Jennifer DeFazio

Citation: Bajaj S, Wolner ZJ, Dusza SW, Braun RP, Marghoob AA, DeFazio J. Total body skin examination practices: a survey study amongst dermatologists at high-risk skin cancer clinics. Dermatol Pract Concept. 2019;9(2):132-138. DOI: https://doi.org/10.5826/dpc.0902a09 Accepted: February 17, 2019; Published: April 30, 2019 Copyright: ©2019 Bajaj et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. The study was approved by the Memorial Sloan Kettering Cancer Center Institutional Review Board. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Jennifer DeFazio, MD, Dermatology Service, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor, Hauppauge, NY 11788 USA. Email: defazioj@mskcc.org Background/Objectives: Although total body skin examination (TBSE) is the primary screening mechanism for melanoma, there is no consensus on which anatomic sites a screening TBSE should include. We sought to establish which anatomic sites are examined during routine (>90%) TBSEs of patients at high risk for skin cancer. Methods: A Google survey was emailed to 173 international dermatologist skin cancer specialists. Results: More than 75% of participants reported routinely examining the scalp, ears, face and neck, trunk, breasts, inframammary areas, axillae, extremities, palms and soles, nails, interdigital spaces, and buttocks. The least frequently inspected anatomic sites included genitalia, with male genitalia more frequently examined than female (penis n = 39; 52%; labia majora n = 21; 28%; P = 0.003), the perianal region (n = 26; 34.7%), and the ocular conjunctiva and oral mucosa (n = 35; 46.7%). Participants cited not screening these areas because of perceived patient discomfort, low prevalence of malignancy, and the expectation that other specialists examine the area. Conclusions: The role of routine surveillance of neglected anatomic sites is unclear and warrants further discussion weighing potential mortality benefit against the incidence of melanoma in obscure sites, morbidity of intervention in sensitive sites, cost-effectiveness, and potential for patient discomfort. Keywords : total body skin examination, skin cancer screening, melanoma, nonmelanoma skin cancer, cutaneous oncology This work is licensed under a Creative Commons Attribution 4.0 International License.

The majority of oral pigmentations are benign lesions such as nevi, melanotic macules, melanoacanthomas or amalgam tattoos. Conversely, mucosal melanomas are rare but often lethal; therefore, excluding oral melanomas in this setting is crucial. Reflectance confocal microscopy is a non-invasive, in vivo imaging system with cellular resolution that has been used to distinguish benign from malignant pigmented lesions in the skin, and more recently in the mucosa. However, lesions located posteriorly in the oral cavity are difficult to assess visually and difficult to biopsy due to their location. Herein we present a patient with previous multiple melanomas presenting with an oral amalgam tattoo in the buccal mucosa, which was imaged using an intraoral telescopic probe attached to a commercially available handheld RCM. In this case report we describe this novel probe, the first RCM description of an amalgam tattoo and we discuss its differences with the findings described in oral melanomas.

Clinical observations and an expanding knowledge of cell-to-cell communication have led us to speculate that the finding of a melanocytic nevus in conjunction with a seborrheic keratosis is more than a coincidental collision of two lesions. Here we present five cases demonstrating dermoscopic features of both melanocytic lesions and seborrheic keratoses with corresponding histology. Four cases demonstrate dermoscopic features of a melanocytic nevus and seborrheic keratosis, and the final case a melanoma arising in association with a seborrheic keratosis.

To assess current practices and recommendations of US physicians regarding depth of excision for melanomas of varying histologic thicknesses. A 2-page, 13-question survey of depth of excision practices for the treatment of melanoma was developed and distributed. Both private and academic settings. A total of 1184 US physicians (1000 dermatologists and 184 melanoma specialists) were sent the survey. The 184 melanoma specialists included dermatologists, oncologists, and surgeons working in pigmented lesion clinics. Depth of excision practices reported for melanomas of varying histologic thicknesses and comparison of treating physician groups. Results were tabulated, and descriptive frequencies were used to describe demographics and survey responses. The final study analysis included 498 completed surveys. The overall response rate was 45% (498 of 1097 [1184 total respondents - 87 ineligibles]). The response rate for the specialists was 63% (115 of 183 [184 total respondents - 1 ineligible]), and for nonspecialist dermatologists it was 43% (383 of 892 [1000 total respondents - 108 ineligibles]). Specialists were more likely to practice in an urban setting than were nonspecialist dermatologists (78% vs 46%) (P < .001). Fifty-eight percent of nonspecialist dermatologists reported more than 400 patient visits per month compared with only 16% of specialists (P < .001). While specialists reported fewer patient visits per month, 51% reported diagnosing over 20 invasive melanomas in the previous year compared with 11% of nonspecialist dermatologists. There was no significant difference in excision depth reported among the specialties for melanoma in situ (P = .15). For invasive melanoma, significant differences were observed among treating groups, with the greatest incongruence reported for thin invasive melanoma (1.00 mm), differences in excision depths among treating physician groups decreased: most physicians in each group reported excising to the fascia. There is considerable variation among physician groups with regard to depth of excision practices for the treatment of melanoma. Given the current lack of clinical data available, studies assessing depth of excision and patient outcomes are needed to better define our surgical management of melanoma.

Images in Clinical Medicine from The New England Journal of Medicine — Dermoscopy of Phthiriasis