesions with a thick intradermal component, these are often treated as for malignant melanoma. CONCLUSION: Because the diagnosis dictates treatment, it is incumbent to establish a diagnosis as definitive as possible, obtaining second or third opinions and using ancillary studies when appropriate. When the diagnosis remains uncertain, it is difficult to provide guidelines for treatment. Clinical care decisions for patients with an uncertain diagnosis are best done on a case-by-case basis weighing probabilities of adverse outcomes against potential benefits and risks from various treatment options.


Assuntos
Melanoma/diagnóstico , Lesões Pré-Cancerosas/diagnóstico , Neoplasias Cutâneas/diagnóstico , Diagnóstico Diferencial , Humanos
18.
Cutis ; 99(5): 346-352, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28632796

RESUMO

Diagnosis and management of lentigo maligna (LM) and LM melanoma (LMM) is challenging. Novel noninvasive imaging technologies such as reflectance confocal microscopy (RCM) have advanced the ability to better diagnose and monitor challenging lesions. In addition, the new handheld RCM (HRCM) together with the use of videomosaics has allowed an accurate evaluation of large lesions in concave/convex areas of the body (eg, the face). Herein, we review the impact of HRCM in the detection, treatment decision-making, and monitoring of 5 cases of complex facial LM/LMM. In the cases presented, HRCM enabled the detection of subclinical margins, presence of invasion, detection of persistence/recurrence, and monitoring of surgical and nonsurgical therapies. In this preliminary report, our results suggest that HRCM is a versatile ancillary tool in pretreatment decision-making, intraoperative surgical mapping, and posttreatment monitoring of complex facial LM/LMM.


Assuntos
Sarda Melanótica de Hutchinson/diagnóstico , Microscopia Confocal/instrumentação , Neoplasias Cutâneas/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Dermoscopia , Diagnóstico Diferencial , Face , Feminino , Humanos , Sarda Melanótica de Hutchinson/patologia , Masculino , Pessoa de Meia-Idade , Neoplasias Cutâneas/patologia
19.
JAMA Dermatol ; 153(7): 689-693, 2017 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-28492924

RESUMO

Importance: Extramammary Paget disease (EMPD) is commonly refractory to surgical and nonsurgical therapies. Identifying recurrent or persistent EMPD is challenging because the disease is multifocal, and multiple blind scouting biopsies are usually performed in this setting. Handheld reflectance confocal microscopy (HRCM) has been used to diagnose and map primary EMPD and therefore may be used to identify EMPD recurrences. Objective: To evaluate HRCM's diagnostic accuracy in the setting of recurrent or persistent EMPD as well as its potential diagnostic pitfalls. Design, Setting, and Participants: This prospective case series study included patients referred to the Dermatology Service at Memorial Sloan Kettering Cancer Center between January 1, 2014, and December 31, 2016, with biopsy-proven EMPD in whom HRCM was used to monitor treatment response. Five patients were included, and 22 sites clinically concerning for recurrent or persistent disease were evaluated using HRCM and histopathologic examination. In 2 patients, video mosaics were created to evaluate large areas. Main Outcomes and Measures: Sensitivity and specificity of HRCM in identifying recurrent or persistent EMPD; causes for false-negative results according to their location, histopathologic findings, and previous treatments. Results: Of the 22 clinically suspicious sites evaluated in 5 patients (4 men, 1 woman; median [range] age, 70 [56-77] years), 9 (40.9%) were positive for recurrent disease on HRCM and histopathologically confirmed, and 13 (59.1%) sites were negative on HRCM, but 3 of the 13 were positive for EMPD on histopathological examination. In general, HRCM had a sensitivity of 75% and a specificity of 100% in identifying recurrent or persistent EMPD. False-negative results were found in 2 patients and occurred at the margins of EMPD, close to previous biopsy sites. Creating video mosaics (or video mosaicking) seemed to improve the detection of EMPD. Conclusions and Relevance: Handheld reflectance confocal microscopy is a useful auxiliary tool for diagnosing EMPD recurrences and can be used to guide scouting biopsies, thus reducing the number of biopsies needed to render a correct diagnosis.


Assuntos
Microscopia Confocal/métodos , Recidiva Local de Neoplasia/diagnóstico , Doença de Paget Extramamária/diagnóstico , Neoplasias Cutâneas/diagnóstico , Idoso , Biópsia/métodos , Reações Falso-Negativas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Doença de Paget Extramamária/patologia , Estudos Prospectivos , Sensibilidade e Especificidade , Neoplasias Cutâneas/patologia , Gravação em Vídeo/métodos
20.
Lasers Surg Med ; 49(9): 819-826, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28555933

RESUMO

INTRODUCTION: Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes. STUDY DESIGN AND METHODS: Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006-2015). Prior cosmetic treatment and biopsies were recorded. Records were reviewed for demographic data, clinical characteristics, and surgical outcomes. RESULTS: 37/503 (7.4%) patients with LM reported prior cosmetic therapy. Most (95%) were on the head and neck; mean size 1.9 cm. Most patients reported cryotherapy (73%), followed by laser (29.7%), topical bleaching agents (18.9%), and electrodessication, and/or curettage (5.3%). Ten patients (27%) received two or more modalities. Eight patients (21.6%) reported prior benign biopsies. Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (11.7%) upstaged upon excision. Average margin for clearance was 9.1 mm. CONCLUSION: Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins. Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment. Lasers Surg. Med. 49:819-826, 2017. © 2017 Wiley Periodicals, Inc.


Assuntos
Técnicas Cosméticas , Procedimentos Cirúrgicos Dermatológicos , Neoplasias de Cabeça e Pescoço/cirurgia , Sarda Melanótica de Hutchinson/cirurgia , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Sarda Melanótica de Hutchinson/patologia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias Cutâneas/patologia , Resultado do Tratamento
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