To the Editor:
Dermatologists sometimes are consulted in the inpatient setting to rule out possible skin cancer. This scenario provides an opportunity to facilitate the diagnosis and treatment of cutaneous malignancy, often in patients who might not have sought regular outpatient dermatology care. Few studies have described the outcomes of inpatient biopsies to identify skin cancer.1,2
Seeking to better understand the nature of these patient encounters, we reviewed all consultations at a medical center for which the referring physician suspected skin cancer rather than only those lesions that were biopsied by the dermatologist. We also collected data about subsequent treatment to better understand the outcomes of these patient encounters.
We conducted a retrospective review of inpatient dermatology referrals at an academic-affiliated tertiary medical center. We identified all patients who were provided with an inpatient dermatology consultation for suspected skin cancer or what was identified as a “skin lesion” between July 1, 2013, and July 1, 2019. We collected information on each patient’s sex, age at time of consultation, and race, as well as the specialty of the referring provider, lesion location, maximum diameter of the lesion, whether a biopsy was performed, where the biopsy was performed (inpatient or outpatient setting), clinical diagnosis, histopathologic diagnosis, and subsequent treatment.
The institutional review board at Eastern Virginia Medical School (Norfolk, Virginia) approved this study, and all protocol conformed to the ethical guidelines of the Declaration of Helsinki.
Thirty-eight patients met the inclusion criteria. Their characteristics are listed in the Table. Consultations for possible skin cancer accounted for 4% (38/950) of all inpatient dermatology consultations over the study period. Outcomes of the referrals are shown in the Figure. Consultations were received from 12 different physician specialties.
In the 38 patients, 47 lesions were identified; most (66% [31/47]) were on the head and neck. Twenty of 38 patients were found to have at least 1 biopsy-confirmed cutaneous malignancy (23 total tumors). Of those 23 identified malignancies, 10 were basal cell carcinoma, 11 squamous cell carcinoma, 1 malignant melanoma, and 1 anaplastic T-cell lymphoma. Of note, 17 of 23 (74%) identified cutaneous malignancies were 2.0 cm in diameter at biopsy or larger. Subsequently performed treatments for these patients included wide local excision (n=3), Mohs micrographic surgery (n=5), radiation therapy (n=3), topical fluorouracil (n=1), electrodesiccation and curettage (n=4), and chemotherapy or immunotherapy (n=2). Two patients who were diagnosed with skin cancer died of unrelated causes before treatment was completed.
In 10 of 38 patients, only nonmalignant entities were diagnosed, including seborrheic keratosis (n=6), benign melanocytic nevus (n=1), epidermal inclusion cyst (n=1), actinic keratosis (n=1), and radiation-induced necrosis (n=1). Of the 8 remaining patients, 4 were ultimately lost to follow-up before planned outpatient biopsy could be completed; 1 opted to follow up for biopsy at an unaffiliated outpatient dermatology provider. For 2 patients, the decision was made to forgo biopsy despite clinical suspicion of skin cancer because of overall poor health status, and 1 additional patient died before a planned outpatient biopsy could be performed.