Profile of the malignant melanoma excised in general practice

Cutaneous melanoma and intervention strategies to reduce tumor-related mortality: what we know, what we don't know, and what we think we know that isn't so

The care of patients who have cutaneous melanoma (CM) has undergone a dramatic change during the past five decades. In an increasing majority of cases, CM is being discovered in a premetastatic phase of tumor progression. Most patients are being treated in the ambulatory setting with a minimum of inconvenience and economic cost, and modest re-excision margins have largely replaced the mutilating surgical exonerations that were once standard only four decades ago. Histopathologic assessment of the primary tumor is the most widely used staging procedure to determine who is most likely to develop metastatic disease. For patients who develop distant metastases, there is no therapy currently available, based on large-scale randomized trials, that will prolong patient survival. Therefore, establishing an early diagnosis in a premetastatic phase of tumor development must be the overriding goal of any intervention strategy that seeks to reduce CM-related mortality. Unfortunately, as a result of public messages that emphasize the role of ultraviolet radiation (UVR) exposure in tumor development, most general physicians and lay people believe that most if not all cases of CM are the direct result of UVR exposure. In fact, we do not know the case fraction of CM directly attributable to UVR, and the unintended consequences of current messages directly linking UVR exposure and CM development may be thwarting the primary intervention goal of reducing tumor-related mortality. More likely to have an immediate positive impact on CM-related mortality are public messages that encourage skin awareness and self-examination by patients, total skin screening examinations by physicians during routine care, and periodic lifetime surveillance of patients determined to have a high CM risk based on identifiable historic and phenotypic traits.

[Pre-malignant and malignant lesions in minor surgery at a health centre. Appearances can't be trusted]

OBJECTIVE

To describe the characteristics of the malignant and pre-malignant lesions found in the minor surgical interventions performed at a health centre.

DESIGN

Retrospective, descriptive study.

PARTICIPANTS

682 lesions: all the lesions extirpated and referred to pathology except for epidermal and trichilemmal cysts, lipomas, molluscum, common warts, and nails.

SETTING

Rochapea Health Centre, Pamplona.Main measurements. We analysed the anatomical-pathological results and the distribution by sex, age-group, location, technique and edges affected in 27 dysplasias and 11 malignant lesions.

RESULTS

We found that malignant and pre-malignant lesions were more common in women, aged 15 to 44 for dysplasias and 45-64 for malignant lesions. The most common location was on the back; the most frequent technique, fusiform excision. This technique had the highest percentage of edges without lesion in dysplasias. The lesions whose edges were affected corresponded to punch and circular excision samples. None of the malignant lesions had their edges affected.

CONCLUSIONS

Most malignant lesions are not suspected. They appear in samples referred with a diagnosis of benign. Employment of techniques such as fusiform excision in lesions which are potentially malign, even though in principle they seem benign, enables them to be extirpated with free edges.

Examination of skin naevi in Australian general practice: dissonance between care and need?

Over 26 months, 223 general practitioners recorded consultations involving the management of skin naevi and some demographic details of the patients. We used data from the Health Insurance Commission and the Australian Bureau of Statistics to estimate population consultation rates. Of 749,171 consultations, 9,729 involved management of naevi. The annual rate per 1,000 of these consultation was 11.3 (95% CI 11.0-11.6) for males and 17.0 (95% CI 16.6-17.5) for females. The rate was significantly higher in the 15-44 year age group, at 21.8 consultations per 1000 individuals annually, compared to 6.3 for younger ages and 16.0, 16.1 and 8.6 for the 45-64, 65-74 and 75+ age groups respectively. There was a seasonal variation, with rates highest in the hot months (of about 16 annual consultations per 1,000 individuals) and lowest in the cooler months (14 for the two years' cooler seasons sampled). There was a significant variation between the rates of different states and territories, but this did not follow a latitude difference. There is a dissonance between the distribution of melanomas (relatively concentrated among older patients and males) and the general practice management of skin naevi (relatively concentrated among younger patients and females). Although melanomas (particularly those with the poorest prognosis) are relatively concentrated in older men, paradoxically, more skin naevi are managed in general practice among younger and female patients.