Kishwer S Nehal

Memorial Sloan-Kettering Cancer Center, New York City, New York, United States

Are you Kishwer S Nehal?

Claim your profile

Publications (61)164.55 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor characterized by a relatively high risk of local recurrence and low risk of metastasis. The NCCN Guidelines for DFSP provide multidisciplinary recommendations on the management of patients with this rare disease. These NCCN Guidelines Insights highlight the addition of the Principles of Pathology section, which provides recommendations on the pathologic assessment of DFSP. Because DFSP can mimic other lesions, immunohistochemical studies are often required to establish diagnosis. Cytogenetic testing for the characteristic translocation t(17;22)(q22;q13) can also be valuable in the differential diagnosis of DFSP with other histologically similar tumors.
    Journal of the National Comprehensive Cancer Network: JNCCN 06/2014; 12(6):863-8. · 5.11 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Fluorescence confocal microscopy (FCM) is an emerging technology for rapid imaging of excised tissue, without the need for frozen or fixed section processing. Basal cell carcinomas (BCCs) can be detected in Mohs excisions although few studies have described the major BCC-findings as seen upon FCM.Objectives To describe the major BCC-findings of excised tissue during Mohs surgery and to correlate them with histopathology.Methods Freshly excised tumors and frozen-thawed discarded tissue of BCC during Mohs surgery were analyzed by means of FCM. A side-by-side correlation between FCM images and histologic sections was performed. The FCM features of overlying skin and adnexal structures were also described.Results64 BCC cases were analyzed. Distinct BCC types appeared unique in term of shape and size of tumor islands (bigger in nodular (18/25), smaller and rounded in micronodular (7/7) and tiny cords for infiltrative ones (24/30)) and for the presence of clefting, palisading and increased nucleus/cytoplasm ratio. An excellent correlation was found between FCM and histologic findings (Cohen's Kappa statistics = 0.9). In 6 cases, the presence of sebaceous glands and intense stroma reaction represented possible confounders.ConclusionsFCM is a fast and new imaging technique that allows an excellent visualization of skin structures and BCC-findings during Mohs surgery.This article is protected by copyright. All rights reserved.
    British Journal of Dermatology 04/2014; · 3.76 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery. OBJECTIVE To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology. EVIDENCE REVIEW Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations. FINDINGS In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions. CONCLUSIONS AND RELEVANCE When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.
    JAMA dermatology. 03/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Merkel cell carcinoma is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative nonmelanoma skin cancer with the regional and distant metastatic rates of thick melanoma. The NCCN Guidelines for Merkel Cell Carcinoma provide recommendations on the diagnosis and management of this aggressive disease based on clinical evidence and expert consensus. This version includes revisions regarding the use of PET/CT imaging and the addition of a new section on the principles of pathology to provide guidance on the analysis, interpretation, and reporting of pathology results.
    Journal of the National Comprehensive Cancer Network: JNCCN 03/2014; 12(3):410-24. · 5.11 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Mohs surgery for the removal of non-melanoma skin cancers (NMSCs) is performed in stages, while being guided by the examination for residual tumor with frozen pathology. However, preparation of frozen pathology at each stage is timeconsuming and labor-intensive. Real-time intraoperative reflectance confocal microscopy (RCM) may enable rapid detection of residual tumor directly in surgical wounds on patients. We report initial feasibility on twenty-one patients, using 35% AlCl3 for nuclear contrast. Imaging was performed in quadrants in the wound, to simulate the Mohs surgeon's examination of pathology. Images and videos of the epidermal and dermal margins were found to be of clinically acceptable quality. Bright nuclear morphology was identified at the epidermal margin. The presence of residual BCC/SCC tumor and normal skin features could be detected in the peripheral and deep dermal margins. Nuclear morphology was detectable in residual BCC/SCC tumors. Intraoperative RCM imaging may enable detection of residual tumor, directly on Mohs patients, and may serve as an adjunct for frozen pathology. However, a stronger source of contrast will be necessary, and also a smaller device with an automated approach for imaging in the entire wound in a rapid and controlled manner for clinical utility.
    02/2014;
  • Dermatologic Surgery 01/2014; · 1.87 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Fluorescence confocal mosaicing microscopy is an emerging technology for rapid imaging of nuclear and morphologic detail directly in excised tissue, without the need for frozen or fixed section processing. Basal cell carcinomas (BCCs) can be detected with high sensitivity and specificity in Mohs excisions with this approach. For translation to clinical trials and toward potentially routine implementation, a new and faster approach called strip mosaicing confocal microscopy was recently developed. OBJECTIVES: To perform a preliminary assessment of fluorescence strip mosaicing confocal microscopy for detecting skin cancer margins in Mohs excisions. METHODS: Tissue from 17 Mohs cases was imaged in the form of strip mosaics. Each mosaic was divided into two halves (submosaics) and graded by a Mohs surgeon and a dermatologist who were blinded to the pathology. The 34 submosaics were compared to the corresponding Mohs pathology. RESULTS: The overall image quality was excellent for resolution, contrast and stitching in the 34 submosaics. Components of normal skin including the epidermis, dermis, dermal appendages and subcutaneous tissue were easily visualized. Preliminary measure of sensitivity and specificity was 94% for detecting skin cancer margins. CONCLUSIONS: The new strip mosaicing approach represents another advance in confocal microscopy for imaging of large areas of excised tissue. Strip mosaicing may enable rapid assessment of BCC margins in fresh excisions during Mohs surgery and may serve as an adjunct for frozen pathology. This article is protected by copyright. All rights reserved.
    British Journal of Dermatology 05/2013; · 3.76 Impact Factor
  • Dermatologic Surgery 04/2013; · 1.87 Impact Factor
  • Plastic and reconstructive surgery 12/2012; 130(6):889e-90e. · 2.74 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair. OBJECTIVE: To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics. METHODS: Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons. RESULTS: The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99). CONCLUSIONS: Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages.
    Dermatologic Surgery 11/2012; · 1.87 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) has traditionally focused on minimizing recurrence and complication rates. However, the assessment of patient satisfaction and quality of life (QOL) is also important. These outcomes are best assessed by patient-reported outcome (PRO) instruments. OBJECTIVES: We sought to conduct a systematic review of published PRO instruments purporting to measure aspects associated with QOL and/or patient satisfaction in the dermatologic BCC/SCC population and evaluate their development, content, and psychometric properties. METHODS: PubMed, Embase, Cochrane via Wiley, PsycINFO, CINAHL, and HaPI from inception to April 2011 were searched. Articles that discussed the instrument development and validation process were included. RESULTS: A total of 2212 articles were identified. Twenty met our inclusion criteria resulting in 6 PRO instruments: 3 general dermatology (Skindex, Dermatology Life Quality Index, dermatology quality of life scales), 1 general plastic surgery (Patient Outcomes of Surgery-Head/Neck), and 2 skin cancer-specific (Skin Cancer Index, disease-specific questionnaire). The 6 instruments all underwent some degree of formal development and validation, however, only the Skin Cancer Index was developed and validated in the BCC/SCC population. LIMITATIONS: The review may not have included all relevant PRO instruments. CONCLUSIONS: The Skin Cancer Index demonstrates the most evidence of its usefulness in patients with BCC/SCC. The Skindex-16, Dermatology QOL Scales, and Dermatology Life Quality Index target different aspects of QOL and should be used depending on the specific question being investigated. The Patient Outcomes of Surgery-Head/Neck may be beneficial to assess perceptions in appearance before and after surgical intervention.
    Journal of the American Academy of Dermatology 10/2012; · 4.91 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: During Mohs micrographic surgery (MMS), situations can arise in which paraffin sections may be used in conjunction with frozen sections. To determine the clinical value of paraffin sections in association with MMS, including frequency, reasons, and information obtained. Single-center retrospective cohort study at a cancer center. MMS cases for nonmelanoma skin cancers over a 5-year period in which paraffin sections were used were identified. Reasons for submitting paraffin sections were reviewed. Initial biopsy, Mohs frozen section, and paraffin section diagnoses and histologic subtypes were compared. In 258 (7.8%) cases, paraffin sections were used in association with MMS. The most common reasons were to further assess high-risk histologic features or unusual frozen section findings, to complete tumor staging of cutaneous squamous cell carcinomas, and to assess perineural invasion (PNI). Initial biopsy diagnosis differed from the Mohs frozen and paraffin section diagnoses in 20% to 22% of cases. The initial biopsy histologic subtype changed from low or indeterminate to high risk in Mohs frozen and paraffin sections in 24% to 29% of cases. In MMS for select high-risk or unusual nonmelanoma skin cancers, paraffin sections are useful in more accurately documenting tumor histology, completing cutaneous squamous cell carcinoma staging, and detecting PNI.
    Dermatologic Surgery 09/2012; 38(10):1631-8. · 1.87 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Complete and accurate excision of cancer is guided by the examination of histopathology. However, preparation of histopathology is labor intensive and slow, leading to insufficient sampling of tissue and incomplete and/or inaccurate excision of margins. We demonstrate the potential utility of multimodal confocal mosaicing microscopy for rapid screening of cancer margins, directly in fresh surgical excisions, without the need for conventional embedding, sectioning, or processing. MATERIALS AND METHODS: A multimodal confocal mosaicing microscope was developed to image basal cell carcinoma margins in surgical skin excisions, with the resolution that shows nuclear detail. Multimodal contrast is with fluorescence for imaging nuclei and reflectance for cellular cytoplasm and dermal collagen. Thirty-five excisions of basal cell carcinomas from Mohs surgery were imaged, and the mosaics analyzed by comparison with the corresponding frozen pathology. RESULTS: Confocal mosaics are produced in about 9min, displaying tissue in fields of view of 12mm with ×2 magnification. A digital staining algorithm transforms black and white contrast to purple and pink, which simulates the appearance of standard histopathology. Mosaicing enables rapid digital screening, which mimics the examination of histopathology. CONCLUSIONS: Multimodal confocal mosaicing microscopy offers a technology platform to potentially enable real-time pathology at the bedside. The imaging may serve as an adjunct to conventional histopathology to expedite screening of margins and guide surgery toward more complete and accurate excision of cancer.
    Journal of Surgical Research 06/2012; · 2.02 Impact Factor
  • Journal of the National Comprehensive Cancer Network: JNCCN 03/2012; 10(3):312-8. · 5.11 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Melanoma of the lentigo maligna subtype presents diagnostic and treatment challenges because of ill-defined clinical margins in cosmetically and functionally sensitive areas of the head and neck with extensive sun damage. This review highlights the natural history, varied clinical presentations, and pitfalls in histologic diagnosis. The focus is on the surgical management, comparing excision and pathologic tissue processing techniques of wide excision, Mohs micrographic surgery, and staged excision. Staged excision is recommended for optimal surgical margin control. Nonsurgical treatment modalities are also reviewed for the elderly or unresectable cases.
    Plastic and reconstructive surgery 02/2012; 129(2):288e-299e. · 2.74 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Dermatologic surgeons perform numerous procedures that put them at risk of developing work-related musculoskeletal disorders. To study the prevalence of work-related musculoskeletal disorders and role of ergonomics in dermatologic surgery. A survey study was sent to members of the American College of Mohs Surgery in 2010. The main outcome measures were survey responses relating to surgeon demographics, musculoskeletal symptoms, workstyle habits and attitudes, and ergonomic practices. Ninety percent of respondents reported some type of musculoskeletal symptoms or injuries. The most common complaints were neck, lower back, shoulder, and upper back pain. Most respondents were not using ergonomic modifications in their practice. Mohs surgeons have a high prevalence of musculoskeletal disorders. Symptoms present early and persist throughout the careers of Mohs surgeons. The nature of the occupation leaves the surgeon vulnerable to injury. Ergonomic modifications in behavior and workplace are recommended to reduce pain and injury to surgeons.
    Dermatologic Surgery 12/2011; 38(2):240-8. · 1.87 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Confocal mosaicing microscopy enables rapid imaging of large areas of fresh tissue, without the processing that is necessary for conventional histology. Mosaicing may offer a means to perform rapid histology at the bedside. A possible barrier toward clinical acceptance is that the mosaics are based on a single mode of grayscale contrast and appear black and white, whereas histology is based on two stains (hematoxylin for nuclei, eosin for cellular cytoplasm and dermis) and appears purple and pink. Toward addressing this barrier, we report advances in digital staining: fluorescence mosaics that show only nuclei, are digitally stained purple and overlaid on reflectance mosaics, which show only cellular cytoplasm and dermis, and are digitally stained pink. With digital staining, the appearance of confocal mosaics mimics the appearance of histology. Using multispectral analysis and color matching functions, red, green, and blue (RGB) components of hematoxylin and eosin stains in tissue were determined. The resulting RGB components were then applied in a linear algorithm to transform fluorescence and reflectance contrast in confocal mosaics to the absorbance contrast seen in pathology. Optimization of staining with acridine orange showed improved quality of digitally stained mosaics, with good correlation to the corresponding histology.
    Journal of Biomedical Optics 07/2011; 16(7):076008. · 2.88 Impact Factor
  • Christine A Liang, Klaus J Busam, Kishwer S Nehal
    [Show abstract] [Hide abstract]
    ABSTRACT: The authors have indicated no significant interest with commercial supporters.
    Dermatologic Surgery 06/2011; 37(10):1515-8. · 1.87 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Confocal mosaicing microscopy enables rapid imaging of large areas of fresh tissue, without the processing that is necessary for conventional histology. Using acridine orange (1 milliMolar, 20 seconds) to stain nuclei, basal cell carcinomas were detected in fluorescence confocal mosaics of Mohs surgical excisions with sensitivity of 96.6% and specificity of 89.2%. A possible barrier toward clinical acceptance is that confocal mosaics are based on a single mode of contrast and appear in grayscale, whereas histology is based on two (hematoxylin for nuclei, eosin for cellular cytoplasm and dermis) and appears purple-and-pink. Toward addressing this barrier, we report progress in developing a multispectral analytical model for digital staining: fluorescence confocal mosaics, which show only nuclei, are digitally stained purple and overlaid on reflectance confocal mosaics, which show only cellular cytoplasm and dermis, and digitally stained pink, to mimic the appearance of histology. Comparison of digitally stained confocal mosaics by our Mohs surgeon to the corresponding Mohs histology shows good correlation for normal and tumor detail. Digitally stained confocal mosaicing microscopy may allow direct examination of freshly excised tissue and serve as an adjunct for rapid pathology at-the-bedside.
    Proc SPIE 02/2011;
  • [Show abstract] [Hide abstract]
    ABSTRACT: The incidence of cutaneous squamous cell carcinoma (cSCC) is increasing. Although most patients achieve complete remission with surgical treatment, those with advanced disease have a poor prognosis. The American Joint Committee on Cancer (AJCC) is responsible for the staging criteria for all cancers. For the past 20 years, the AJCC cancer staging manual has grouped all nonmelanoma skin cancers, including cSCC, together for the purposes of staging. However, based on new evidence, the AJCC has determined that cSCC should have a separate staging system in the 7th edition AJCC staging manual. We sought to present the rationale for and characteristics of the new AJCC staging system specific to cSCC tumor characteristics (T). The Nonmelanoma Skin Cancer Task Force of AJCC reviewed relevant data and reached expert consensus in creating the 7th edition AJCC staging system for cSCC. Emphasis was placed on prospectively accumulated data and multivariate analyses. Concordance with head and neck cancer staging system was also achieved. A new AJCC cSCC T classification is presented. The T classification is determined by tumor diameter, invasion into cranial bone, and high-risk features, including anatomic location, tumor thickness and level, differentiation, and perineural invasion. The data available for analysis are still suboptimal, with limited prospective outcomes trials and few multivariate analyses. The new AJCC staging system for cSCC incorporates tumor-specific (T) staging features and will encourage coordinated, consistent collection of data that will be the basis of improved prognostic systems in the future.
    Journal of the American Academy of Dermatology 01/2011; 64(6):1051-9. · 4.91 Impact Factor

Publication Stats

484 Citations
164.55 Total Impact Points

Institutions

  • 2001–2014
    • Memorial Sloan-Kettering Cancer Center
      • • Hematology Service
      • • Department of Medicine
      New York City, New York, United States
  • 2011
    • Brigham and Women's Hospital
      • Department of Dermatology
      Boston, MA, United States
  • 2009
    • New York University
      • Department of Dermatology
      New York City, NY, United States
  • 2003–2005
    • New York Presbyterian Hospital
      • Department of Dermatology
      New York City, New York, United States
  • 2004
    • Cornell University
      • Department of Dermatology
      Ithaca, NY, United States