Kishwer S Nehal

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

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Publications (67)164.22 Total impact

  • Journal of Biomedical Optics 06/2015; 20(6):61103. DOI:10.1117/1.JBO.20.6.061103 · 2.75 Impact Factor
  • Rajiv I Nijhawan, Erica H Lee, Kishwer S Nehal
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    ABSTRACT: Determining the biopsy site location of a skin cancer before treatment is often challenging. To study the implementation and effectiveness of biopsy site selfies as a quality improvement measure for correct surgical site identification. In the first phase, the ability of dermatologic surgeon and patient to definitively identify the biopsy site and whether photography was needed to ensure site agreement were recorded. In the second phase, patients were requested to take biopsy site selfies, and after implementation, similar data were collected including whether a biopsy site selfie was helpful for definitive site identification. In the first phase, the physician and patient were unable to identify the biopsy site 17.6% (49/278) and 25.5% (71/278) of cases, respectively. A photograph was needed in 22.7% of cases (63/278). After implementation of biopsy site selfies, the physician and patient were unable to identify the biopsy site 17.4% (23/132) and 15.2% (20/132) of cases, respectively. Biopsy site selfies were available for 64.1% of cases for which no internal image was available and critical for site identification in 21.4% of these cases. Biopsy site selfies has proven to be helpful for correct surgical site identification by both the physician and the patient and may also provide further reassurance and confidence for patients.
  • Anthony M Rossi, Kishwer S Nehal, Erica H Lee
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    ABSTRACT: Radiation dermatitis is a frequent sequela of adjuvant radiation therapy for breast cancer. Clinical manifestations include prominent telangiectasias that may be physically disfiguring and psychologically distressing for the patient. The objective of this study was to review cases of breast cancer patients with radiation-induced breast telangiectasias treated with the pulsed dye laser and assess clinical efficacy. The patient's perception of treatment was also reviewed. A retrospective chart review of patients treated for radiation-induced telangiectasias was conducted at the Dermatology Division of Memorial Sloan-Kettering Cancer Center. Pre- and post-clinical photos were used to assess clearance by two independent raters. Patient's comments were assessed from visit notes and the treating physicians for the impact of treatment on the patient's overall well-being. All patients (n=11) experienced clinical improvement in the radiation-induced telangiectasias. The mean number of treatments was 4.3 (2-9) with an average fluence of 4.2J/cm(2) (585nm platform) and 7.8J/cm(2) (595nm) (4-8 J/cm(2)) used. The mean percent clearance was 72.7 percent (50-90%). Adverse effects were not encountered including those with breast implants or flap reconstruction. Patients reported an improvement in their well-being, including an improved sense of confidence. LIMITATIONS include the small sample size, nonstandardized digital images, and nonsystematic collection of patient-reported outcomes. The pulsed dye laser is an efficacious treatment for radiation-induced breast telangiectasias. Multiple treatments are required for greater than 50-percent clearance and conservative treatment parameters are advised. Patients also reported an improved quality of life.
    Journal of Clinical and Aesthetic Dermatology 12/2014; 7(12):34-7.
  • Rajiv I Nijhawan, Kishwer S Nehal, Klaus J Busam
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    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. · 4.24 Impact Factor
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    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; 171(3). DOI:10.1111/bjd.13070 · 4.10 Impact Factor
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    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.
    03/2014; 150(5). DOI:10.1001/jamadermatol.2013.9804
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    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. · 4.24 Impact Factor
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    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.
    Proceedings of SPIE - The International Society for Optical Engineering 02/2014; DOI:10.1117/12.2039590 · 0.20 Impact Factor
  • Dermatologic Surgery 01/2014; DOI:10.1111/dsu.12429 · 1.56 Impact Factor
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    ABSTRACT: Background Fluorescence confocal mosaicing microscopy is an emerging technology for rapid imaging of nuclear and morphological 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 towards 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 samples from 17 Mohs cases were 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 with the corresponding Mohs pathology. ResultsThe 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. The preliminary measures of sensitivity and specificity were both 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 to frozen pathology.
    British Journal of Dermatology 05/2013; 169(4). DOI:10.1111/bjd.12444 · 4.10 Impact Factor
  • Dermatologic Surgery 04/2013; 39(7). DOI:10.1111/dsu.12221 · 1.56 Impact Factor
  • Plastic and Reconstructive Surgery 12/2012; 130(6):889e-90e. DOI:10.1097/PRS.0b013e31826d9e72 · 3.33 Impact Factor
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    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; 39(1). DOI:10.1111/dsu.12045 · 1.56 Impact Factor
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    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; 69(2). DOI:10.1016/j.jaad.2012.09.017 · 5.00 Impact Factor
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    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. DOI:10.1111/j.1524-4725.2012.02570.x · 1.56 Impact Factor
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    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; DOI:10.1016/j.jss.2012.05.059 · 2.12 Impact Factor
  • Journal of the National Comprehensive Cancer Network: JNCCN 03/2012; 10(3):312-8. · 4.24 Impact Factor
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    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. DOI:10.1097/PRS.0b013e31823aeb72 · 3.33 Impact Factor
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    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. DOI:10.1111/j.1524-4725.2011.02237.x · 1.56 Impact Factor