Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, e122ee123
CORRESPONDENCE AND COMMUNICATION Letter in response to: ‘Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.’ Dear Sir, We read with interest the recent study entitled “Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.”1 We appreciate the difficulties in clinically assessing skin lesions with the naked eye. Clinical experience is very difficult to substitute, with evidence to show that training plays a significant role in the accuracy of diagnosis of skin lesions.2 However, the consequences of unnecessary excision cannot be ignored. In general, the majority of excisions are on the head and neck and can give cosmetic sequelae. The patient population is older and with co-morbidities, and hence more complications. It is therefore important that clinical diagnosis is as accurate as possible. This study reports 204 false positives for the diagnosis of BCC. Accounting for the 15 non-BCC lesions which would have necessitated excision independent of this diagnosis (lentigo maligna melanoma, squamous cell carcinoma), and the 15 cases of Bowen’s disease, for which surgery is an option, there were 174 non-indicated excisions. If extrapolated across all plastic surgery units, then this obviously has financial and logistical implications, in addition to the risks posed to the individual patient. As previously published in this journal, dermoscopy is a sensitive addition to naked eye examination. The use of dermoscopy reduces unnecessary excision, increases diagnostic accuracy, and is very cost effective. Even with a very short, one-day course in dermoscopy, the relative odds ratio of increased accuracy in diagnosis when using dermoscopy was 5.2, when compared with the naked eye
(p < 0.05).3 One independent study has reported a sensitivity of diagnosis of 97% when dermoscopy is used appropriately4 in the assessment of basal cell carcinoma. Using dermoscopy, a number of key and typical features can be used as part of the evidence to help diagnose BCCs, including the presence of pigmented structures (blue/gray globules and ovoid nests, maple-leaf areas) and typical vascular structures including arborizing telangiectasia.5 We would argue that with the availability of sustained, repeatable Level II evidence of the benefits of dermoscopy,6 this examination technique should become an essential tool in the modern plastic surgeon’s armamentarium, a recommendation supported by recent NICE guidelines.7 It was previously published as a suggestion that perhaps it was “time for plastic surgeons to embrace a new diagnostic tool.” We now suggest that failure to embrace this established technique reduces our role in managing primary skin cancer.
Conflict of interest None.
Funding None.
References 1. Farroha A, Dziewulski P, Shelley OP. Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma. J Plast Reconstr Aesthet Surg JPRAS 2013;66(7):1013e5. 2. Pearl RA, Townley W, Stott D, Grobbelaar AO. Diagnosis of skin lesions by trainee surgeons: experience improves accuracy. Ann R Coll Surg Engl 2009 Sep;91(6):494e9. 3. Townley WA, Cassell OC, Bowling J. Dermoscopyetime for plastic surgeons to embrace a new diagnostic tool? J Plast Reconstr Aesthet Surg 2011;64(10):1386e7. 4. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy WH, Katz B. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000;136(8):1012. 5. Altamura D, Menzies SW, Argenziano G, et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010;62(1):67e75.
DOI of original article: http://dx.doi.org/10.1016/ j.bjps.2013.01.030. 1748-6815/$ - see front matter Crown Copyright ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.11.005
Correspondence and communication 6. Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala ` C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumors. J Am Acad Dermatol 2010;63(3):361e74. 7. Marsden JR, Newton-Bishop JA, Burrows L, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. J Plast Reconstr Aesthet Surg 2010 Sep;63(9):1401e19.
e123 Foiz Ahmed Jonathan Bowling Oliver Cassell Oxford Radcliffe Hospitals NHS Trust, UK E-mail address: [email protected]
14 August 2013
CORRESPONDENCE AND COMMUNICATION Letter in response to: ‘Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.’ Dear Sir, We read with interest the recent study entitled “Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.”1 We appreciate the difficulties in clinically assessing skin lesions with the naked eye. Clinical experience is very difficult to substitute, with evidence to show that training plays a significant role in the accuracy of diagnosis of skin lesions.2 However, the consequences of unnecessary excision cannot be ignored. In general, the majority of excisions are on the head and neck and can give cosmetic sequelae. The patient population is older and with co-morbidities, and hence more complications. It is therefore important that clinical diagnosis is as accurate as possible. This study reports 204 false positives for the diagnosis of BCC. Accounting for the 15 non-BCC lesions which would have necessitated excision independent of this diagnosis (lentigo maligna melanoma, squamous cell carcinoma), and the 15 cases of Bowen’s disease, for which surgery is an option, there were 174 non-indicated excisions. If extrapolated across all plastic surgery units, then this obviously has financial and logistical implications, in addition to the risks posed to the individual patient. As previously published in this journal, dermoscopy is a sensitive addition to naked eye examination. The use of dermoscopy reduces unnecessary excision, increases diagnostic accuracy, and is very cost effective. Even with a very short, one-day course in dermoscopy, the relative odds ratio of increased accuracy in diagnosis when using dermoscopy was 5.2, when compared with the naked eye
(p < 0.05).3 One independent study has reported a sensitivity of diagnosis of 97% when dermoscopy is used appropriately4 in the assessment of basal cell carcinoma. Using dermoscopy, a number of key and typical features can be used as part of the evidence to help diagnose BCCs, including the presence of pigmented structures (blue/gray globules and ovoid nests, maple-leaf areas) and typical vascular structures including arborizing telangiectasia.5 We would argue that with the availability of sustained, repeatable Level II evidence of the benefits of dermoscopy,6 this examination technique should become an essential tool in the modern plastic surgeon’s armamentarium, a recommendation supported by recent NICE guidelines.7 It was previously published as a suggestion that perhaps it was “time for plastic surgeons to embrace a new diagnostic tool.” We now suggest that failure to embrace this established technique reduces our role in managing primary skin cancer.
Conflict of interest None.
Funding None.
References 1. Farroha A, Dziewulski P, Shelley OP. Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma. J Plast Reconstr Aesthet Surg JPRAS 2013;66(7):1013e5. 2. Pearl RA, Townley W, Stott D, Grobbelaar AO. Diagnosis of skin lesions by trainee surgeons: experience improves accuracy. Ann R Coll Surg Engl 2009 Sep;91(6):494e9. 3. Townley WA, Cassell OC, Bowling J. Dermoscopyetime for plastic surgeons to embrace a new diagnostic tool? J Plast Reconstr Aesthet Surg 2011;64(10):1386e7. 4. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy WH, Katz B. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000;136(8):1012. 5. Altamura D, Menzies SW, Argenziano G, et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010;62(1):67e75.
DOI of original article: http://dx.doi.org/10.1016/ j.bjps.2013.01.030. 1748-6815/$ - see front matter Crown Copyright ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.11.005
Correspondence and communication 6. Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala ` C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumors. J Am Acad Dermatol 2010;63(3):361e74. 7. Marsden JR, Newton-Bishop JA, Burrows L, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. J Plast Reconstr Aesthet Surg 2010 Sep;63(9):1401e19.
e123 Foiz Ahmed Jonathan Bowling Oliver Cassell Oxford Radcliffe Hospitals NHS Trust, UK E-mail address: [email protected]
14 August 2013
