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American Family Physician Jul 2012Family physicians are regularly faced with identifying, treating, and counseling patients with skin cancers. Nonmelanoma skin cancer, which encompasses basal cell and... (Review)
Review
Family physicians are regularly faced with identifying, treating, and counseling patients with skin cancers. Nonmelanoma skin cancer, which encompasses basal cell and squamous cell carcinoma, is the most common cancer in the United States. Ultraviolet B exposure is a significant factor in the development of basal cell and squamous cell carcinoma. The use of tanning beds is associated with a 1.5-fold increase in the risk of basal cell carcinoma and a 2.5-fold increase in the risk of squamous cell carcinoma. Routine screening for skin cancer is controversial. The U.S. Preventive Services Task Force cites insufficient evidence to recommend for or against routine whole-body skin examination to screen for skin cancer. Basal cell carcinoma most commonly appears as a pearly white, dome-shaped papule with prominent telangiectatic surface vessels. Squamous cell carcinoma most commonly appears as a firm, smooth, or hyperkeratotic papule or plaque, often with central ulceration. Initial tissue sampling for diagnosis involves a shave technique if the lesion is raised, or a 2- to 4-mm punch biopsy of the most abnormal-appearing area of skin. Mohs micrographic surgery has the lowest recurrence rate among treatments, but is best considered for large, high-risk tumors. Smaller, lower-risk tumors may be treated with surgical excision, electrodesiccation and curettage, or cryotherapy. Topical imiquimod and fluorouracil are also potential, but less supported, treatments. Although there are no clear guidelines for follow-up after an index nonmelanoma skin cancer, monitoring for recurrence is prudent because the risk of subsequent skin cancer is 35 percent at three years and 50 percent at five years.
Topics: Aminoquinolines; Antineoplastic Agents; Biopsy; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Cryotherapy; Curettage; Dermatologic Surgical Procedures; Desiccation; Fluorouracil; Humans; Imiquimod; Mohs Surgery; Risk Factors; Skin; Skin Neoplasms
PubMed: 22962928
DOI: No ID Found -
The Journal of Nutrition Jan 2004Numerous reports have indicated that the biological activity of all-trans retinoyl beta-glucuronide (RAG) is similar to that of all-trans-retinoic acid (RA), but without... (Comparative Study)
Comparative Study Review
Numerous reports have indicated that the biological activity of all-trans retinoyl beta-glucuronide (RAG) is similar to that of all-trans-retinoic acid (RA), but without the toxic side effects of RA. In the present series of studies, we report new findings that support the contention that RAG can function as a nontoxic substitute for RA in a variety of clinic settings. One study on the effects of s.c. injected graded doses of RA and RAG (20-480 micromol/kg BW) into pregnant Sprague-Dawley rats showed that any differences between RAG and RA could be observed only at the highest dose levels of 360 and 420 micromol/kg BW, with RAG being much less toxic than RA. Similarly, daily topical application of RAG (0.16-1.6%) and RA (0.1-0.5%) to shaved swine dorsal skin for six mo resulted in redness and scabbing in RA-treated patches, and to a lesser extent in 1.6% RAG-treated, but not in other RAG-treated patches. Histological scores were significantly higher in the dermis and epidermis of RA-treated pigs than in RAG-treated pigs. Studies to document the pharmacokinetics of chronically administered RAG in mice indicated that, unlike RA, sustained blood levels of parent retinoid (RAG) can be achieved during at least 2 mo of daily administration. Another investigation to study the effects of RAG on the development and growth in nude mice of tumors derived from the human neuroblastoma cell line LA-N-5 showed that s.c. injection of RAG (30 micromol/kg BW) reduced tumor formation when the retinoid was first administered 3 d before tumor injection and continued daily for 30 d thereafter. In established tumors, RAG was shown to inhibit progressive tumor growth, the antitumor effects of RAG being comparable with RA. However, with RAG, as opposed to RA, there were no significant adverse physical side effects. Based on the results of these series of studies along with ample published reports over the last 15 y, we conclude that RAG may be a safe and effective alternative to RA and some other retinoids that are presently being utilized in the clinic.
Topics: Animals; Cell Division; Humans; Injections, Subcutaneous; Neoplasm Transplantation; Neuroblastoma; Tretinoin
PubMed: 14704335
DOI: 10.1093/jn/134.1.286S -
The Medical Journal of Australia May 2023To determine the proportions of newly diagnosed melanomas treated by different medical specialist types, to describe the types of excisions performed, and to investigate...
OBJECTIVES
To determine the proportions of newly diagnosed melanomas treated by different medical specialist types, to describe the types of excisions performed, and to investigate factors associated with treating practitioner specialty and excision type.
DESIGN, SETTING
Prospective cohort study; analysis of linked data: baseline surveys, hospital, pathology, Queensland Cancer Register, and Medical Benefits Schedule databases.
PARTICIPANTS
Random sample of 43 764 Queensland residents aged 40-69 years recruited during 2011, with initial diagnoses of in situ or invasive melanoma diagnosed to 31 December 2019.
MAIN OUTCOME MEASURES
Treating practitioner type and treatment modality for first incident melanoma; second and subsequent treatment events for the primary melanoma.
RESULTS
During a median follow-up of 8.4 years (interquartile range, 8.3-8.8 years), 1683 eligible participants (720 women, 963 men) developed at least one primary melanoma (in situ melanoma, 1125; invasive melanoma, 558), 1296 of which (77.1%) were initially managed in primary care; 248 were diagnosed by dermatologists (14.8%), 83 by plastic surgeons (4.9%), 43 by general surgeons (2.6%), and ten by other specialists (0.6%). The most frequent initial procedures leading to histologically confirmed melanoma diagnosis were first excision (854, 50.7%), shave biopsy (549, 32.6%), and punch biopsy (178, 10.6%); 1339 melanomas (79.6%) required two procedures, 187 (11.1%) three. Larger proportions of melanomas diagnosed by dermatologists (87%) or plastic surgeons (71%) were in people living in urban areas than of those diagnosed in primary care (63%); larger proportions of melanomas diagnosed by dermatologists or plastic surgeons than of those diagnosed in primary care were in people with university degrees (45%, 42% v 23%) or upper quartile clinical risk scores (63%, 59% v 47%).
CONCLUSIONS
Most incident melanomas in Queensland are diagnosed in primary care, and nearly half are initially managed by partial excision (shave or punch biopsy). Second or third, wider excisions are undertaken in about 90% of cases.
Topics: Male; Humans; Female; Prospective Studies; Melanoma; Skin Neoplasms; Australia; Melanoma, Cutaneous Malignant
PubMed: 37041657
DOI: 10.5694/mja2.51919 -
Anais Brasileiros de Dermatologia 2017Recurrent melanocytic nevus is a proliferation of melanocytes arising from a melanocytic nevus removed partially. Asymmetry and irregular pigmentation may lead to...
Recurrent melanocytic nevus is a proliferation of melanocytes arising from a melanocytic nevus removed partially. Asymmetry and irregular pigmentation may lead to misdiagnosis of melanoma. We report a patient presented with a lesion on the lower abdomen, which was removed by shave excision. Anatomopathological examination revealed an intradermal melanocytic nevus. Two months later, a new irregular hyperpigmented lesion appeared in the surgical scar. Histopathology of the excisional biopsy revealed a recurrent melanocytic nevus. Recurrent melanocytic nevus manifests as a scar with hyper or hypopigmented areas, linear streaking, stippled pigmented halos, and/or diffuse pigmentation patterns. Histologically, the dermoepidermal junction and the superficial dermis show melanocytic proliferation overlying the scarred area. When a pathological report of the previous lesion is not available, complete excision is the gold standard. Otherwise, regular dermoscopic monitoring is a therapeutic option. The present report emphasizes the importance of histopathological examination of the excised material - even in cases of suspected benign lesions - and warns patients about the possibility of recurrence in case of incompletely removed lesions.
Topics: Biopsy; Cell Proliferation; Dermoscopy; Female; Humans; Melanocytes; Middle Aged; Neoplasm Recurrence, Local; Nevus, Pigmented; Skin Neoplasms
PubMed: 28954104
DOI: 10.1590/abd1806-4841.20176190 -
Modern Pathology : An Official Journal... Aug 2021The surgical margin status of breast lumpectomy specimens for invasive carcinoma and ductal carcinoma in situ (DCIS) guides clinical decisions, as positive margins are...
The surgical margin status of breast lumpectomy specimens for invasive carcinoma and ductal carcinoma in situ (DCIS) guides clinical decisions, as positive margins are associated with higher rates of local recurrence. The "cavity shave" method of margin assessment has the benefits of allowing the surgeon to orient shaved margins intraoperatively and the pathologist to assess one inked margin per specimen. We studied whether a deep convolutional neural network, a deep multi-magnification network (DMMN), could accurately segment carcinoma from benign tissue in whole slide images (WSIs) of shave margin slides, and therefore serve as a potential screening tool to improve the efficiency of microscopic evaluation of these specimens. Applying the pretrained DMMN model, or the initial model, to a validation set of 408 WSIs (348 benign, 60 with carcinoma) achieved an area under the curve (AUC) of 0.941. After additional manual annotations and fine-tuning of the model, the updated model achieved an AUC of 0.968 with sensitivity set at 100% and corresponding specificity of 78%. We applied the initial model and updated model to a testing set of 427 WSIs (374 benign, 53 with carcinoma) which showed AUC values of 0.900 and 0.927, respectively. Using the pixel classification threshold selected from the validation set, the model achieved a sensitivity of 92% and specificity of 78%. The four false-negative classifications resulted from two small foci of DCIS (1 mm, 0.5 mm) and two foci of well-differentiated invasive carcinoma (3 mm, 1.5 mm). This proof-of-principle study demonstrates that a DMMN machine learning model can segment invasive carcinoma and DCIS in surgical margin specimens with high accuracy and has the potential to be used as a screening tool for pathologic assessment of these specimens.
Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Deep Learning; Female; Humans; Image Interpretation, Computer-Assisted; Margins of Excision; Mastectomy, Segmental; Neoplasm, Residual
PubMed: 33903728
DOI: 10.1038/s41379-021-00807-9 -
Plastic and Reconstructive Surgery.... Dec 2020Proper management of Spitz nevi continues to be debated, with treatment ranging from observation to surgery. To better characterize the outcome of surgical procedures...
UNLABELLED
Proper management of Spitz nevi continues to be debated, with treatment ranging from observation to surgery. To better characterize the outcome of surgical procedures performed for incomplete initial excision or biopsy, we sought to ascertain the histopathological presence of residual Spitz nevi in a set of surgical specimens.
METHODS
We retrospectively reviewed 123 records with histologically-confirmed Spitz nevus. Data concerning treatment, clinical features, histopathological margin involvement, and presence of residual lesion on subsequent procedural specimens were collected.
RESULTS
Fifty-three percent of lesions (n = 65) were initially sampled by shave or punch biopsy, and the remainder (n = 58) were formally excised without initial biopsy. The rates of re-excision for involved margins were: shave biopsy (92.2%), punch biopsy (78.6%), and formal excision (13.8%). In total, 61.0% of patients who underwent an initial procedure of any kind had involved margins, but only half of those re-excised for involved margins (57.6%) had histologically residual lesion on repeated excision. A significantly higher proportion of initial punch biopsies (90.9%) resulted in residual lesion (in secondary excision specimens) when compared with shave biopsy (48.9%) and formal excision (62.5%; < 0.05).
CONCLUSIONS
Findings suggest that clinicians may consider shave biopsy over punch biopsy for diagnosing suspected lesions, when indicated and appropriate. Given the rarity of malignant transformation and the frequency of residual nevus, observation may be reasonable for managing pediatric patients with histologically-confirmed Spitz nevi, who are post initial biopsy or excision despite known histopathological margin involvement.
PubMed: 33425580
DOI: 10.1097/GOX.0000000000003244 -
JAMA Dermatology Nov 2021Medicare enrollment, dermatologist utilization of Medicare, and dermatologic procedural volume have all increased over time. Despite this, there are limited studies...
IMPORTANCE
Medicare enrollment, dermatologist utilization of Medicare, and dermatologic procedural volume have all increased over time. Despite this, there are limited studies evaluating changes in Medicare reimbursement within dermatology.
OBJECTIVE
To identify trends in Medicare reimbursement for 46 common dermatologic procedures from 2007 to 2021.
DESIGN, SETTING, AND PARTICIPANTS
In this cross-sectional study, reimbursement data were obtained from the Centers for Medicare & Medicaid Services Physician Fee Schedule for commonly used dermatologic Current Procedural Terminology (CPT) codes from 2007 to 2021. The CPT codes in several major dermatologic categories were analyzed, including skin biopsy, shave removal, benign/premalignant/malignant destruction, benign/malignant excision, Mohs micrographic surgery, simple/intermediate/complex repair, flap, graft, and laser/phototherapy. All procedure prices were adjusted for inflation to January 2021 dollar value.
MAIN OUTCOMES AND MEASURES
The primary outcomes were percentage changes and cumulative annual growth rates of pricing for each dermatologic procedure.
RESULTS
From 2007 to 2021, there was a mean decrease in dermatologic procedure reimbursement of -4.8% after adjusting for inflation. Mean inflation-adjusted changes in reimbursements during this time period significantly varied by procedure type, including skin biopsy (+30.3%), shave removal (+24.5%), benign/premalignant/malignant destruction (-7.5%), Mohs micrographic surgery (-14.4%), benign/malignant excision (-3.9%), simple/intermediate/complex repair (-9.9%), flap repair (-14.1%), graft repair (-12.0%), and laser/phototherapy (-6.6%; P < .001). Changes in reimbursement did not vary by anatomical risk categories.
CONCLUSIONS AND RELEVANCE
The findings of this cross-sectional analysis suggest that changes in Medicare reimbursement can have several downstream effects, including concomitant private insurance changes and decreased patient access. Future adjustments in reimbursement should balance high-value care with sustainable pricing to optimize patient access.
Topics: Aged; Cross-Sectional Studies; Current Procedural Terminology; Humans; Insurance, Health, Reimbursement; Medicare; Physicians; United States
PubMed: 34524396
DOI: 10.1001/jamadermatol.2021.3453 -
Cureus May 2023Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomy but is associated with higher rates...
Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomy but is associated with higher rates of local recurrence. Positive surgical margins in BCS are the most important predictor of local recurrence. The aim of our study was to assess the risk factors associated with positive margins in women undergoing BCS for breast cancer in order to inform our clinical practice and minimize re-operation rates. Methods Patients with a diagnosis of breast cancer who underwent BCS from January 2013 to January 2021 were identified from our pathology database and included in the study. All patients underwent a lumpectomy with the removal of additional shaved cavity margins. Statistical analysis was used to assess the effect of patient clinical and pathological risk factors on the rate of positive margins. Results One hundred and twenty patients underwent BCS for breast cancer. Twenty-four percent of patients had positive margins. Of the 29 patients that underwent subsequent re-excisions, only 13 (45%) had residual disease in the re-excision specimen. In younger patients, tumors localized in lower quadrants and the presence of extensive intraductal component within invasive breast cancer increased the risk of positive margins. In addition, positive margins were encountered more significantly in patients with ductal carcinoma in situ (DCIS) compared to invasive tumors. Multivariate analysis showed that DCIS and young age were the only factors independently associated with positive margins. Conclusion DCIS and younger patients have a higher rate of positive margins during BCS than invasive breast cancer. For such patients at higher risk of positive margins, excision of cavity shave margins and intraoperative inking may be done to lower positive margin rates. Preoperative review of breast imaging, core biopsies, and counseling of patients about the likelihood of positive margins is important.
PubMed: 37265920
DOI: 10.7759/cureus.38399 -
Acta Dermatovenerologica Alpina,... Dec 2009A cutaneous horn is a conical, dense, hyperkeratotic protrusion that often appears similar to the horn of an animal. It is a morphologic designation referring to an... (Review)
Review
A cutaneous horn is a conical, dense, hyperkeratotic protrusion that often appears similar to the horn of an animal. It is a morphologic designation referring to an unusually cohesive keratinized material, not a true pathologic diagnosis. Cutaneous horns occur in association with, or as a response to, a wide variety of underlying benign, pre-malignant, and malignant cutaneous diseases. The most important common concern is distinguishing a hyperkeratotic actinic keratosis from a cutaneous squamous cell carcinoma. Keratoacanthoma is another cause, as illustrated herein as a projective cutaneous tumor with a fingernail-like appearance. The treatment of choice for cutaneous horns is shave excision with subsequent histopathologic evaluation to rule out underlying malignancy and to guide potential further therapy.
Topics: Humans; Keratoacanthoma; Keratosis; Keratosis, Actinic
PubMed: 20043059
DOI: No ID Found -
International Journal of Trichology 2019This study aims to report a rare case of melanoacanthoma of the eyelid. Melanoacanthoma is very rare variant of seborrheic keratosis presenting as a rare benign...
This study aims to report a rare case of melanoacanthoma of the eyelid. Melanoacanthoma is very rare variant of seborrheic keratosis presenting as a rare benign pigmented lesion composed of both melanocytes and keratinocytes usually presenting over the head, neck, and trunk of elderly people. A 61-year-old female presented with 8 mm × 4 mm × 3 mm brownish black mass in her right lower lid for the past 4 years associated with itching. Clinical differential diagnosis of seborrheic keratosis and nevus was offered. The patient underwent shave biopsy, and biopsy tissue was sent for histopathological examination. A diagnosis of melanoacanthoma was made on histopathology. Melanoacanthoma of the eyelid is a rare entity, and one should consider in differential diagnosis of pigmented lesion of the eyelid mass.
PubMed: 31523108
DOI: 10.4103/ijt.ijt_51_19