Managing your Practice: 10 Pearls about Contracts from Whitney High, MD, JD, MEng

  • Contracts are intended to memorialize a “meeting of the minds,” where goods and services are exchanged for considerations/benefits.
  • Contracts are all around you and they consist of an OFFER and ACCEPTANCE for a CONSIDERATION.
  • If you bought coffee this morning – coffee was OFFERED at X dollars, you ACCEPTED by placing your order, and the CONSIDERATION was money in exchange for the coffee.
  • Contract law is governed by state law. In many states, items purchased for greater than a certain dollar amount, should be placed in writing (Statute of Frauds).
  • Courts seek to identify the intent of the agreement. The most important document in ascertaining this intent is the contract itself. However, in many states outsides (parol) evidence may also be also considered.
  • You cannot ever contract for something that is illegal. Failure to honor terms of a contract is a BREACH of said contract (either minor or major/material).
  • The parties entering a contract must be mentally competent to do so, and the court would prefer that parties be negotiating from relatively equal strength.
  • A contract that is offered without any real choice, and that is offered from a party with strength to a vulnerable party is called an “adhesion contract” and may not be enforced by a court.
  • If a contract is ambiguous in some regard, then states will often turn to outside (parol) evidence to ascertain the “meeting of the minds,” and will hold parties to that interpretation.
  • There are various “canons of construction” that courts use to resolve contracts when a contract is ambiguous.
    • Ejusdem generis – general word following specific words not expansive
    • Expresio unius est exclusio alterus – express mention of one thing excludes others
    • Generalia specialibus non derogant – the general does not detract from the specifc
    • Noscitur a sociis – word is known by the company it keeps
    • Contra proferentum – if ambiguity cannot be resolved it is resolved against drafter

10 Pearls About Pigmented Lesions from the Perspective of the Dermatopathologist: Whitney A. High, MD, JD, MEng

  • There are distinct histologic differences between wholly bland nevi, and what has come to be known as an “atypical nevus,” a “dysplastic nevus,” or a“Clark’s nevus.”
  • There is no single criterion (not even mitoses or pagetoid spread) that is diagnostic of only melanoma. There is not a “melanoma stain” that wholly discriminates between atypical nevi and melanoma. “Borderline” lesions represent subjective assessments that are impacted by the viewpoint and skill of the examiner.
  • Biopsy use is increasing. In nine geographic areas of the USA, over 1986-2001, the biopsy rate among those persons >65 years of age rose 5-fold, while the melanoma rate rose 2.4-fold.
  • In many areas of the country, atypical nevi are graded “mild,” “moderate,” or “severe,” but this is not universalyl employed. Some dermatopathologists “lump” mild and moderate together, and have just two categories. In other areas of the county nevi are not formally graded, or are graded in a less straight-forward way (i.e. “nevus,” “Clark’s nevus,” and “Clark’s nevus, re-excise”).
  • The dermatopathologist is examining only a small portion of your biopsy, and this must be considered with regard to the “representative” nature of the results. A 2010 study showed the odds of misdiagnosis for pigmented lesions were considerably higher when a punch biopsy technique was employed in comparison to an excisional biopsy (see: Ng et al. 2010).
  • There are special situations where the diagnosis of melanoma is challenging, such as:
Nevoid melanoma Desmoplastic melanoma
Spitz nevi Atylical Spitz nevi (Spitz tumors)
Recurrent nevi (“pseudomelanoma”) Nevi on the scalp of children
Pigmented lesions of the nail unit Pigmented lesions of the genitalia

 

  • There are some immunostains that can “assist” in the assessment of melanoma, or “bolster” the one’s confidence in a diagnosis, and these include: Mart1/Ki67 (a combination stain), P16, and HMB45, but again, there is, however, no singular “melanoma” stain.
  • Spitz nevi, in particular, may be confused with melanoma, and vice versa. Generally, if the patient is older than 20 years of age, it is wise to ensure that the dermatopathologist examining a case of a Spitz nevus or spitzoid melanoma has experience with difficult pigmented lesions.
  • Desmplastic nevi may be difficult to distinguish from other malignant processes (such as an atypical fibroxanthoma or spindle cell squamous cell carcinoma), and desmoplastic melanoma may also be confused with simple scarring, particularly in a shallow specimen. Stains and careful examination may often be employed in such a case.
  • Synoptic reporting (a “grid-like” summary) of characteristics that allow for the pathologic staging of melanoma is an emerging standard in dermatopathology, and probably more rapidly and more accurately transmits key therapeutic and prognostic information to the clinician.

Core Principles of Cutaneous Surgery – Victoria Lazareth

Victoria Lazareth MA, MSN, NP-C, DCNP

Increased Risk for Bleeding

High Risk Sites (acral)

Scalp, Face (ears, nose, eyes, lips), Digits, genitals

Danger zones

temple (temporal artery), base of ala (angular artery), mandible (mental artery)

 

Increased Risk for Nerve damage

Facial nerve (temporal branch of CN VII)

over zygomatic arch through temporal fossa

Innervates the frontalis & orbicularis oculi & anterio-superior muscles of the ear

Damage: eyebrow ptosis (impaired eyelid elevation & closure)

Spinal accessory nerve (Cranial Nerve XI)

emerges near Erb’s point

posterior triangle of neck behind the sternocleidomastoid ~2cm above clavicle

Innervates the trapezius muscle

Damage: shoulder droop & winged scapula

Trigeminal nerve (Cranial Nerve V)

Opthalmic V1 division                  (scalp, forehead, nose)

Maxillary V2 division                  (lateral forehead, medial cheek, upper cutaneous lip)

Mandibular V3 division (lateral temple, lateral cheek, upper ear, cutaneous lower lip)

Damage: sensory innervation of face, motor innervation of mastication muscles

 

 

Increased Risk for Tumor Recurrence

NMSC at High-Risk for recurrence

Location

Scalp, eyes, ears, nose, lips, genitalia, hands, feet

Size      

> 6 mm at scalp, eyes, ears, nose, lips, genitalia, hands, feet

>10 mm at the head, forehead, cheeks, neck

>20 mm at all other areas

History           

Recurrent tumor, Older age, male gender, Immunocompromised pt

History of XRT, PUVA at site, arsenic ingestion

Histology

Recurrent BCC

clinical extension

Micronodular, Morpheaform, Sclerosing, Infiltrative, Basosquamous

Metastatic BCC

very large tumor (>10cm sq)

peri-neural invasion. Basosquamous or Morpheaform sub-types

Recurrent / Metastatic SCC

peri-neural invasion, perivascular invasion

moderately differentiated, poorly differentiated, single cell sub-types

 

Performing the Eliptical Excision

Excise the ellipse through full-thickness skin to appropriate depth

Hold scalpel perpendicular to skin surface to avoid beveling the wound margins

Common mistake   leaving more fat & dermal tissue at the tip & tail of the ellipse than at the center  

     à leads to redundancies & elevations at the ends of the ellipse

 

 

Anatomic Level of Undermining

SCALP

subgaleal space: virtually avascular plane

Large vertically-oriented FOREHEAD wounds

beneath frontalis muscle

Sebaceous areas of the NOSE

subdermal

Dorsum of the NOSE, FOREHEAD, EYELIDS, LIPS, LIMBS

fat-fascia interface   ! Temporal branch of Facial n. (CN VII) @ zygomatic arch

CHEEK, NECK

beneath deep plexus in high subcutis   ! Spinal accessory nerve (CN XI) @ Erb’s point

BEARD, SIDEBURN

deep subcutis beneath follicles   ! Facial nerve (CN VII) @ marginal mandibular

 

Electrosurgery

Includes 3 types of procedures

  1. Electrolysis
  2. Electrocautery

Hot tip, Direct current, Mono-terminal, Tissue touched, Degree of damage ++++

  1. High Frequency Electrosurgery

Electrocutting (Bi / damage ++++)

Electrocoagulation

Cold tip, Alternating high frequency current, Bi terminal, Degree of damage +++

Electrodesiccation (Mono / damage +) Electrofulguration (Mono / damage +)
Planning the Closure

Ensure complete extirpation of malignant lesion

Malignant cells left behind can grow

along undermining plane, in scar tissue, along nerves, long before becoming visible!

            May not be able to identify original lesion site to clear persistent tumor cells if tissue is       moved with a flap for closure

Know the Anatomy, Have a Back-up Closure Plan, Assure meticulous Hemostasis

Use Surgical Techniques to avoid dead space, avoid blunt trauma, avoid flap elevation

 

Closure Techniques

Advancement Flaps: Epidermis plus full thickness of dermis

Full Thickness Skin Graft: Best choice when clearance of malignancy is uncertain

 

Ways to Speed Healing

Stiches / Adhesive bandage strips establish apposition of wound edges; minimizing distance cells need to migrate

Aseptic technique             minimizes bacterial contamination

Proper hemostasis                       prevents hematoma formation

Close dead space                          prevents seroma formation

Avoid suture strangulation            prevents tissue necrosis

Pigmented Lesions: Clinical Pearls from Hensin Tsao, MD, PhD

  • For the diagnosis of melanoma, best procedure is excision with 2-3mm margins;
  • Treatment of primary melanoma is excision with 1-2cm margins;
  • Sentinel lymph node biopsy should be seriously considered in anyone with melanoma >1mm;
  • Interferon approved for Stage IIC and III melanoma;
  • Anti-BRAF and anti-MEK treatments highly effective for BRAF-mutated melanomas;
  • Checkpoint therapy exploding onto the scene.

Cutaneous Oncology Pearls from David Ozog, MD

  1. Have a low biopsy threshold for “growing scar” which can suggest dermatofibrosarcoma protuberans (DFSP)
  2. Eyelid “bump/lesion” which does not resolve after a few weeks should be considered for biopsy to evaluate for sebaceous carcinoma (particularly elderly)
  3. Desmoplastic Trichoepithelioma can be a challenging clinical and histologic diagnosis
  4. Adjuvant radiation improves outcomes in Merkel Cell Carcinoma in retrospective studies

10 Pearls on the Basic Structure of Skin from Whitney A. High, MD, JD, MEng

  • The skin consists of “three layered cake.” The epidermis (an outer protective outer layer), the dermis (a middle layer that provides “tensile” strength), and the subcutis with insulating fat.
  • The epidermis gets all its nutrition and sustenance from the dermis. The dermis contains all the “supportive” structures of the skin, such as blood vessels, nerves, and many “adnexal structures.”
  • The epidermis consists chiefly of keratinocytes (“skin cells”). These cells are arranged in layers to form a “maturing” protective layer that replaces itself every ~28 days:
    • stratum basal = the germinative layer of the skin that divides to regenerate the epidermis
    • stratum spinosum = names for the intraspinous properties that bind the keratinocytes
    • straum granulosum = the granular layer where keratohyaline granules are produced
    • stratum corneum = the “dead” outer layer the provides the most barrier function
  • The dermis is comprised of three main building blocks: collagen, elastic fibers, and “ground substance. Collagen is the material that provides the tensile strength to the skin. Elastic fibers provide skin resiliency. Ground substance facilitates the diffusion of nutrients and oxygen.
  • The “dermoepidermal junction” is where the epidermis attaches to the dermis. This is also the location of melanocytes that make protective melanin for the skin. The DEJ is where most nonmelanoma skin cancer invades the dermis, the place where nearly all melanoma originates, and the place where many bullous and “interface” diseases transpire.
  • When confronted with a skin disease, one must ask themselves, “where do I believe that that pathology is occurring?” For example, the pathologic process might be:
    • epidermal – such as the spongiosis (intraepidermal edema) and weeping of dermatitis, or the yeast/hyphae of tinea versicolor/pityriasis versicolor growing in the stratum corneum
    • dermal – such as the histiocytic/macrophagic infiltrate of granuloma annulare, or the neutrophilic inflammation of small blood vessels in leukocytoclastic vasculitis
    • subcuticular – such as the panniculitis of erythema nodosum
  • Being able to predict where the likely pathology is occurring also facilitates the securing of a “representative” biopsy, which is always the responsibility of the clinician.
  • Adnexal structures may be the site of inflammatory pathologic processes (acne, hidradenitis), may be the site of neoplastic processes (sebaceous carcinoma), or these structures may simply behave in an undesired way (seborrhea, hyperhidrosis).
  • Uncontrolled and unchecked growth of certain components of the skin leads to cancer, such as basal cell carcinoma (from basilar keratinocytes), squamous cell carcinoma (also from keratinocytes) and melanoma (from melanocytes).
  • Skin structure and function changes with age, such as dyspigmentation and facial wrinkling, formation of “solar elastosis” (damaged elastic), and increased water loss to the environment.