Dermatological Surgery

154 views 2 04/16/2020 05/09/2020

  1. Clinics should be triaged to review only urgent patients in person, and using telemedicine where possible.
  2. Consider cancelling all elective surgeries. 
  3. To minimize COVID-19 spread during office-based excisional surgery: 
    • All surgical patients should be considered as potentially COVID-19 positive. 
    • Smoke extractor systems are the most effective way to minimise risk. Using bipolar diathermy rather than hyfrecation is suggested. 
    • Use N95 masks and face shields for periorofacial surgery. 
    • Reduce to minimum the number of healthcare professionals required for the procedure. 
    • Use dissolving sutures to minimize multiple presentations.
  4. The following table shows suggestions for management of skin cancer: 
Benign lesions  Defer for now. 

** Procedures which alleviate significant morbidity (eg incision and drainage of hidradenitis suppurativa abscesses)  should be pursued as soon as feasible 
Basal cell carcinoma Superficial : defer treatment for 6 months

All other: defer surgery for 3-6 months 
Squamous cell carcinoma (SCC) Actinic keratosis and SCC-in-situ : defer for now 

SCC: prioritise these tumors: rapidly-enlarging, poorly-differentiated, perineural, ulcerated and symptomatic, immunosuppression.
Merkel cell carcinoma Should not be deferred:

  • Office-based wide local excision may be undertaken with deferral of sentinel lymph node biopsy if OR are unavailable.
  • Management of patients with clinical stage III should be discussed with a multidisciplinary team : definitive resection of the primary  with complete lymphadenectomy versus immunotherapy.
Melanoma  Diagnostic biopsy: 

  • Attempt excisional/complete biopsy with 2 mm border when melanoma suspected with intent to remove the clinical lesion. 
  • Broad shave biopsy for larger suspected melanoma in situ and lentigo maligna type lesions. 

Wide excision of in situ and invasive melanoma: 

  • Melanoma-in-situ and T1: defer treatment for 2-3 months even for positive margin on biopsy.
  • Invasive melanoma: if histological clearance obtained, defer wide excision and/or sentinel lymph node biopsy for 3 months.
  • Surgical management of T3/T4 melanomas should be prioritized over T1/T2 melanomas.

These recommendations come from documents produced by the British Association of Dermatologists and British Society of Dermatological Surgery, and the National Comprehensive Cancer Network on melanoma and non-melanoma skin cancer management. Der Sarkissian et al and Geskin et al propose perspectives for management of dermatologic surgery during the COVID-19 outbreak.

 

Sources: 

  1. British Association of Dermatologists and British Society of Dermatological Surgery. Clinical Guidance for the Management of Skin Cancer Patients During the Coronavirus Pandemic. Retrieved from https://www.bsds.org.uk/
  2. Der Sarkissian SA, Kim L, Veness M. et al. (2020, April 10) Recommendations on dermatologic surgery during the COVID-19 pandemic, Journal of the American Academy of Dermatology, https://doi.org/10.1016/j.jaad.2020.04.034.
  3. Geskin LJ., Trgaer MH., Aasi SZ., et al (May 1, 2020) Perspectives on the Recommendations for Skin Cancer Management During the COVID-19 Pandemic, Journal of American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2020.05.002 
  4. National Comprehensive Cancer Network. (April 22, 2020) Advisory Statement for Non-Melanoma Skin Cancer Care During the COVID-19 Pandemic. Retrieved from https://www.nccn.org/covid-19/default.aspx
  5. National Comprehensive Cancer Network. Short-Term Recommendation for Cutaneous Melanoma Management During COVID-19 Pandemic. Retrieved from https://www.nccn.org/covid-19/default.aspx
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