Prebiopsy Photos Help Prevent Wrong-Site Surgery

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness