Comfere, Nneka I.

Abstract: The recently published 2016 revision of the WHO classification of lymphoid neoplasms includes primary cutaneous acral CD8-positive T-cell lymphoma (PCATCL) as a provisional entity. This is a rare indolent lymphoma characterized by papules or nodules on the ear and a dermal infiltrate of CD8-positive T-lymphocytes with cytotoxic marker expression. A retrospective review of a single institutional experience with PCATCL identified 3 patients (mean age 54; range 49–62) with papules or nodules on the ear. Lesional biopsies demonstrated a dense diffuse dermal infiltrate of atypical lymphocytes with a Grenz zone in 2 cases and focal epidermotropism in 1 case. The atypical lymphocytes were predominantly CD3 and CD8 positive with expression of cytotoxic marker TIA1. Staging evaluation failed to reveal systemic disease. Two patients underwent local excision, and the third received local radiation therapy all with complete response and no disease recurrence at last follow-up 3 months (range 2–5 months). Our cases add to the existing limited literature on the clinical and histopathological features of PCATCL. We also performed an updated systematic literature view of the entity.

BackgroundAppropriate use criteria (AUC) provide physicians guidance in test selection, and can affect health care delivery, reimbursement policy and physician decision‐making.ObjectivesThe American Society of Dermatopathology, with input from the American Academy of Dermatology and the College of American Pathologists, sought to develop AUC in dermatopathology.MethodsThe RAND/UCLA appropriateness methodology, which combines evidence‐based medicine, clinical experience and expert judgment, was used to develop AUC in dermatopathology.ResultsWith the number of ratings predetermined at 3, AUC were developed for 211 clinical scenarios involving 12 ancillary studies. Consensus was reached for 188 (89%) clinical scenarios, with 93 (44%) considered “usually appropriate,” 52 (25%) “rarely appropriate” and 43 (20%) “uncertain appropriateness.”LimitationsThe methodology requires a focus on appropriateness without comparison between tests and irrespective of cost.ConclusionsThe ultimate decision of when to order specific test rests with the physician and is one where the expected benefit exceeds the negative consequences. This publication outlines the recommendations of appropriateness—AUC for 12 tests used in dermatopathology. Importantly, these recommendations may change considering new evidence. Results deemed “uncertain appropriateness” and where consensus was not reached may benefit from further research.

BackgroundAppropriate use criteria have been developed for many tests using expert judgment, evidence‐based practice and clinical experience. In this context, we report the opinions of practitioners about clonality assays in various clinical scenarios where cutaneous lymphoma is suspected.MethodsAn Appropriate Use Criteria Task Force sponsored by the American Society of Dermatopathology (ASDP) synthesized clinical scenarios for cutaneous lymphoproliferative disorders (LPDs). We conducted, summarized and presented a relevant literature search to an audience of 144 dermatopathologists with a variety of practice experiences at the 53rd Annual Meeting of the ASDP in Chicago, IL.ResultsTwenty‐seven clinical scenarios for LPDs (13 T‐cell and 14 B‐cell) were defined. Forty relevant studies for T‐cell receptor gene clonality assays and 20 relevant studies for IgH/IgK clonality assays were identified. Audience response data from participating dermatopathologists reflected a wide variety of approaches to the application of clonality assays in the evaluation of LPDs, based on practice setting, personal experience and test availability.ConclusionsOur clinical scenario analysis and literature review revealed well‐supported clinical scenarios and identified opportunities for additional research to further define the utility of clonality assays in some clinical scenarios.

AbstractBackgroundUntreated calciphylaxis is a fatal disease of intra‐ and extravascular calcification, most commonly presenting in end‐stage renal disease (ESRD) patients. While early identification is critical for timely treatment, early‐stage clinical and histopathological descriptions have not, to our knowledge, been elucidated. As early clinical recognition is essential to prompt definitive histopathological diagnosis, this study describes a range of clinical and histopathological manifestations of early‐stage calciphylaxis.MethodsFive patients with clinical photographs of lesions of early‐phase calciphylaxis were chosen from a recent database of 101 patients. Their clinical histories were reviewed and correlated with their respective clinical and histopathological images of early‐stage disease and progression of the disease.ResultsTwo of the five patients were identified early to have calciphylaxis and were promptly initiated on aggressive, multimodal therapy, resulting in complete resolution and remission of calciphylaxis. The other three patients were also recognized in early stages, one without renal disease, although the disease had progressed to more advanced stages associated with greater morbidity and mortality.ConclusionsThese cases demonstrate that calciphylaxis may be clinically misdiagnosed due to ill‐defined presentations, particularly in the early stages without the characteristic features of livedo racemosa and ulceration. However, recognition in the early stages is critical to implement timely treatment. As such, definitively diagnostic skin biopsy should be considered early in suspected cases to confirm the diagnosis of calciphylaxis and ensure prompt management of this lethal disease.

110 Background: Assessment of compliance with national quality guidelines for the management of melanoma may be complicated by controversy about selection of patients for nodal surgery and limited by a lack of data on quality metrics. Previous reports suggest suboptimal overall compliance, with sentinel lymph node biopsy (SLNB) not performed for many suitable patients and completion lymph node dissection (CLND) omitted in many biopsy-proven node-positive (LN+) cases. The purpose of this study was to assess compliance with national ASCO/SSO guidelines for lymph node (LN) surgery for T2 and T3 (intermediate thickness, 1.01-4.00 mm) primary cutaneous melanoma patients and elucidate factors associated with non-compliance. Methods: All cases of T2 and T3, M0 melanoma were identified from 2004-2010 SEER data. Multivariable logistic regression was utilized to identify independent predictors of compliance. Five-year cancer specific survival (CSS) was estimated using the Kaplan-Meier method. Results: Overall, 75.3% (6,609/8,782) of T2-T3 primary cutaneous melanoma patients underwent LN staging including SLNB in 6,330 (74.5%) of 8,492 clinically LN negative patients. Among these 6,609 patients, 1,279 (19.4%) had one or more LN+. 940 LN+ patients (73.4%) underwent CLND with removal of a mean (median, IQR) of 20.7 (18, 11-27) LNs. Compliance with LN staging and management guidelines was associated with truncal primary site (for SLNB), p<0.001 and with patient age <65 yrs and increasing number of metastatic LNs (for CLND), both p<0.0001. Compliance with CLND for LN+ patients was associated with improved 5 year CSS: 70.0% vs 64.6%, p<0.001. Conclusions: Compliance with guidelines for LN surgery in T2 and T3 melanoma is poor despite the well-defined benefit for this group of patients. These data suggest that non-compliance is multifactorial and not simply due to practice differences arising from the controversial aspects of melanoma management. Room for improvement exists. Assessment of modifiable factors associated with poor compliance, design of strategies to improve compliance and the development of performance measures around appropriate LN staging and management of T2 and T3 melanoma deserve further investigation.

Purpose To summarize characteristics and validity evidence of tools that assess teamwork in undergraduate medical education (UME), and provide recommendations for addressing the interprofessional collaboration competencies of the Association of American Medical Colleges (AAMC). Method The authors conducted a systematic review, searching MEDLINE, MEDLINE In-process, CINAHL, and PsycINFO from January 1, 1979, through April 1, 2014; they searched reference lists and national meeting abstracts. They included original research reports that described a quantitative tool used to assess teamwork in UME. They abstracted characteristics and validity evidence for the tools, plus study quality, according to established frameworks. Two authors independently abstracted 25% of articles and calculated agreement. Authors then applied predefined criteria to identify tools best suited to address the AAMC’s teamwork competencies. Results Of 13,549 citations, 70 articles describing 64 teamwork assessment tools were included. Of these 64 tools, 27 (42%) assessed teamwork in classroom, 31 (48%) in simulation, and only 7 (11%) in actual clinical settings. The majority (47; 73%) of tools assessed medical students’ teamwork in interprofessional teams. On the basis of content concordance, strength of validity evidence, generalizability of scores, and level of outcomes, four published tools were recommended to assess the AAMC’s teamwork competencies: the Collaborative Healthcare Interdisciplinary Relationship Planning Scale, Readiness for Interprofessional Learning Scale, Communication and Teamwork Skills assessment, and Teamwork Mini-Clinical Evaluation Exercise. Conclusions Substantial validity evidence supports the use of several UME teamwork assessments. Four tools have been appropriately designed and sufficiently studied to constitute appropriate assessments of the AAMC’s teamwork competencies.

AbstractPatient‐centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient‐centered emergency diagnostic imaging. This article summarizes findings reached during the patient‐centered outcomes session of the 2015 Academic Emergency Medicine consensus conference “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization.” The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient‐centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging.

Frozen section pathology is routinely used for margin assessment of non‐melanoma skin cancer ( NMSC ). Frozen section can also be used for the primary diagnosis of several skin lesions. Limited data exist on the accuracy of frozen section in the diagnosis of NMSC . We performed a retrospective chart review of 300 cases in which frozen section diagnoses were compared with permanent section diagnoses of NMSC . Frozen section and permanent section pathology were concordant 83.3% of the time, with the highest concordance rates noted for basal cell carcinoma (145/153, 95%). Our results show a high level of concordance between frozen section and corresponding permanent section pathology diagnosis for NMSC . The rapidity of frozen section tissue processing and pathology reporting makes this technique useful in dermatologic practice for immediate diagnosis and management of NMSC . Further studies should explore strategies to decrease or eliminate discrepancies between frozen and permanent section diagnosis.