Dr. Phillip P. Williford

"It's a better system than the old one in many, many ways," says Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery at Wake Forest University School of Medicine, Winston-Salem, NC."It defines more accurately those prognostic factors that were shown in large studies to be important."The new system also holds importance for clinical research.Previously, staging might not have allowed accurate comparisons between studies."It's difficult to historically look at trials and make much of them because the staging system was so different," says Dr. Williford.
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"There is pretty clear data from large studies involving tens of thousands of patients," says Dr. Williford, "that ulceration, as an independent prognostic factor, has a great deal of power in predicting how people do." In fact, beyond T1 lesions (those greater than 1 mm in thickness), "ulceration probably has the most predictive power â€" more predictive power than Breslow's depth," Dr. Williford says.It also has predictive power with nodal disease, Dr. Williford says he believes.Patients with ulceration and lymph node disease, he says, do worse than those with lymph node disease and no ulceration.He regards nodal disease with ulceration as a "far worse animal" than nodal disease with no ulceration.
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diagnostic and prognostic workups, says Dr. Williford.Clinical staging, says the sixth edition, includes microstaging of the primary melanoma and clinical/radiological evaluation for metastases.Pathologic staging includes microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy.One implication of having clinical and pathologic systems is that a sentinel node biopsy might place a patient into a worse category, reflecting a more accurate real-world assessment of disease.For instance, consider a patient, age 49, with a cutaneous lesion 1.1-mm depth on his right arm who has no clinical evidence of metastatic or node disease.A sentinel node biopsy reveals microscopic involvement in two nodes. For this patient, the clinical stage would be the same but the pathologic stage would be significantly different, says Dr. Williford.What's more, two groups of these two different types of patients would reveal substantially different outcomes â€" those with microscopic disease would fare much worse.

Thickness Instead of Level of Invasion Both Breslow's depth and Clark's level, says Dr. Williford, arose out of an attempt to develop prognostic clues for how patients would fare with presentations of melanoma.
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"Most pathologists would readily admit that the reproducibility of a Breslow's depth far exceeds the reproducibility of a Clark's level," according to Dr. Williford."It's fairly clear," says Dr. Williford, "that the Breslow's depth overall is a much more powerful indicator of prognosis than is the Clark's level."An overwhelming majority of studies show that adding Clark's level to Breslow's depth "adds little or nothing to the prognostic information."Note, however, that Clark's level still pertains to the T1 group of lesions.After that, Clark's level doesn't contribute to the prognostic model.Dr. Williford suggests that some would find this an anachronism that should be eliminated.
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Dr. Williford says he's not aware of one study that shows that size of a lymph node is important in how patients fare, while many studies show that the number of lymph nodes is important.
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• The new system, says Dr. Williford, acknowledges that, as with most solid tissue tumors, the finding of cancer in a lymph node system or equivalent is a poor prognostic sign.The system thus allows clinicians to better stage patients who heretofore clinically would have been staged as having not that serious a disease.This allows sentinel node biopsy to substantially improve the ability to stage patients, define a prognosis, and put them in various treatment groups to see if the physician can find a treatment to improve overall outcome.• If your patient's melanoma thickness is 1.0 mm or greater, discuss with him or her possible referral for a sentinel node biopsy for prognostic reasons, Dr. Williford says.• For patients who have a defined risk of nodal disease, make sure to refer the patient for lymphatic mapping at 1-mm depth, Dr. Reintgen notes. • Don't lump all Stage III patients into one basket of poor prognosis, notes Dr. Williford.
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But Dr. Williford holds that ulceration isn't extremely well-defined.In his view, ulceration should involve full thickness loss of epidermis and dermis.Among pathologists, he feels there needs to be a better definition of what constitutes a histopathologic diagnosis of ulceration.Some pathologists mistakenly classify erosions as ulcers, he suggests.

Sun damage is the major precursor to skin cancer and the prevalence of pre-cancerous lesions, known as actinic keratoses, increases with age and years and years of sun exposure, according to co-author Phillip P. Williford, MD, a dermatologic surgeon at Wake Forest University School of Medicine.AK accounts for about four and one-half million physician visits a year.The purpose of the research was to examine its association with skin cancer in an elderly population.

"Although individual AK lesions do not uniformly develop into skin cancer, the presence of AK significantly increases the risk of skin cancer, including melanoma," said Dr. Williford."This elevated risk was unmatched by any other variable we analyzed and, overall, older white males with AK seem to be at very high risk."

Dr. Williford said elderly men and women should seek medical advice at the first sign of skin lesions on areas of the body that get the most sun exposure, or if they spot changes in the look or size of moles.He added that AK lesions can vary in appearance but in advanced stages they usually develop a crusty scale.

Zoe Diana Draelos, M.D., clinical associate professor of dermatology, Wake Forest School of Medicine, Winston-Salem, N.C., and Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery, Wake Forest University School of Medicine, discuss the treatment of nonmelanoma skin cancer by dermatologists and other physician specialties.

Interferon started as a great hope for melanoma patients with advanced disease, said Phillip Williford, M.D., a dermatologist and associate professor at Wake Forest University School of Medicine.

"There is no doubt that interferon makes an impact, but the impact is small," he said.

Don't fret too much, said Dr. Phillip Williford, a dermatologist at Wake Forest University Baptist Medical Center who specializes in skin cancers.

Phillip Williford, M.D.Dermatologic Surgery9th Floor Clinical Science TowerMedical Center BoulevardWinston-Salem, NC 27156

Dr. Phillip Williford, a dermatologist at Wake Forest University Baptist Medical Center says, "If you're looking for a sunscreen that's going to give you good blockage of UVA, again that's the one that's going to cause pigment changes and wrinkling and the things that we don't like about aging, you want to look for zinc oxide, titanium dioxide or a product that's called parsol and another name for it is called avobenzone.

Dr. Phillip Williford, a dermatologist at Wake Forest University Baptist Medical Center says, "For years now, the American Academy of Dermatology has sponsored a screening, the idea is if we can see people with early pigmented lesions, catch those lesions early, and do the appropriate therapy, cut them out, then we can save lives."

Doctors at Wake Forest Baptist are offering a free screening this afternoon.