UK guidelines for the management of cutaneous melanoma

Immunotherapy Options for Acral Melanoma, A fast-growing but Neglected Malignancy

Melanoma is the deadliest form of skin cancer. It is classified as cutaneous and non-cutaneous, with the former characterized by developing in sun-exposed areas of the skin, UV-light radiation being its most important risk factor and ordinarily affecting fair skin populations. In recent years, the incidence of melanoma has been increasing in populations with darker complexion, for example, Hispanics, in which acral melanoma is highly prevalent. The WHO estimates that the incidence and mortality of melanoma will increase by more than 60% by 2040, particularly in low/medium income countries. Acral melanoma appears in the palms, soles and nails, and because of these occult locations, it is often considered different from other cutaneous melanomas even though it also originates in the skin. Acral melanoma is very rare in Caucasian populations and is often not included from genetic analysis and clinical trials. In this review, we present the worldwide epidemiology of acral melanoma; we summarize its genetic characterization and point out important signaling pathways for targeted therapy. We also discuss how genetic analyses have shown that acral melanoma carries a sufficient mutational load and neoantigen formation to be targeted by the immune system, arguing for a potential benefit with novel immunotherapeutic strategies, alone or combined with targeted therapy. This is important because chemotherapy remains the first-line treatment in non-developed nations despite a disheartening response. In summary, the increased incidence and mortality of acral melanoma in low/medium income countries calls for increasing our knowledge about its nature and therapeutic options and leveling off the asymmetric research conducted primarily on Caucasian populations.

Excision Margins for Melanoma In Situ on the Head and Neck

BACKGROUND

Complete surgical excision of melanoma in situ (MIS) is curative. A 5-mm margin is often taken as the standard primary excision margin despite increasing evidence that this is frequently inadequate for tumor clearance.

OBJECTIVE

To calculate the proportion of patients requiring >5 mm margin for clearance and to investigate any patient/lesion characteristics necessitating larger margins.

MATERIALS AND METHODS

Three hundred forty-three primary MIS cases on the head and neck treated in the authors' department by Mohs micrographic surgery (MMS) over a 65-month period were retrospectively analyzed. Records were made of patient and lesion characteristics, and the total surgical margin for clearance calculated.

RESULTS

Sixty-five percent were cleared by a 5-mm margin; for a 97% clearance rate, 15 mm was necessary. The increased clearance with additional margin was significant (p < .0001). Patient age, lesion site, and preoperative size did not predict margin.

CONCLUSION

These results verify that MIS on the head and neck can spread significantly beyond the clinical margin and demonstrate the importance of confirming clearance histologically before closure procedures. Mohs micrographic surgery has the advantage of total margin evaluation and where available it may be reasonable to start with a 5-mm margin. Where MMS is not a treatment option, the authors would advocate larger excision margins of ≥10 mm.

Synchronous metastatic omental melanoma and colonic adenocarcinoma: a case report

Background

Malignant melanoma is a rare malignancy of the skin with very high mortality rates. Distal metastases are common especially to other areas of the skin, subcutaneous tissues lungs or liver. There are no previously reported cases of skin melanoma metastasizing to the omentum.

Case presentation

A 62 year-old white British man with a past medical history of a malignant melanoma of the skin underwent a laparotomy for a partially obstructing sigmoid tumour. Intra-operatively, a round, smooth textured black lesion was identified on the anterior surface of the omentum; the nodule was confirmed to be a metastatic malignant melanoma with abundant brown pigment and a focal necrotic area.

Conclusion

A metastatic malignant melanoma was discovered incidentally on the omentum during a laparotomy for bowel obstruction. The significance of this is unclear but it is possible that the omentum may have played a protective role in limiting its spread systemically.

Melanoma of the Hand: Current Practice and New Frontiers

Melanoma of the hand represents a complicated clinical entity. Anatomic features of the hand create challenges in successful management of melanoma not encountered elsewhere in the body. The objectives of this article are to outline current standards for managing melanoma of the hand including diagnosis, surgical, and chemotherapeutic management. Particular emphasis will be placed on currently debated topics of the role of sentinel lymph node biopsy, the role of Mohs micrographic surgery, tissue sparing management of subungual melanoma, and the consideration of melanoma of the hand as a distinct entity based on clinical and molecular studies.

Current status of diagnostic and prognostic markers in melanoma

Melanoma is the most life-threatening common form of skin cancer. While most cutaneous melanomas are cured by surgical resection, a minority will relapse locally, regionally, or distantly. Biomarkers have represented a focal point for research aimed at improving diagnostic accuracy as well as providing prognostic information that may help to guide therapeutic decisions. While systemic melanoma therapies were of extremely limited utility for patients with advanced disease in the past, two drugs have been approved the FDA within the past several years, and it is possible that they may provide even greater impact if employed earlier in the disease process. To optimally employ these therapies, prognostic biomarkers may offer significant value. This article reviews methodologies for both discovery and routine testing of melanoma biomarkers. It also focuses on specific commonly used markers, as well as approaches to studying their applications to specific clinical settings. As the armamentarium of melanoma drugs grows, it is hoped that specific biomarkers will aid in guiding the use of these agents for patients in the clinic.

Accuracy of diagnostic biopsy for cutaneous melanoma: implications for surgical oncologists

BACKGROUND AND OBJECTIVES

While excisional biopsy is recommended to diagnose cutaneous melanoma, various biopsy techniques are used in practice. We undertook this study to identify how frequently final tumor stage and treatment recommendations changed from diagnostic biopsy to final histopathology after wide local excision (WLE).

METHODS

We compared the histopathology of the dermatopathologist-reviewed diagnostic biopsy and final WLE in 332 cutaneous melanoma patients.

RESULTS

Tumor sites were extremity (51%), trunk (33%), and head/neck (16%). Initial biopsy types were excisional (56%), punch (21%), shave (18%), and incisional (5%). Most diagnostic biopsies were margin positive regardless of technique, and 36% of patients had residual melanoma on WLE. T-stage changed in 8% of patients, of whom 59% were diagnosed by punch biopsy, 15% by incisional biopsy, 15% by shave biopsy, and 11% by excisional biopsy (P < 0.0001). Treatment recommendations changed in 6%: 2% after excisional biopsy, 5% after shave biopsy, 18% after punch biopsy, and 18% after incisional biopsy (P < 0.0001).

CONCLUSIONS

Although most biopsy margins were positive, T-stage and treatment changed for only a minority of melanoma patients. Our data provide valuable information to inform patient discussion regarding the likelihood of a change in prognosis and the need for secondary procedures after WLE. These data support the superiority of dermatopathologist-reviewed excisional biopsy when feasible.

Diagnosis of ocular surface lesions using ultra-high-resolution optical coherence tomography

PURPOSE

To assess the use of ultra-high-resolution (UHR) optical coherence tomography (OCT) in the diagnosis of ocular surface lesions.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

Fifty-four eyes of 53 consecutive patients with biopsy-proven ocular surface lesions: 8 primary acquired melanosis lesions, 5 amelanotic melanoma lesions, 2 nevi, 19 ocular surface squamous neoplasia lesions, 1 histiocytosis lesion, 6 conjunctival lymphoma lesions, 2 conjunctival amyloidosis lesions, and 11 pterygia lesions.

INTERVENTION

Ultra-high-resolution OCT imaging of the ocular surface lesions.

MAIN OUTCOME MEASURES

Clinical course and photographs, UHR OCT image, and histopathologic findings.

RESULTS

Ultra-high-resolution OCT images of all examined ocular surface lesions showed close correlation with the obtained histopathologic specimens. When clinical differential diagnosis of ocular surface lesions was broad, UHR OCT images provided optical signs indicating a more specific diagnosis and management. In cases of amelanotic melanoma, conjunctival amyloidosis, and primary histiocytosis and in 1 case of ocular surface squamous neoplasia, UHR OCT was instrumental in guiding the diagnosis. In those cases, UHR OCT suggested that the presumed clinical diagnosis was incorrect and favored a diagnosis that later was confirmed by histopathologic examination.

CONCLUSIONS

Correlations between UHR OCT and histopathologic findings confirm that UHR OCT is an adjunctive diagnostic method that can provide a noninvasive means to help guide diagnosis and management of ocular surface lesions.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Follicular hyperplasia -- a rare differential to metastatic malignant melanoma

The assumption in a patient with a history of melanoma is that any subsequent lymphadenopathy is metastatic disease. We present a case where a seemingly obvious case of metastatic malignant melanoma proved to be Reactive Follicular Hyperplasia, illustrating it is important to be aware of all differential diagnoses, even when a cause appears obvious.

Plasma markers for identifying patients with metastatic melanoma

PURPOSE

With the rising incidence of melanoma, more patients are undergoing surveillance for disease recurrence. Our purpose was to study levels of proteins that might be secreted in the blood of patients with metastatic melanoma that can be used for monitoring these individuals.

METHODS

Genome-wide gene expression data were used to identify abundantly expressed genes in melanoma cells that encode for proteins likely to be present in the blood of cancer patients, based on high expression levels in tumors. ELISA assays were employed to measure proteins in plasma of 216 individuals; 108 metastatic melanoma patients and 108 age- and gender-matched patients with resected stage I/II disease split into equal-sized training and test cohorts.

RESULTS

Levels of seven markers, CEACAM (carcinoembryonic antigen-related cell adhesion molecule), ICAM-1 (intercellular adhesion molecule 1), osteopontin, MIA (melanoma inhibitory activity), GDF-15 (growth differentiation factor 15), TIMP-1 (tissue inhibitor of metalloproteinase 1), and S100B, were higher in patients with unresected stage IV disease than in patients with resected stage I/II disease. About 81% of the stage I/II patients in the training set had no marker elevation, whereas 69% of the stage IV patients had elevation of at least one marker (P < 0.0001). Receiver operating characteristic curves for the markers in combination in these two patient populations had an area under curve (AUC) of 0.79 in the training set and 0.8 in the test set. A CART (Classification and Regression Trees) model developed in the training set further improved the AUC in the test set to 0.898.

CONCLUSIONS

Plasma markers, particularly when assessed in combination, can be used to monitor patients for disease recurrence and can compliment currently used lactate dehydrogenase and imaging studies; prospective validation is warranted.

Continuous local analgesic therapy reduces pain after radical inguinal/iliacal lymph node dissection

BACKGROUND

To optimize postoperative pain therapy after a radical inguinal/iliacal lymph node dissection (RILND), we investigated the influence of a continuous application of a local anaesthetic via a subfascial wound catheter in the abdominal wall in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Between July 2007 and December 2009, 50 patients with stage III/IV of melanoma disease received, in an observational study, a systemic analgesic therapy. Of these patients, 30 were additionally treated with a subfascial catheter. Main outcome criterion was the pain under mobilisation at the first postoperative morning registered via a visual analogue score. Minor criteria were the analgesic requirement, the specific (surgical) complications and the day of discharge.

RESULTS

Patients treated with the subfascial catheter had significant less pain at the first postoperative morning in rest (p = 0.02) and after mobilisation (p = 0.03) without increased morbidity (p = 0.45). Less patients of the treatment group needed a supplementary analgesic medication (p = 0.01) and were able to leave hospital earlier than patients of the control group (p = 0.01).

CONCLUSIONS

A subfascially placed pain catheter enhances postoperative pain therapy after RILND.

Melanoma staging: facts and controversies

The value of staging examinations remains controversial for the initial staging in melanoma patients at the time of the primary diagnosis and for surveillance. Issues concerning tumor recurrences and progression must be discussed separately for different risk groups. For low-risk patients (stage IA; tumor thickness less than 1 mm), staging examinations like sentinel lymph node biopsy (SLNB), blood tests, or imaging can generally be abandoned. Baseline staging with simple techniques is at the discretion of the physician. In intermediate-risk patients (stages IB and IIA), an initial staging examination involving SLNB and computed tomography (CT) scans is recommended. Further follow-up may be restricted to physical examinations, blood tests of tumor marker protein S100beta, and to lymph node ultrasonography. If findings are suspicious, further imaging procedures may be involved. In high-risk patients (stages IIB to III), an initial staging examination with CT is recommended, and regular follow-up every 6 months with whole body imaging by CT or magnetic resonance imaging seems useful. Physical examinations, blood tests of tumor marker protein S100beta, and lymph node ultrasound imaging should be routine. This intense follow-up may enable surgical treatments with complete removal of all recognizable metastases in about 15% to 25% of patients and improve their prognosis. The risk of recurrence or tumor progression is very high in stage IV patients, and their management is individualized.

Development of a practical guide for the early recognition for malignant melanoma of the foot and nail unit

Background

Malignant melanoma is a rare but potentially lethal form of cancer which may arise on the foot. Evidence suggests that due to misdiagnosis and later recognition, foot melanoma has a poorer prognosis than cutaneous melanoma elsewhere.

Methods

A panel of experts representing podiatry and dermatologists with a special interest in skin oncology was assembled to review the literature and clinical evidence to develop a clinical guide for the early recognition of plantar and nail unit melanoma.

Results

A systematic review of the literature revealed little high quality data to inform the guide. However a significant number of case reports and series were available for analysis. From these, the salient features were collated and summarised into the guide. Based on these features a new acronym "CUBED" for foot melanoma was drafted and incorporated in the guide.

Conclusions

The use of this guide may help clinicians in their assessment of suspicious lesions on the foot (including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for expert assessment and definitive diagnosis. The guide is currently being field tested amongst practitioners.

Whole body positron emission tomography in follow-up of high risk melanoma

The aim of this study was to determine the clinical impact of whole body positron emission tomography (FDG PET) to detect clinically silent metastases in the follow-up of patients with high risk melanoma. FDG PET was performed to 30 asymptomatic melanoma patients (AJCC stage IIB-IIIC) 7-24 months after the primary surgery and sentinel node biopsy. FDG PET was able to detect six of seven recurrences, constituting 20% of all study patients. One patient presented with a negative FDG PET finding at the very first scanning, but was positive later in a repeated scan after manifestation of palpable mass in the axilla. The positive PET finding had an impact on treatment decisions in every case: three patients underwent surgical resection and four patients received chemotherapy or interferon. The mean follow-up time was 27 months (range, 12-48 months) and during that time the other 23 patients with true negative FDG PET were disease-free. One of the seven recurrences was in remission after surgical metastasectomy. In conclusion, whole body FDG PET is a valuable follow-up tool in high risk melanoma to diagnose recurrences and to select the patients, who are suitable for surgical metastasectomy.

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.

Follow-up care for young adult survivors of cancer: lessons from pediatrics

INTRODUCTION

Recent advances in treatment of childhood cancer have resulted in overall survival rates approaching 75%, but approximately two-thirds experience late-effects related to the disease or treatment. Consequently, recommendations for comprehensive follow-up have been made. As the number of survivors of adult cancers increase, similar concerns about how to provide follow-up and achieve optimal quality of life are being raised. In this paper we propose that management of cancer survivors diagnosed in young adulthood (18-45 years) could benefit from experience gained treating survivors of childhood cancer.

MATERIALS AND METHODS

We reviewed research relating to differences in survival rates and late-effects; current arrangements for follow-up; effectiveness; and problems in organization of follow-up separately for survivors of child and adult cancers.

RESULTS

A number of models of follow-up were identified. Rationale for follow-up included early identification and treatment of second cancer and late-effects, health promotion and screening. Increasing numbers of survivors and range of late-effects were identified as problems in organizing services. A possible solution is risk-stratified follow-up, currently being developed in pediatrics.

CONCLUSIONS

New models of follow-up are needed that take account of financial costs for health services and survivors' concerns about their current and future health. Implications for continuing refinement of treatment protocols must be an integral part of the service.

IMPLICATIONS FOR CANCER SURVIVORS

International standards are needed to ensure all survivors have access to expert follow-up care and can benefit from new information that might lead to earlier treatment of late-effects.

Current clinical overview of cutaneous melanoma

This article reviews current evidence on epidemiology, diagnosis and management of cutaneous melanoma. Incidence of cutaneous melanoma is rising in all Caucasian populations across the world; thus, melanoma represents a significant public health burden. Although, incidence of melanoma is in continuous increase, a decrease of mortality and improved survival has been observed in most western European populations. Clinical characteristics of four major types of melanoma (superficial spreading, nodular, lentigo maligna melanoma and acral lentiginous melanoma) have been described. Surgical removal of melanoma remains the standard care in all primary melanomas. Current evidence suggests use of 1 to 2 cm excision margins. Wider margins may be necessary in patients with thicker melanomas with higher risk for local recurrence. In the treatment of regional lymph nodes elective lymphadenectomy has been surpassed by the sentinel lymph node biopsy (SLNB). However, although prognostic value of SLNB has been confirmed, its therapeutical benefit still needs to be evaluated. Currently there is no standard adjuvant therapy for melanoma although interferon-alpha has been the most widely used treatment in the adjuvant setting. The role of metastasectomy (removal of distant metastases) is still controversial. Chemotherapeutic agents have a limited activity in patients with metastatic melanoma with response rates up to 25%. Although different vaccines have been tested in melanoma patients their role still remain to be established in phase III trials. Progresses in molecular biology and genetics of melanoma may lead to the development of novel melanoma therapies.

Differentiation of Melanoma from Non-Cancerous Tissue in an Animal Model Using Elastic Light Single-Scattering Spectroscopy

Cutaneous melanoma is the most serious form of skin cancer and is curable only if it is detected early. The most effective treatment for the melanoma is surgical excision of the lesion. Traditionally, wide margins of excision have been used for effective treatment, but are not always desirable due to increased risk of infection and esthetic reasons. Besides, safe surgical margins of the lesion are not always correlated well with the size of the lesions. We have previously developed a system using elastic light single-scattering spectroscopy to differentiate cancerous tissue from non-cancerous tissue and tested it in vitro. The goal of this study was, therefore, to determine the effectiveness of this system ex vivo by using a mouse model of melanoma. First, a melanoma cell line; B16F10 were injected subcutaneously at right mid flank region of C57BL6 mice (n=5) and allowed to develop for two weeks. Tumors were dissected and spectra were taken on tumor tissue and on normal looking skin tissue that was 10 mm distant from the incision. Since these tumors become markedly necrotic in the middle, spectra of necrotic area was also taken. Slopes of the spectra were positive taken on non-cancerous skin tissues that were later verified by histological examination. On the other hand, it gave negative slopes on melanomas. Increased sizes of the nuclei correlated with the negative slope while smaller nuclei found in non-cancerous tissue gave positive slope. Spectrum taken from necrotic area differed from both cancerous and non-cancerous tissue such that it gave a U-shaped spectrum. These results demonstrate that elastic light single-scattering spectroscopy system can differentiate cancerous tissue from non-cancerous and has potential to be used intraoperatively to determine the surgical margins.

Biopsy for malignant melanoma--are we following the guidelines?

INTRODUCTION

Guidelines for suspected malignant melanoma recommend a prompt, full-thickness excision biopsy allowing diagnosis and assessment of the Breslow thickness. Incisional biopsy is acceptable only for extensive facial lentigo maligna or acral melanoma. Punch, shave and other types of biopsies do not allow pathological staging and are, therefore, not recommended.

PATIENTS AND METHODS

A total of 100 referrals for histology-proven malignant melanoma were assessed retrospectively over a 1-year period (2005).

RESULTS

Of the 100 patients included in this study, 52 were male and 48 female. Ages ranged from 18-91 years, with a mean of 63 years. Origin of referrals was: dermatology, 63%; general practitioner (GP), 33%; and other sources in the remaining 4% of cases. Malignant melanoma was suspected in 84% and a benign lesion in remaining 16% of patients. However, only 56% of the patients were seen in our unit within 14 days of the referral as per the 2-week cancer rule. In these 100 patients, various types of biopsy were performed: 50 were referred without biopsy, 17 excision, 20 punch, 3 shave, 1 curettage, and 1 incisional biopsy. The type of biopsy was not recorded in the remaining 3 patients. Of the GP group, 48% were referred without biopsy, 12% had excision and 3% had incisional biopsies. The remaining 30% were punch, shave biopsies, and even curettage, inconsistent with current recommendations. Of the dermatology group, 54% were referred without biopsy, 21% underwent excision biopsy and 22% were punch biopsies. In total, 20 punch biopsies were performed, of which 7 were for lesions on the face ranging from 1.7-25 mm in size. The remaining punch biopsies were for lesions on the trunk or limbs (4-50 mm). Of the 20 punch biopsies performed, Breslow thickness was available in only 9 cases (45%). Sixteen of the punch biopsies were done when malignant melanoma was suspected and lesion otherwise was suitable for excisional biopsy. In the GP group, 3 shave biopsies and 1 curettage were performed, of which malignant melanoma was clinically suspected in one patient. The Breslow thickness was not obtained from any of the shave biopsies or curettage cases. Of the 17 excision biopsies performed, 3 were incompletely excised (2 by dermatology and 1 by GP).

CONCLUSIONS

A significant proportion of biopsies are inappropriate and inconsistent with the malignant melanoma guidelines. Punch biopsies are performed even when malignant melanoma is clinically suspected and excision biopsy is feasible. Only a small proportion of patients appear to be seen on an urgent basis within 14 days of referral. Such factors can lead to a delay in diagnosis, subsequent definitive treatment and adversely affect patient outcome. This study identifies a need to provide feedback and education to sources of malignant melanoma referrals.

Stratification of patients by melanoma cell adhesion molecule (MCAM) expression on the basis of risk: implications for sentinel lymph node biopsy

BACKGROUND

The usual indication for sentinel lymph node biopsy (SLNB) in melanoma is a primary tumour >1mm thickness but under these criteria less than 20% of SLNBs are positive. Of those patients with a negative sentinel node (SN) over 10% will have disease recurrence within 3 years. A more accurate delineation of candidate patients for SLNB and risk profile for negative SN patients is therefore desirable. Melanoma cell adhesion molecule (MCAM) is a predominant cell adhesion molecule of melanomas and its expression has been implicated in tumour progression and metastasis.

AIMS

To compare MCAM expression in primary and metastatic melanoma and to investigate if MCAM expression in patients meeting the criteria for SLNB correlated with patient outcome.

METHODS

Tissue arrays of primary (n=78) and metastatic (n=92) melanomas were constructed from archived paraffin embedded tissue and MCAM expression detected by immunohistochemistry. Staining positivity and intensity were assessed by visual scoring and correlated with clinical outcome.

RESULTS

In patients meeting the current criteria for SLNB, Cox multivariate analysis showed both MCAM expression positivity and intensity were independently predictive of survival (P=0.007) and development of lymph node disease (P=0.01) in primary melanoma over and above established markers of prognosis, such as Breslow thickness. MCAM-negative patients had a 5-year survival of 92% compared with 40% for MCAM positive.

CONCLUSIONS

Measurement of MCAM expression represents a potential method to stratify SLNB patients on the basis of risk. This would have considerable benefits in terms of both cost and patient morbidity.

Tumours of the hand

Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.

Psychological distress surrounding diagnosis of malignant and nonmalignant skin lesions at a pigmented lesion clinic

This study aimed prospectively to investigate psychological distress throughout the diagnostic process in an outpatient pigmented lesion clinic (PLC). Psychological distress was measured at pre clinical diagnosis, post clinical diagnosis, pre histological diagnosis (including a benign follow-up) and post histological diagnosis stages using standard anxiety measurement scales and a study specific measure of satisfaction with care. In total 324 patients undergoing investigation of a suspicious skin lesion consented to take part out of a cohort of 463 patients who attended the PLC in a 6 month period. Using recognised cut-off scores, 27% of women on clinic arrival reported clinically high levels of anxiety, in comparison with 10% of men (p < 0.0001). Patients given an immediate benign post clinical diagnosis reported a reduction in anxiety (p < 0.0001) but patients requiring a biopsy reported elevated levels of anxiety. Approximately, 30% of these biopsy patients reported clinically high levels of anxiety both before and after diagnosis. Patients who received a post histological diagnosis of malignant melanoma also reported the pre histological stage at the clinic as more distressing than waiting for and receiving results (p < 0.01). Patient's quality of life prior to diagnosis was excellent, but emotional functioning (p < 0.05), insomnia (p<or=0.001), and global health status (p<or=0.001) deteriorated throughout the diagnostic process for those patients who were finally diagnosed as having malignant melanoma. Patients reported high levels of satisfaction with clinic attendance and treatment, regardless of diagnosis but a need for further information was identified. This study has implications for all healthcare professionals involved in the provision of care through Pigmented Lesion Clinics in UK. The diagnostic process of a suspicious lesion is evidently a 'critical' stage requiring appropriate provision of care to meet patients' psychosocial and information needs if distress is to minimised for the large numbers of patients attending a PLC each year.

The Conundrum of Follow-Up: Should it be Abandoned?

This article critically evaluates the practice of follow-up for patients who have undergone treatment for a primary melanoma without evidence of metastases. One conclusion from this analysis is that the benefits of routine imaging and blood testing are insufficient to warrant a place in routine follow-up. Few patients who have metastases are identified in this fashion and even fewer survive because they underwent these tests. Far more often, false-positive results occur, which invariably cause unnecessary concern, lead to additional unnecessary testing, and may even result in needless surgery. Based on the evidence available, the relevance of follow-up per se must even be challenged. No convincing evidence exists that regional control, survival, and quality of life improve through surveillance. Other reasons for surveillance may be present, but these are less imperative. The present findings challenge current practice.

Views of UK melanoma patients on routine follow-up care

Although the need for melanoma follow-up is universally accepted, there is still much debate on the duration and frequency of appointments. The UK guidelines were revised in June 2002 to streamline melanoma follow-up. Following the change in protocol, some of our patients expressed concern at the shorter duration of follow-up. We therefore polled all our active melanoma patients to obtain their views on the outpatient clinics. In particular we asked whether they would be happy to have routine follow-up in a primary care setting. In conjunction with the department of psychology, a short questionnaire was devised assessing patient satisfaction and concerns about follow-up. This was sent to all active melanoma patients in our trust. Out of 304 eligible patients currently attending outpatients, 231 (76%) completed replies were received. Ninety-eight percent of respondents found the clinics to be useful. Twenty two and a half percent felt it was difficult to attend the clinic and this was mainly due to logistical problems, i.e. hospital car parking. The majority were reassured by the clinic visits and felt it was a chance to ask questions and check for new disease. Of the 12% of respondents who had a recurrence, 52% indicated that they had detected it themselves. Sixty percent of patients would be happy to consider routine follow-up with their GP, provided they were suitably experienced and trained. A survey of 50 local GP's found that 70% would be unhappy to monitor their patients. Patients want and benefit from follow-up. However, they are an increasing burden on outpatient clinics, given the increasing incidence of melanoma. GP follow-up may be appropriate for a small subgroup of patients. This combined with shared care and practice based clinical nurse specialists may be the way forward in melanoma follow-up.

Mélanome de l’avant-bras. À propos d’un cas historique

We present the case of a melanoma of the forearm notable for its depth (Breslow index 35 mm), due to a longstanding lack of interest and care by the patient as well as her physician. Because of systemic metastases, only palliative treatment, consisting of an excision of the lesion for local hygiene, could be offered. The patient survived for only three months. This case illustrates the absolute necessity to remove without delay, any cutaneous tumor that resembles a melanoma, in order to avoid diagnosis being made at a late stage when curative treatment cannot be performed.

Human herpesvirus type 6 and type 1 infection increases susceptibility to nonmelanoma skin tumors

In order to investigate herpesvirus (HHV) role in the susceptibility to skin cancer, we compared HHV6 and HHV1 incidence in DNA samples extracted from 120 lesions and 41 normal skin tissues. HHV6 (31.7%) and HHV1 (23.8%) were detected more frequently in skin cancer than in control individuals (14.6 and 5%, respectively) (P=0.0391 and P=0.00094, respectively). The risk of presenting basal cell carcinomas (BCC) was more than 3 times higher for HHV-6 infected patients (OR=3.182; 95% CI: 1.125-8.997). The risk for HHV-1 infected individuals of presenting BCC and squamous cell carcinomas was increased 8 and 6 times, respectively (OR=8.125; 95% CI: 1.735-38.043 and OR=6.290; 95% CI: 1.283-30.856, respectively).

Excision margins in high-risk malignant melanoma

BACKGROUND

Controversy exists concerning the necessary margin of excision for cutaneous melanoma 2 mm or greater in thickness.

METHODS

We conducted a randomized clinical trial comparing 1-cm and 3-cm margins.

RESULTS

Of the 900 patients who were enrolled, 453 were randomly assigned to undergo surgery with a 1-cm margin of excision and 447 with a 3-cm margin of excision; the median follow-up was 60 months. A 1-cm margin of excision was associated with a significantly increased risk of locoregional recurrence. There were 168 locoregional recurrences (as first events) in the group with 1-cm margins of excision, as compared with 142 in the group with 3-cm margins (hazard ratio, 1.26; 95 percent confidence interval, 1.00 to 1.59; P=0.05). There were 128 deaths attributable to melanoma in the group with 1-cm margins, as compared with 105 in the group with 3-cm margins (hazard ratio, 1.24; 95 percent confidence interval, 0.96 to 1.61; P=0.1); overall survival was similar in the two groups (hazard ratio for death, 1.07; 95 percent confidence interval, 0.85 to 1.36; P=0.6).

CONCLUSIONS

A 1-cm margin of excision for melanoma with a poor prognosis (as defined by a tumor thickness of at least 2 mm) is associated with a significantly greater risk of regional recurrence than is a 3-cm margin, but with a similar overall survival rate.

Geographic and Patient Variation in Receipt of Surveillance Procedures After Local Excision of Cutaneous Melanoma11Tables 4, 6, and appendix can be found at http://www.blackwellpublishing.com/products/journals/suppmat/jid/jid22238/jid22238sm.htm

Little is known about variation in surveillance practices following the diagnosis of invasive melanoma. The objective of this study was to characterize geographic, patient, and tumor variation in the use of follow-up surveillance testing in patients with local or regional stage melanoma. A cohort of Medicare beneficiaries > or =65 y diagnosed with invasive melanoma during 1992 to 1996 living in a Surveillance, Epidemiology, and End Results registry area was studied. Outpatient and inpatient Medicare claims 3 mo following diagnosis were examined for up to 2 y for surveillance procedures of interest. Use of chest X-ray, chest computed tomography scan, abdominal and/or pelvic computed tomography scan, abdominal ultrasound, head computed tomography scan, head magnetic resonance imaging, laboratory testing, and skin examinations were compared between patient groups and geographic regions. A total of 3389 patients were identified for the analysis. Surveillance testing was relatively common, ranging from 13% for abdominal ultrasound to 80% for laboratory testing. Follow-up skin examinations were performed in 70% to 90% of patients. The use of most surveillance procedures was associated (p<0.01) with younger age, male gender, regional stage tumors, and geographical area, with up to 2-fold differences observed. In contrast, there was much less variability in the receipt of skin examinations. Further studies are needed to determine the etiology and impact of such disparities, and the influence of surveillance procedures on morbidity and mortality.

Where to draw the line: the error in marking surgical excision margins defined

We studied the accuracy of marking surgical margins for excision surrounding skin lesions, to assess if the percentage error would differ for varying increments in margin measurements. In designing an experiment to test this hypothesis, surgeons of differing experience (n=19) marked excision margins of 2, 5 and 10 mm around a standard circular lesion drawn on paper. Use of surgical markers, rulers and loupe magnification were all permitted, with five attempts for each margin. The percentage error found was 35, 14 and 4% for the 2, 5 and 10 mm margins, respectively (regardless of the grade of surgeon). Repetition of the experiment on volunteer skin demonstrated a percentage error of 45, 16 and 8% for 2, 5 and 10 mm margins (significantly greater than the corresponding errors on paper, p<0.001 in all cases). These findings indicate that for these surgically marked margins, the term "accurate excision margins" may be inaccurate to a significant degree. This study has defined the errors inherent in the marking of surgical margins, and these should be taken into account when assessing studies that report margins around tumours. Specifically, comparisons between surgical and histological margins would aid assessment of reports detailing surgical margins dawn around skin tumours.

Sentinel node biopsy in patients with in-transit recurrence of malignant melanoma

Sentinel node biopsy (SNB) is now widely used for accurate staging of patients with clinical stage I or II malignant melanoma. We describe the use of SNB in five patients with in-transit recurrence (stage IIIB) and demonstrate that it provides accurate staging of the lymph nodes in this group of patients.