Pigmented Lesions of the Eyelid Margin

The eyelid area poses a diagnostic and therapeutic challenge due to its specific anatomy. The eyelid is composed of skin, orbicularis muscle, tarsus, and the eyelid margin is continuous with palpebral conjunctiva. Among pigmented tumors, benign lesions such as epidermal or intradermal nevi, freckles, lentigo, or seborrheic keratosis are the most common. Melanoma is relatively rare in this location. A suspicious lesion may be biopsied or excised. Surgery in the eyelid area requires special considerations to maintain a safe surgical margin, vital function of the eyelid, and acceptable cosmetic effect due to the exposure of the eyelid region of the face.

Successful adaptation during COVID-19 pandemic: suspected head and neck cancer biopsies under local anaesthetic

The patients suspected to have cancer in the head and neck region including pharynx and larynx undergo biopsy of the suspicious lesion under general anaesthetic. This is a long established practice but lately, biopsy of such lesions under local anaesthetic in the outpatient setting is promoted. During the current COVID-19 pandemic our access to operating theatre is significantly reduced. We have, therefore, modified our practice to allow us to carry out such biopsies under local anaesthetic in the outpatient setting. We share our experience with 20 patients who successfully underwent this procedure. The patients reported no side effects and were happy to avoid undergoing a general anaesthetic and its associated risks. We would encourage colleagues in other units to consider this option when dealing with such patients.

Renal artery aneurysm misdiagnosed as renal cell carcinoma

Renal tumors are best diagnosed by contrast-enhanced computed tomography (CECT) abdomen along with history and physical examination. In case of suspicious lesions in respect to location like lesion arising from the bifurcation of renal artery and close to major vessels with all features suggesting of tumor with absent contrast enhancement and absent color flow on Doppler study should be further investigated keeping other possibility of Renal artery aneurysm with thrombus mimicking as renal tumor. CT angiography should be done in every case of suspicious lesion because this will change the further management protocol from Nephrectomy in case of renal tumor to kidney preserving minimally invasive procedure for renal artery aneurysm. Like in this case diagnosis of Renal cell carcinoma was made on the basis of CECT abdomen findings and managed further as per the management protocol for renal tumor but intraoperatively found renal artery aneurysm. On conclusion every suspicious lesion of kidney should be further investigated for renal artery aneurysm so that kidney preserving procedure could be planned preoperatively.

Detection of clinically significant prostate cancer after negative fusion and systematic biopsy.

288 Background: MRI/Ultrasound fusion biopsy of the prostate has enhanced the detection of clinically significant prostate cancer (csPCa). Detection of csPCa is greatest when fusion and systematic biopsies are combined. However, the finding of a negative fusion and negative systematic biopsy in patients with suspicious lesion on imaging raises the question of either falsely positive imaging or a false negative biopsy. Methods: We retrospectively reviewed our database of patients undergoing MRI/transrectal US-guided fusion biopsy. All images were graded according to the Prostate Imaging Reporting and Data System version (PIRADS) 2.0. Patients underwent targeted biopsy followed by systematic 12-core double sextant biopsy within the same session. csPCa was defined as Grade Group (GG) ≥2 PCa. Patients with no prostate cancer (PCa) found on biopsies were followed. MRI studies with PIRADS v2 score ≤ 2 were considered to have no MRI evidence of PCa. Results: A total of 400 patients had at least one PIRADS ≥3 lesion and underwent fusion/systematic biopsy. Of these, 113 (28.3%) patients had no evidence of PCa on either fusion or systematic biopsy. Median follow-up was 32.5 months. 44 (39%) patients underwent repeat MRI and of these, 24 (54%) had no evidence of PCa on repeat MRI. PIRADS lesion disappearance was associated with lower PSA Density (PSAd) (0.12 vs 0.20; P = 0.0319) and decreased progression to repeat biopsy (8.33% vs 95%; P < 0.0001). Patients who had a repeat biopsy had a greater PSAd ( 0.21 vs 0.12; P = 0.0054). Of 113 patients with negative initial biopsy, 23 (20.4 %) underwent repeat biopsy: 16 (14.2 %) had PCa and 11 (9.7%) had csPCa. Thus, 48% of patients who underwent repeat biopsy had csPCa. Among patients with a PCa on repeat biopsy, cancer was sampled by MRI targeted cores in 80% of patients. Conclusions: Despite a negative initial fusion/systematic biopsy, at least 10% of patients were subsequently diagnosed with clinically significant PCa. The combination of elevated PSAd and the persistence of a suspicious lesion on repeat MRI appears selective for previously missed PCa. However, after negative fusion biopsy, repeat MRI yields a high rate of PIRADS lesion disappearance in patients with low PSAd.

Sentinel node theory helps tracking of primary lesions of cancers of unknown primary

Background: Sentinel lymph node is the first stop of lymphatic spreading of cancer with known primary. The lymph node metastasis pattern of cancer of unknown primary (CUP) is unclear and has been presumed to follow the same pathway. To test this hypothesis, data of all 716 patients clinically diagnosed as CUP in our center were collected.Methods: Diagnoses of lymph node metastasis were established by 18F-FDG PET-CT and/or biopsy pathology. Three hundred and forty-seven cases meeting the criteria were divided into three groups: pathology-confirmed primary with invasive biopsy or surgery of the suspicious lesion (group A, n=64), primary still unknown even with invasive biopsy or surgery of the suspicious lesion (group B, n=204), and others with no suspicious lesion or lesions who had not been sampled due to medical or other reasons (group C, n=79). We assessed the clinicopathological features between these groups, and the relationship between lymph node metastasis pattern and confirmed primary site. Results: In group A, the primary sites of 61 cases were compatible with sentinel node theory, resulting in a positive predictive value of 95%. No significant differences in age, sex, bone metastasis, or visceral metastasis observed between group A and group B, except that group A had a higher ratio of differentiated carcinoma (94% vs. 77%, P=0.003). Conclusion: To our knowledge, this is the first evidence indicating that the majority of clinical CUP cases follow the sentinel node theory to spread in lymph nodes, which helps tracking the primary, especially for differentiated carcinoma.

A Survey of Licensed Massage Therapists’ Perceptions of Skin Cancer Prevention and Detection Activities

Background: Skin cancer is the most common cancer in the US. Training massage therapists (MTs) in skin cancer prevention and detection cre-ates opportunity for reducing skin cancer burden. Little is known about MTs’ perceptions of skin cancer prevention and detection, their discussions of these topics with clients, or their referral recom-mendations for suspicious skin lesions. Purpose: We surveyed MTs’ perceptions of their role in engaging in conversations about skin cancer prevention, viewing the skin for suspicious lesions, and referring clients with such lesions to health care providers.Setting, Participants, Research Design: We ad-ministered an online survey from 2015–2017 of licensed MTs practicing in the US and at least age 21 years (n = 102); quantitative and qualitative data were analyzed in 2017.Main Outcome Measures: The main variables assessed were MTs perceptions of (a) appropriate-ness for asking clients about skin cancer history, skin cancer prevention, suspicious lesion referral and follow-up; and (b) comfort with recognizing and discussing suspicious lesions, recommending a client see a doctor for suspicious lesion, and discussing skin cancer prevention.Results: Quantitative data revealed that most MTs were amenable to discussing skin cancer prevention during appointments; few were en-gaging in these conversations. MTs were more comfortable discussing suspicious lesions and recommending that a client see a doctor than they were sharing knowledge about skin cancer and sun safety. Categories based on qualitative content analysis were: sharing information for the client’s benefit, and concerns about remaining within scope of practice.Conclusions: MTs have boundaries for skin cancer risk-reduction content to include in a client discussion and remain in their scope of practice. These findings will help support a future educa-tional intervention for MTs to learn about and incorporate skin cancer risk-reduction messages and activities into their practice.

From Disease to Risk

In Chapter 2, I consider several “line-drawing” problems. First, in the diagnosis of early-stage cancer, there is an epistemic risk involved in assessing whether a suspicious lesion is likely to progress to metastasis. Pathologists’ assessment of a disease state is not strictly an empirical judgment, but also an evaluative one. This raises some interesting questions about what role values should play in diagnosis and treatment decisions. Second, in decisions about when, whether, and how often to screen, the evidence underdetermines judgments of “effectiveness.” Finally, early-stage cancer raises interesting questions about the line between health and disease.