Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults.

BACKGROUND: Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged. OBJECTIVES: To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA: Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise. MAIN RESULTS: We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs. AUTHORS' CONCLUSIONS: Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.

Optical coherence tomography for diagnosing skin cancer in adults.

BACKGROUND: Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers, which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised, with potential to infiltrate and damage surrounding tissue. Anxiety around missing early cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Optical coherence tomography (OCT) is a microscopic imaging technique, which magnifies the surface of a skin lesion using near-infrared light. Used in conjunction with clinical or dermoscopic examination of suspected skin cancer, or both, OCT may offer additional diagnostic information compared to other technologies. OBJECTIVES: To determine the diagnostic accuracy of OCT for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants, basal cell carcinoma (BCC), or cutaneous squamous cell carcinoma (cSCC) in adults. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA: We included studies of any design evaluating OCT in adults with lesions suspicious for invasive melanoma and atypical intraepidermal melanocytic variants, BCC or cSCC, compared with a reference standard of histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a standardised data extraction and quality assessment form (based on QUADAS-2). Our unit of analysis was lesions. Where possible, we estimated summary sensitivities and specificities using the bivariate hierarchical model. MAIN RESULTS: We included five studies with 529 cutaneous lesions (282 malignant lesions) providing nine datasets for OCT, two for visual inspection alone, and two for visual inspection plus dermoscopy. Studies were of moderate to unclear quality, using data-driven thresholds for test positivity and giving poor accounts of reference standard interpretation and blinding. Studies may not have been representative of populations eligible for OCT in practice, for example due to high disease prevalence in study populations, and may not have reflected how OCT is used in practice, for example by using previously acquired OCT images.It was not possible to make summary statements regarding accuracy of detection of melanoma or of cSCC because of the paucity of studies, small sample sizes, and for melanoma differences in the OCT technologies used (high-definition versus conventional resolution OCT), and differences in the degree of testing performed prior to OCT (i.e. visual inspection alone or visual inspection plus dermoscopy).Pooled data from two studies using conventional swept-source OCT alongside visual inspection and dermoscopy for the detection of BCC estimated the sensitivity of OCT as 95% (95% confidence interval (CI) 91% to 97%) and specificity of 77% (95% CI 69% to 83%).When applied to a hypothetical population of 1000 lesions at the mean observed BCC prevalence of 60%, OCT would miss 31 BCCs (91 fewer than would be missed by visual inspection alone and 53 fewer than would be missed by visual inspection plus dermoscopy), and OCT would lead to 93 false-positive results for BCC (a reduction in unnecessary excisions of 159 compared to using visual inspection alone and of 87 compared to visual inspection plus dermoscopy). AUTHORS' CONCLUSIONS: Insufficient data are available on the use of OCT for the detection of melanoma or cSCC. Initial data suggest conventional OCT may have a role for the diagnosis of BCC in clinically challenging lesions, with our meta-analysis showing a higher sensitivity and higher specificity when compared to visual inspection plus dermoscopy. However, the small number of studies and varying methodological quality means implications to guide practice cannot currently be drawn.Appropriately designed prospective comparative studies are required, given the paucity of data comparing OCT with dermoscopy and other similar diagnostic aids such as reflectance confocal microscopy.

The Use of Chemotherapeutics for the Treatment of Keloid Scars.

Keloid scars are pathological scars, which develop as a result of exaggerated dermal tissue proliferation following cutaneous injury and often cause physical, psychological and cosmetic problems. Various theories regarding keloidogenesis exist, however the precise pathophysiological events remain unclear. Many different treatment modalities have been implicated in their management, but currently there is no entirely satisfactory method for treating all keloid lesions. We review a number of different chemotherapeutic agents which have been proposed for the treatment of keloid and hypertrophic scars while giving insight into some of the novel chemotherapeutic drugs which are currently being investigated. Non-randomized trials evaluating the influence of different chemotherapeutic agents, such as 5-fluorouracil (5-FU); mitomycin C; bleomycin and steroid injection, either alone or in combination with other chemotherapeutic agents or alternative treatment modalities, for the treatment of keloids were identified using a predefined PubMed search strategy. Twenty seven papers were identified. Scar improvement ≥50% was found in the majority of cases treated with 5-FU, with similar results found for mitomycin C, bleomycin and steroid injection. Combined intralesional 5-FU and steroid injection produced statistically significant improvements when compared to monotherapy. Monotherapy recurrence rates ranged from 0-47% for 5-FU, 0-15% for bleomycin and 0-50% for steroid injection. However, combined therapy in the form of surgical excision and adjuvant 5-FU or steroid injections demonstrated lower recurrence rates; 19% and 6% respectively. Currently, most of the literature supports the use of combination therapy (usually surgery and adjuvant chemotherapy) as the mainstay treatment of keloids, however further investigation is necessary to determine success rates over longer time frames. Furthermore, there is the potential for novel therapies, but further investigation is required to elucidate their true efficacy.

Management of extensive facial burns in the intensive care unit: introducing a novel device with a four-fold use.

Perioral facial burns have a high propensity to formation of microstomia and numerous prosthetic devices have been described that can be used postoperatively to address this problem. We introduce a novel device, the Whiston Buccal Prosthesis, which is used intraoperatively and in the early postoperative period and it acts as a surgical aid to prevent or curtail microstomia, as well as to address other problems associated with facial burns. Our device has an overall 4-fold purpose; 1) it acts as a commissural and circumoral retractor, 2) as a means of counter-pressure during excision of burn eschar, 3) counter-pressure for the graft after its placement, and 4) for access to the mouth to maintain oral hygiene. It has been used on 3 patients who have benefited from all or some of the above uses. We have used this device in 3 patients thus far. One died 2 months after her operation but received benefit in the daily maintenance of oral hygiene and also the skin grafts. The other 2 patients were young adults, 19 and 20 years old at the time of injury, who after a 3-year follow-up were discharged not having required any further surgical intervention for microstomia. The Whiston Buccal Prostheses were used for a length of time between 1 and 3 months. Although limited objective evidence exists for our device, subjectively we have seen value intraoperatively, in the prevention of microstomia, the maintenance of oral hygiene, and maintenance of grafts.

Primary squamous cell carcinoma of the nipple: a diagnosis of suspicion.

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.

Does the dual use of toluidine blue and hematoxylin and eosin staining improve basal cell carcinoma detection by Mohs surgery trainees?

BACKGROUND: Although a number of Mohs surgeons currently use Toluidine blue stain, alone or in combination with hematoxylin and eosin (H&E), the effects on the trainees' histologic accuracy of adding toluidine blue to their H&E training was unknown. OBJECTIVE: To assess a trainees' histological accuracy when trained in a unit that routinely employs the dual staining technique and to determine whether the addition of toluidine blue improves, or impairs, the training process. METHODS: A fellow examined slides from 403 consecutive Mohs cases over 3 months, from the start of his training period. H&E slides for each case were examined first, followed by the toluidine blue slides, with recordings made of the diagnosis based on each. The fellows' findings were then checked against those of the senior Mohs surgeons and a consultant histopathologist. RESULTS: According to H&E alone, the fellow completely excised 96.3% of 352 basal cell carcinomas; this increased to 99.7% by adding toluidine blue. False-positive rates were 1.5% for H&E alone and 1.7% when using both stains. CONCLUSION: The addition of toluidine blue increased the diagnostic accuracy of the trainee, and we encourage the use and teaching of this stain in Mohs surgery.

Visualizing the vascular history of nonmelanoma skin tumors: an in vivo human study.

INTRODUCTION: The formation of cutaneous carcinoma has been shown to rely on neovascularization, with angiogenesis being implicated in the invasive process of skin malignancy and metastasis. To date, studies of angiogenesis have generally been limited to in vitro, animal (often murine), or postexcision histopathologic models. METHODS: To demonstrate the angiogenic progression of human tumors in vivo, this study has used the Spectrophotometric Intracutaneous Analyser (SIAscope; Biocompatibles, Surrey, United Kingdom) to produce parametric images of 250 nonmelanoma skin cancers and 13 actinic keratoses. This provides a history, in images, of the vascular basis of skin cancer formation. RESULTS AND CONCLUSIONS: While displaying that the in vitro findings of angiogenesis are indeed occurring in vivo in humans, this technique also suggests a practical means to allow accurate application and monitoring of antiangiogenic therapy. In addition, it raises the possibility of differentiating superficial from nonsuperficial nonmelanoma skin cancers in an office-based setting, thus allowing accurate usage of surgical or nonsurgical treatment methods.

Surgical staple as a transcutaneous transducer for ECG electrodes in burnt skin: safe surgical monitoring in major burns.

It is often difficult to apply traditional ECG electrodes on patients with extensive burns due to a large operative site, compromise of sterility, the fact that traditional placement would be within the operative site or because stick-on pads cannot stick due to prep solution, bleeding and other factors. We present an effective solution based on our experience, of using a common staple or "clip" where the ECG electrode is attached. We can see the patient in the prone position with the back having been debrided and grafted. This technical improvisation gives clinicians the ability to monitor safely and accurately the patients' physiological parameters.

The pectoralis minor pedicled muscle flap in axillary reconstruction.

We report on the case of a patient undergoing resection of a large axillary and chest wall tumor, resulting in exposure of the brachial plexus and axillary vessels. Our experience of the use of the pectoralis minor pedicled flap for the reconstruction of such a defect is described, providing for excellent postoperative mobility of the axilla and minimal donor-site morbidity.

Spectrophotometric intracutaneous analysis: a novel imaging technique in the assessment of acute burn depth.

The noncontact spectrophotometric intracutaneous analysis scope (SIAscope) is a novel portable imaging device that rapidly produces images of the blood and melanin content of large areas of skin. The estimation of burn depth is often difficult in the clinical setting, and this pilot study was conducted to assess the potential for the SIAscope in aiding burn assessment. Nine patients with a variety of burn injuries had images taken of their acute burns within 48 hours of injury, both with a noncontact SIAscope and a laser Doppler perfusion imaging system (LDPI). Results showed that superficial partial thickness burns had increased hemoglobin and loss of melanin on SIAgraphs, whereas deep partial thickness burns had more pronounced hemoglobin concentrations and apparent melanin increases, helping to differentiate these 2 burn types. The SIAscope, a relatively inexpensive, portable device, has the potential to be a highly useful clinical adjunct in the bedside estimation of acute burn depth.