tbuckley/cabot-search huggingface dataset:
P020 Lentigo maligna: a vanishing act
Authors: Lisa Murphy, Caitriona Hackett
Journal: British Journal of Dermatology (2024)

Abstract The abscopal effect is a phenomenon seen in the treatment of metastatic cancer, whereby the treatment of a tumour with radiotherapy results in the shrinkage of another tumour elsewhere in the body. We report the case of a biopsy-proven lentigo maligna that self-resolved in the setting of radiotherapy for a preceding malignant melanoma on the left chest. Our patient was a 57-year-old man who was originally referred to the clinic with a lesion on his left chest wall. His history was significant for sun exposure, as he had previously worked in the army, and had completed numerous army tours in Lebanon. He was reviewed in clinic, and the lesion was deemed clinically suspicious for melanoma. He was diagnosed with a superficial spreading malignant melanoma on his left chest wall in March 2019 (Breslow thickness 3.6 mm). Wide local excision was negative. A sentinel lymph node biopsy was also performed and this was positive (T3N1M0). He proceeded to have an axillary lymph node dissection. He completed 20 fractions of radiotherapy to his left axillary region in May 2021 and he was commenced on pembrolizumab with the oncology team in July 2021. On routine surveillance review in January 2022, he was noted to have an irregular-shaped lentigo on his right infraorbital cheek. Pigment clods and rhomboidal structures were seen, suggestive of lentigo maligna. An incisional biopsy was arranged, and histology was consistent with a lentigo maligna. He was referred to have this lesion excised. A mapping biopsy was performed in June 2022, and this did not show any evidence of lentigo maligna. He completed his immunotherapy treatment with pembrolizumab in May 2022. At a further follow-up review, the pigmented lesion was no longer clinically evident. It was agreed that an excisional biopsy should be performed to assess for any histological evidence of lentigo maligna. Once more there was no further evidence seen of lentigo maligna on histology. He was reviewed in clinic subsequent to this again, and the site was clear. It is our hypothesis that the lentigo maligna may have resolved due to the abscopal effect, as a result of his radiation treatment for the melanoma on his chest. We suspect that this response would also have been primed by the immunotherapeutic agent pembrolizumab, to help mediate this antitumour response.
P025 Community lesion imaging clinics for tele-triage of suspected skin cancer: implementation of a low-cost model in an NHS trust
Authors: Hannah Morgan, Huw Greenish, Hafsa Faarax Shirwac, Colin Fleming, Alexander D G Anderson
Journal: British Journal of Dermatology (2024)

Abstract Across the NHS there has been a significant and sustained rise in referrals for suspected skin cancer, resulting in a capacity crisis in many NHS trusts. Teledermatology has been successfully used to triage suspected skin cancer referrals nationally, but often involves dedicated medical photographers and expensive equipment. The aim of this study was to report the initial results of tele-triage based on a low-cost community imaging lesion clinic (CLIC) service using dermatology staff and readily available equipment. CLICs were provided in a community hospital setting and staffed by band 3 healthcare assistants. A structured questionnaire was completed and data entered directly into a cloud-based software platform (Islacare, London, UK) using an iPad. The same iPad was used to capture a localizing shot, a close-up macro shot using a readily available clip-on macro lens and a dermoscopic image using a Dermlite DL4. Patients under 18 years of age, those referred with more than three lesions, and patients with genital lesions were excluded. Referral letters, questionnaire data and images were reviewed by a senior dermatologist within 48 h on the Isla platform. In total, 438 patients were reviewed (489 lesions) between August and November 2023. The male-to-female ratio was 1.08, with a median age of 72 years (interquartile range 62–80). Overall, 122 of 438 patients (27.9%) were discharged directly from triage, with advice returned to the referrer. An additional 91 of 438 (20.8%) were identified as suitable for direct listing for biopsy or simple excision. Four of 438 (0.9%) were referred to another specialty following triage, one of 438 (0.2%) had a delayed face-to-face assessment organized, one of 438 (0.2%) declined to participate in tele-triage and requested a face-to-face appointment, one of 438 (0.2%) experienced technical problems, and in one of 438 (0.2%) the site for review was not clear. A potential total of 218 of 438 (49.8%) face-to-face assessments were avoided. The average time for clinician review was 2 min 55 s per patient. Tele-triage using a low-cost CLIC was well tolerated, feasible and effective and resulted in a capacity increase of almost 50%. A significant proportion of patients were managed in a community setting without the need for travel to hospital. One further advantage was the creation of a consecutive series of images and metadata suitable for future study of diagnostic artificial intelligence algorithms or submission to a national dataset.
P024 Skin cancer referrals by nonmedical practitioners: a prospective observational study
Authors: Alexander D G Anderson, Sarah Carswell, Harry Heath, James Koutsis, Pascale Guitera
Journal: British Journal of Dermatology (2024)

Abstract A shortage of general practitioners (GPs) and increasing healthcare burden have led to nonmedical practitioners (NMPs) assuming new roles in many countries. It is now commonplace in the UK for nurses, paramedics and other NMPs to refer patients to secondary care. Despite this, there is little real-world information regarding clinical performance. The aim of this study was to investigate the appropriateness of skin cancer referrals made by NMPs and to compare this with referrals made by local GPs. Data were collected prospectively from patients referred to an NHS hospital dermatology department with a skin lesion of concern on the ‘2-week-wait’ pathway during a 2-month period in 2022. The profession of the referrer was ascertained from review of referral letters, from direct questioning of each patient and by contacting the GP surgery if required. Patient records and subsequent histology reports were reviewed to determine ultimate diagnosis. The proportion of patients diagnosed with skin malignancy (malignant melanoma, malignant melanoma in situ, squamous cell carcinoma, basal cell carcinoma, rare skin cancer) and in whom the dermatology clinician arranged an intervention (biopsy, excision, referral to another specialty for treatment) were recorded. In total, 753 patients were included. The overall malignancy rate was 29.3%. Overall, 668 of 753 patients (88.7%) were referred by a GP vs. 85 of 753 (11.3%) by an NMP. Seventy-two of the NMP referrals were made by 47 named individuals. The remaining 13 were made by unnamed practice nurses. Patients recalled an NMP asking for a second opinion in only 15 of 85 cases (18%) cases. Overall, 73% of NMP referrals were made by nurses, 24% by paramedics and 4% by physicians associates. Following clinic visit, 340 of 668 patients (50.9%) in the GP group and 47 of 85 (55%) in the NMP group were discharged without intervention (P = 0.45). An ultimate diagnosis of skin malignancy was made in 196 of 668 patients (29.3%) in the GP group and 25 of 85 (29%) in the NMP group (P = 0.99). Over 10% of referrals on the suspected skin cancer pathway were made by NMPs. There were no significant differences in diagnostic accuracy (number of malignancies) or referral appropriateness (referrals resulting in intervention) between NMPs and GPs. These early data suggest significant potential for NMPs to become more involved in skin lesion assessment. Further work should focus on understanding successful NMP education and supervision strategies and result in standardization and accreditation of training pathways for this increasingly important cohort of referrers.
BT41 Piloting a hospital-based teledermatology and artificial intelligence service for urgent suspected skin cancer alongside an established community-based teledermatology advice and guidance service
Authors: Helen Frow, Alistair Brown, Muhammad Waqas, Zachary Skittrall, Carolyn Charman
Journal: British Journal of Dermatology (2024)

Abstract The aim of this pilot was to assess the value of a hospital-based teledermatology hub for urgent suspected skin cancer referrals in a semirural integrated care system. The hub uses a new medical photography-led teledermoscopy service to assess both teledermatology and artificial intelligence (AI) compared with face-to-face outpatient review in clinic. The deployment and this work were funded as part of the National Health Service AI in Health and Care Award. In parallel, the existing advice and guidance (A&amp;G) service using images taken by general practice teams was promoted for all referrals other than urgent suspected skin cancer, including low-risk basal cell carcinomas and precancerous lesions. Analysis of the first 100 patients through the teledermoscopy–AI service showed that 18% of patients were diagnosed with benign lesions using the AI (and second-read dermatologist), 25% of patients required face-to-face review for diagnosis, 45% were triaged directly for a surgical procedure with a preoperative telephone call, 6% were prescribed topical therapy virtually, and 6% were discharged using images and telephone consultation without requiring treatment. Subsequent expansion of the dermatology medical photography team using both medical photographers and a trained healthcare assistant has supported extension of the teledermoscopy–AI service, with the pilot running to August 2024. Expansion to community hospital teledermoscopy hubs and extension of the urgent skin cancer service to the community diagnostic centre are changes supported by the pilot, to develop more streamlined pathways for patients with urgent suspected skin cancer. Through 2023 the community A&amp;G service also expanded from around 250 requests per month to over 400 requests per month, with maintenance of conversion rates to referral of 30%, and redirection of patients with low-risk basal cell carcinomas to community skin surgery services. Development of the new urgent suspected skin cancer virtual teledermatology–AI pathway has required administrative adaptations within the hospital electronic patient record to support patient tracking, resourcing and job planning for image review. Training of photographers has been supported by online teledermoscopy resources developed by the Institute of Medical Illustrators. Selection of appropriate patients for the teledermoscopy–AI pathway while maintaining patient choice and safety has remained central to the teledermoscopy–AI pilot.
BT35 Quality improvement project: modernizing the inpatient dermatology handover
Authors: Rishi Shah, Jenny Whitehead, Amrika Ramoutar
Journal: British Journal of Dermatology (2024)

Abstract Dermatology is unique in our region because it provides on-call services to multiple sites and different National Health Service (NHS) trusts locally. This presents a number of challenges as different NHS trusts utilize different information technology and procedural systems. This quality improvement project (QIP) aimed to find a solution to the problem of having an effective and efficient handover system for inpatients across different trusts. Prior to this QIP, the handover consisted of an email that was sent at the end of each day summarizing the inpatient cohort. This had several issues including missing details, delayed updates and not updating all of the relevant staff. The initial Plan Do Study Act (PDSA) cycle surveyed the clinical staff to assess whether there was a problem with the current handover and potential solutions that could be considered. The results showed that the team were dissatisfied with the current handover and the majority utilized the on-call service to find out about the inpatients. Of the available solutions, the majority of staff wanted to explore an online solution via Microsoft Teams. The main challenge with the proposed handover on Teams was maintaining patient confidentiality given the sensitivity of the data being held. This was reviewed with the clinical governance team and a data protection impact assessment was carried out and approved. A Teams group and handover file were then created. The feedback highlighted that the handover template needed optimization, resulting in a second PDSA cycle. Senior colleagues approved a suitable template that was then trialled on the Teams group for handover. The survey results showed a significant improvement in the content, accessibility, usability and means of handover. The main issue identified was that some staff did not know how to access the Teams group to view the handover. This was remedied with the creation of a standard operating procedure, which provided instructions on how to access and use the new handover. This QIP with two PDSA cycles provided a number of advantages such as the ability of the handover to be accessible to a predefined group of people from any site or trust, and that it can be updated in real time. It can also be utilized and updated during virtual board rounds. Most importantly, this change has created an effective and efficient means of handover, as is reflected in the results of the postintervention survey.
BT39 Teledermatology assessment of community skin lesion referrals: insights, challenges and recommendations
Authors: Vivienne Nguyen, Ruth Jones, Girish Gupta
Journal: British Journal of Dermatology (2024)

Abstract Consultations for skin lesions rank are a very common reason for general practitioner (GP) visits, with the urgent suspicion of cancer (USOC) referral pathway directing potentially cancerous lesions to dermatologists in our region. Despite the valuable role of clinical photographs alongside referrals, the variable quality poses a significant challenge. From March to April 2023, 100 GP referrals containing photos in our USOC pathway underwent analysis by two independent consultant dermatologists. They provided their top three diagnoses with free-text comments on image quality. Notably, prevalent image comments included ‘out of focus (60%)’ and ‘poor illumination’ (55%). Dermoscopy images were included in 15 community photos. Consultant 1 (G.G.) identified seborrhoeic keratosis as the primary diagnosis in 32%, while consultant 2 (R.J.) noted it as the top diagnosis in 34%. Consultant 1 included the GP’s diagnosis in their top three differentials 40% of the time, while consultant 2 did so 30% of the time. Existing guidance on teledermatology image quality is limited but emphasizes clear, well-lit photos with proper focus, taken from various angles and distances. Despite this, our data reveal a noticeable deviation from these practices. We propose that possible contributory factors leading to poor-quality images include time constraints during GP consultations, lack of awareness regarding guidance, and the use of devices with suboptimal image resolution. Notably, there are no local specific guidelines for community photos in our area. Based on our findings, we have created a local guideline, emphasizing the need for clear, focused images where the lesion is centrally framed, utilizing natural sunlight ideally at an angle to highlight skin texture. Additionally, an enlarged photo is recommended, balancing size with the maintenance of focus on the area of interest. Teledermatology provides broader access to expert advice, facilitates timely consultations, improves efficiency, and encourages global collaboration. However, the heterogeneity in photos can lead to misdiagnosis, inappropriate triage, and inefficient resource allocation. The implementation of guidance for referral photos can optimize resource use, enhance patient satisfaction, and streamline workflow.
P023 Real-world melanoma miss rate in an NHS hospital dermatology service
Authors: Hafsa Faarax Shirwac, Hannah Morgan, Huw Greenish, Sarah Carswell, Harry Heath, James Koutsis, Pascale Guitera, Alexander D G Anderson
Journal: British Journal of Dermatology (2024)

Abstract The aim of this retrospective study was to assess the ‘miss rate’ of dermatology clinicians for detecting malignant melanoma among patients referred on the 2-week-wait skin cancer pathway over a 2-year period. We reviewed patient records from the previous 5 years to identify instances where malignant melanoma might have been misdiagnosed. Malignant melanoma can be missed at various stages of the patient’s journey, leading to delayed diagnosis and potentially serious consequences. Our geographically isolated rural county relies exclusively on a single NHS dermatology department for 2-week-wait skin cancer services, providing a unique opportunity to assess the incidence of missed melanoma. We used a regional cancer registry to identify all primary invasive malignant melanomas (ICD-10 C43) diagnosed between August 2020 and July 2022. Records of any patient who had attended the dermatology department within the 5 years preceding diagnosis were reviewed to identify patients where melanoma might have been previously misdiagnosed. In total, 432 primary melanomas were identified. The male-to-female ratio was 202 : 230 and the median age was 71 years (interquartile range 57–79). Stage at presentation was IA (176, 40.7%), IB (98, 22.7%), II (134, 31.0%), III (19, 4.4%) and IV (5, 1.2%). Nine patients (2.1%) had been given an erroneous benign diagnosis for the same lesion and discharged within 13 months of diagnosis (missed melanoma). The stages of the missed melanomas were IA (two patients), IB (four patients) and II (three patients). In a further four cases (0.9%) the melanoma had prompted action, but the diagnosis was delayed; one had an erroneous negative biopsy, one missed an urgent review, one lesion was monitored, leading to a 6-month delay in diagnosis, and one was incorrectly diagnosed as a basal cell carcinoma, leading to a delay in surgery. A final four (0.9%) cases were diagnosed as benign more than 2 years prior to melanoma diagnosis. These were classified as ‘possible’ misses, as they could have evolved into malignant melanomas in the interim period. Our study reveals a low yet quantifiable melanoma miss rate in a high-volume NHS dermatology service. Future multicentre studies with large datasets are required, to identify risk factors for misdiagnosis. Clinicians managing skin lesion clinics may consider melanoma miss rate as a key performance metric. Strategies to improve the accuracy of this important metric might include the use of prospective databases incorporating digital images of lesions suspected to be benign. The utility of this approach should be investigated further.
BT38 Patient satisfaction of teledermoscopy service in a UK university health board: a service evaluation
Authors: Anna Hughes, Rachel Abbott
Journal: British Journal of Dermatology (2024)

Abstract Around 20 000 teledermatology referrals are reviewed by dermatology consultants in our UK university health board each year, including urgent suspected cancer referrals. More recently, an additional ‘teledermoscopy service’ was introduced so that dermatology consultants can request dermoscopy photos – in addition to standard clinical photos – for remote review. With the rising incidence of skin cancer in the UK, and a backlog of referrals created by the COVID-19 pandemic, the demand for access to dermatological care heightens the need for teledermatology services, including teledermoscopy. This service evaluation sought to evaluate the patient satisfaction of the new teledermoscopy service. Over 3 weeks, patient satisfaction of the teledermoscopy service was assessed via a 14-question survey that was developed and piloted in a neighbouring health board. The survey was offered to patients after their appointment in the medical illustration teledermoscopy clinic. Waiting times, hospital accessibility, preappointment information and appointment experience were evaluated using Likert scaling, a five-point scale using the terms; ‘strongly agree’, ‘agree’, ‘don’t know’, ‘disagree’ and ‘strongly disagree’. Overall experience was assessed on a scale of 1–10, and the final question of the survey allowed for free writing of any comments the participants had. In total, 100 patients (mean age 55 years, range 16–90; 42% male) responded to the survey. Overall, 84 of 100 respondents replied to the question asking them to rate their overall experience from 1 to 10: 83 of 84 (99%) rated the service ≥ 8 out of 10, and 62 of 84 (74%) respondents rated the service 10 out of 10. With regards to patient experiences of the appointment, the responses were very positive: 98 of 100 respondents (98%) ‘agreed’ or ‘strongly agreed’ that the procedure was clearly explained to them, and 99% of respondents ‘agreed’ or ‘strongly agreed’ that the photographer acted professionally, and the photographic environment was appropriate. Contrastingly, the responses regarding the preappointment information were less positive: 35 of 99 patients (35%) ‘disagreed’ or ‘strongly disagreed’ that they were given sufficient information about the teledermatology service prior to their appointment. Importantly, 9 of the 100 (9%) reported that they thought their appointment was to see a dermatologist, not a medical photographer. In total, 85 of 100 patients (85%) agreed that the hospital was easy to attend, while 6 of the 100 (6%) expressed a preference for a closer hospital. Finally, 18 of the 100 respondents answered the open-ended ‘further comments’ question. The written feedback provided was mostly positive. The majority of patients were highly satisfied with the teledermoscopy service; however, over one-third felt that more information was needed prior to their appointment.