Recognising Skin Cancer in Primary Care

Skin cancer, including melanoma, basal cell carcinoma and cutaneous squamous cell carcinoma, has one of the highest global incidences of any form of cancer. In 2016 more than 16,000 people were diagnosed with melanoma in the UK. Over the last decade the incidence of melanoma has increased by 50% in the UK, and about one in ten melanomas are diagnosed at a late stage. Among the keratinocyte carcinomas (previously known as non-melanoma skin cancers), basal cell carcinoma is the most common cancer amongst Caucasian populations. The main risk factor for all skin cancer is exposure to ultraviolet radiation-more than 80% are considered preventable. Primary care clinicians have a vital role to play in detecting and managing patients with skin lesions suspected to be skin cancer, as timely diagnosis and treatment can improve patient outcomes, particularly for melanoma. However, detecting skin cancer can be challenging, as common non-malignant skin lesions such as seborrhoeic keratoses share features with less common skin cancers. Given that more than 80% of skin cancers are attributed to ultraviolet (UV) exposure, primary care clinicians can also play an important role in skin cancer prevention. This article is one of a series discussing cancer prevention and detection in primary care. Here we focus on the most common types of skin cancer: melanoma, squamous cell carcinoma and basal cell carcinoma. We describe the main risk factors and prevention advice. We summarise key guidance on the symptoms and signs of skin cancers and their management, including their initial assessment and referral. In addition, we review emerging technologies and diagnostic aids which may become available for use in primary care in the near future, to aid the triage of suspicious skin lesions.

Dermoscopy for melanoma detection and triage in primary care: a systematic review

OBJECTIVE

Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation.

DESIGN

A systematic literature review and narrative synthesis.

DATA SOURCES

We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions.

INCLUSION CRITERIA

Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies.

RESULTS

23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care.

CONCLUSIONS

Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care.

TRIAL REGISTRATION NUMBER

CRD42018091395.

The Importance of Integration of Stakeholder Views in Core Outcome Set Development: Otitis Media with Effusion in Children with Cleft Palate

Background

Approximately 75% of children with cleft palate (CP) have Otitis Media with Effusion (OME) histories. Evidence for the effective management of OME in these children is lacking. The inconsistency in outcome measurement in previous studies has led to a call for the development of a Core Outcome Set (COS). Despite the increase in the number of published COS, involvement of patients in the COS development process, and methods to integrate the views of patients and health professionals, to date have been limited.

Methods and Findings

A list of outcomes measured in previous research was identified through reviewing the literature. Opinion on the importance of each of these outcomes was then sought from key stakeholders: Ear, Nose and Throat (ENT) surgeons, audiologists, cleft surgeons, speech and language therapists, specialist cleft nurses, psychologists, parents and children. The opinion of health professionals was sought in a three round Delphi survey where participants were asked to score each outcome using a bespoke online system. Parents and children were also asked to score outcomes in a survey and provided an in-depth insight into having OME through semi-structured interviews. The results of the Delphi survey, interviews and parent/patient survey were brought together in a final consensus meeting with representation from all stakeholders. A final set of eleven outcomes reached the definition of “consensus in” to form the recommended COS: hearing; chronic otitis media (COM); OME; receptive language skills; speech development; psycho social development; acute otitis media (AOM); cholesteatoma; side effects of treatment; listening skills; otalgia.

Conclusions

We have produced a recommendation about the outcomes that should be measured, as a minimum, in studies of the management of OME in children with CP. The development process included input from key stakeholders and used novel methodology to integrate the opinion of healthcare professionals, parents and children.

Using the 7-point checklist as a diagnostic aid for pigmented skin lesions in general practice: a diagnostic validation study

BACKGROUND

GPs need to recognise significant pigmented skin lesions, given rising UK incidence rates for malignant melanoma. The 7-point checklist (7PCL) has been recommended by NICE (2005) for routine use in UK general practice to identify clinically significant lesions which require urgent referral.

AIM

To validate the Original and Weighted versions of the 7PCL in the primary care setting.

DESIGN AND SETTING

Diagnostic validation study, using data from a SIAscopic diagnostic aid randomised controlled trial in eastern England.

METHOD

Adults presenting in general practice with a pigmented skin lesion that could not be immediately diagnosed as benign were recruited into the trial. Reference standard diagnoses were histology or dermatology expert opinion; 7PCL scores were calculated blinded to the reference diagnosis. A case was defined as a clinically significant lesion for primary care referral to secondary care (total 1436 lesions: 225 cases, 1211 controls); or melanoma (36).

RESULTS

For diagnosing clinically significant lesions there was a difference between the performance of the Original and Weighted 7PCLs (respectively, area under curve: 0.66, 0.69, difference = 0.03, P<0.001). For the identification of melanoma, similar differences were found. Increasing the Weighted 7PCL's cut-off score from recommended 3 to 4 improved detection of clinically significant lesions in primary care: sensitivity 73.3%, specificity 57.1%, positive predictive value 24.1%, negative predictive value 92.0%, while maintaining high sensitivity of 91.7% and moderate specificity of 53.4% for melanoma.

CONCLUSION

The Original and Weighted 7PCLs both performed well in a primary care setting to identify clinically significant lesions as well as melanoma. The Weighted 7PCL, with a revised cut-off score of 4 from 3, performs slightly better and could be applied in general practice to support the recognition of clinically significant lesions and therefore the early identification of melanoma.

The cost-effectiveness of a novel SIAscopic diagnostic aid for the management of pigmented skin lesions in primary care: a decision-analytic model

OBJECTIVES

Pigmented skin lesions are commonly presented in primary care. Appropriate diagnosis and management is challenging because the vast majority are benign. The MoleMate system is a handheld SIAscopy scanner integrated with a primary care diagnostic algorithm aimed at improving the management of pigmented skin lesions in primary care.

METHODS

This decision-model-based economic evaluation draws on the results of a randomized controlled trial of the MoleMate system versus best practice (ISRCTN79932379) to estimate the expected long-term cost and health gain of diagnosis with the MoleMate system versus best practice in an English primary care setting. The model combines trial results with data from the wider literature to inform long-term prognosis, health state utilities, and cost.

RESULTS

Results are reported as mean and incremental cost and quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness ratio with probabilistic sensitivity analysis, and value of information analysis. Over a lifetime horizon, the MoleMate system is expected to cost an extra £18 over best practice alone, and yield an extra 0.01 QALYs per patient examined. The incremental cost-effectiveness ratio is £1,896 per QALY gained, with a 66.1% probability of being below £30,000 per QALY gained. The expected value of perfect information is £43.1 million.

CONCLUSIONS

Given typical thresholds in the United Kingdom (£20,000-£30,000 per QALY), the MoleMate system may be cost-effective compared with best practice diagnosis alone in a primary care setting. However, there is considerable decision uncertainty, driven particularly by the sensitivity and specificity of MoleMate versus best practice, and the risk of disease progression in undiagnosed melanoma; future research should focus on reducing uncertainty in these parameters.

Effect of adding a diagnostic aid to best practice to manage suspicious pigmented lesions in primary care: randomised controlled trial

OBJECTIVES

To assess whether adding a novel computerised diagnostic tool, the MoleMate system (SIAscopy with primary care scoring algorithm), to current best practice results in more appropriate referrals of suspicious pigmented lesions to secondary care, and to assess its impact on clinicians and patients.

DESIGN

Randomised controlled trial.

SETTING

15 general practices in eastern England.

PARTICIPANTS

1297 adults with pigmented skin lesions not immediately diagnosed as benign.

INTERVENTIONS

Patients were assessed by trained primary care clinicians using best practice (clinical history, naked eye examination, seven point checklist) either alone (control group) or with the MoleMate system (intervention group).

MAIN OUTCOME MEASURES

Appropriateness of referral, defined as the proportion of referred lesions that were biopsied or monitored. Secondary outcomes related to the clinicians (diagnostic performance, confidence, learning effects) and patients (satisfaction, anxiety). Economic evaluation, diagnostic performance of the seven point checklist, and five year follow-up of melanoma incidence were also secondary outcomes and will be reported later.

RESULTS

1297 participants with 1580 lesions were randomised: 643 participants with 788 lesions to the intervention group and 654 participants with 792 lesions to the control group. The appropriateness of referral did not differ significantly between the intervention or control groups: 56.8% (130/229) v 64.5% (111/172); difference -8.1% (95% confidence interval -18.0% to 1.8%). The proportion of benign lesions appropriately managed in primary care did not differ (intervention 99.6% v control 99.2%, P=0.46), neither did the percentage agreement with an expert decision to biopsy or monitor (intervention 98.5% v control 95.7%, P=0.26). The percentage agreement with expert assessment that the lesion was benign was significantly lower with MoleMate (intervention 84.4% v control 90.6%, P<0.001), and a higher proportion of lesions were referred (intervention 29.8% v control 22.4%, P=0.001). Thirty six histologically confirmed melanomas were diagnosed: 18/18 were appropriately referred in the intervention group and 17/18 in the control group. Clinicians in both groups were confident, and there was no evidence of learning effects, and therefore contamination, between groups. Patients in the intervention group ranked their consultations higher for thoroughness and reassuring care, although anxiety scores were similar between the groups.

CONCLUSIONS

We found no evidence that the MoleMate system improved appropriateness of referral. The systematic application of best practice guidelines alone was more accurate than the MoleMate system, and both performed better than reports of current practice. Therefore the systematic application of best practice guidelines (including the seven point checklist) should be the paradigm for management of suspicious skin lesions in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79932379.

Accuracy of SIAscopy for pigmented skin lesions encountered in primary care: development and validation of a new diagnostic algorithm

Background

Diagnosing pigmented skin lesions in general practice is challenging. SIAscopy has been shown to increase diagnostic accuracy for melanoma in referred populations. We aimed to develop and validate a scoring system for SIAscopic diagnosis of pigmented lesions in primary care.

Methods

This study was conducted in two consecutive settings in the UK and Australia, and occurred in three stages: 1) Development of the primary care scoring algorithm (PCSA) on a sub-set of lesions from the UK sample; 2) Validation of the PCSA on a different sub-set of lesions from the same UK sample; 3) Validation of the PCSA on a new set of lesions from an Australian primary care population. Patients presenting with a pigmented lesion were recruited from 6 general practices in the UK and 2 primary care skin cancer clinics in Australia. The following data were obtained for each lesion: clinical history; SIAscan; digital photograph; and digital dermoscopy. SIAscans were interpreted by an expert and validated against histopathology where possible, or expert clinical review of all available data for each lesion.

Results

A total of 858 patients with 1,211 lesions were recruited. Most lesions were benign naevi (64.8%) or seborrhoeic keratoses (22.1%); 1.2% were melanoma. The original SIAscopic diagnostic algorithm did not perform well because of the higher prevalence of seborrhoeic keratoses and haemangiomas seen in primary care. A primary care scoring algorithm (PCSA) was developed to account for this. In the UK sample the PCSA had the following characteristics for the diagnosis of 'suspicious': sensitivity 0.50 (0.18-0.81); specificity 0.84 (0.78-0.88); PPV 0.09 (0.03-0.22); NPV 0.98 (0.95-0.99). In the Australian sample the PCSA had the following characteristics for the diagnosis of 'suspicious': sensitivity 0.44 (0.32-0.58); specificity 0.95 (0.93-0.97); PPV 0.52 (0.38-0.66); NPV 0.95 (0.92-0.96). In an analysis of lesions for which histological diagnosis was available (n = 111), the PCSA had a significantly greater Area Under the Curve than the 7-point checklist for the diagnosis of melanoma (0.83; 95% CI 0.71-0.95 versus 0.61; 95% CI 0.44-0.78; p = 0.02 for difference).

Conclusions

The PCSA could have a useful role in improving primary care management of pigmented skin lesions. Further work is needed to develop and validate the PCSA in other primary care populations and to evaluate the cost-effectiveness of GP management of pigmented lesions using SIAscopy.

Protocol for the MoleMate UK Trial: a randomised controlled trial of the MoleMate system in the management of pigmented skin lesions in primary care [ISRCTN 79932379]

Background

Suspicious pigmented lesions are a common presenting problem in general practice consultations; while the majority are benign a small minority are melanomas. Differentiating melanomas from other pigmented lesions in primary care is challenging: currently, 95% of all lesions referred to a UK specialist are benign. The MoleMate system is a new diagnostic aid, incorporating a hand-held SIAscopy scanner with a primary care diagnostic algorithm. This trial tests the hypothesis that adding the MoleMate system to current best primary care practice will increase the proportion of appropriate referrals of suspicious pigmented lesions to secondary care compared with current best practice alone.

Methods/design

The MoleMate UK Trial is a primary care based multi-centre randomised controlled trial, with randomisation at patient level using a validated block randomisation method for two age groups (45 years and under; 46 years and over). We aim to recruit adult patients seen in general practice with a pigmented skin lesion that cannot immediately be diagnosed as benign and the patient reassured. The trial has a 'two parallel groups' design, comparing 'best practice' with 'best practice' plus the MoleMate system in the intervention group. The primary outcome is the positive predictive value (PPV) of referral defined as the proportion of referred lesions seen by secondary care experts that are considered 'clinically significant' (i.e. biopsied or monitored). Secondary outcomes include: the sensitivity, specificity and negative predictive value (NPV) of the decision not to refer; clinical outcomes (melanoma thickness, 5 year melanoma incidence and mortality); clinician outcomes (Index of Suspicion, confidence, learning effects); patient outcomes (satisfaction, general and cancer-specific worry), and cost-utility.

Discussion

The MoleMate UK Trial tests a new technology designed to improve the management of suspicious pigmented lesions in primary care. If effective, the MoleMate system could reduce the burden on skin cancer clinics of patients with benign pigmented skin lesions, and improve patient care in general practice.

Evaluation of the MoleMate training program for assessment of suspicious pigmented lesions in primary care

BACKGROUND

Pigmented skin lesions or 'moles' are a common presenting problem in general practice consultations: while the majority are benign, a minority are malignant melanomas. The MoleMate system is a novel diagnostic tool which incorporates spectrophotometric intracutaneous analysis (SIAscopy) within a non-invasive scanning technique and utilises a diagnostic algorithm specifically developed for use in primary care. The MoleMate training program is a short, computer-based course developed to train primary care practitioners to operate the MoleMate diagnostic tool.

OBJECTIVES

This pre-trial study used mixed methods to assess the effectiveness and acceptability of a computer-based training program CD-ROM, developed to teach primary care practitioners to identify the seven features of suspicious pigmented lesions (SPLs) seen with the MoleMate system.

METHOD

Twenty-five practitioners worked through the MoleMate training program: data on feature recognition and time taken to conduct the assessment of each lesion were collected. Acceptability of the training program and the MoleMate system in general was assessed by questionnaire.

RESULTS

The MoleMate training program improved users' feature recognition by 10% (pre-test median 73.8%, p<0.001), and reduced the time taken to complete assessment of 30 SPLs (pre-test median 21 minutes 53 seconds, median improvement 3 minutes 17 seconds, p<0.001). All practitioners' feature recognition improved (21/21), with most also improving their time (18/21). Practitioners rated the training program as effective and easy to use.

CONCLUSION

The MoleMate training program is a potentially effective and acceptable informatics tool to teach practitioners to recognise the features of SPLs identified by the MoleMate system. It will be used as part of the intervention in a randomised controlled trial to compare the diagnostic accuracy and appropriate referral rates of practitioners using the MoleMate system with best practice in primary care.

A prospective comparison of spectrophotometric intracutaneous analysis to clinical judgment in the diagnosis of nonmelanoma skin cancer

INTRODUCTION

Research indicates that spectrophotometric intracutaneous analysis (SIAscopy) may be a useful adjunct in nonmelanoma skin cancer (NMSC) diagnosis. A study was performed to prospectively assess the accuracy of NMSC diagnosis by the SIAscope as compared with a clinician.

METHODS

Prior to excision, 323 consecutive lesions were examined and diagnosed by a clinician. SIAgraphs were then taken of the lesions and examined blindly at a later date. Diagnostic accuracy for the clinician and SIAscope was compared between the clinician and SIAscope and to histology.

RESULTS

Sensitivity, specificity, positive and negative predictive values for clinical diagnoses were 95.6%, 75.8%, 0.79, and 0.95, respectively. Results for SIA diagnoses were 97.5%, 86.7%, 0.88, and 0.97. Statistical comparison revealed comparable sensitivities for the 2 groups but significantly better specificity for the SIAscope at the 95% confidence level.

CONCLUSION

This study indicates that the SIAscope may be useful in NMSC diagnosis, with accuracies comparable to a clinician.

Clinical resolution of a neonatally eroded giant congenital melanocytic nevus

We report an unusual occurrence of spontaneous pigmentary regression with a desmoplastic reaction in a neonatally eroded giant congenital melanocytic nevus. This process has been documented with photographs and skin biopsy specimens. Neonatal histology demonstrated connective tissue proliferation. Histology at age 5 years also demonstrated a very high proportion of amelanotic dermal nevus cells. Regression of pigmentation in our patient may be due to a decrease in melanin production by dermal nevus cells rather than a decrease in their number.

Vincristine as a treatment for a large haemangioma threatening vital functions

We report the use of vincristine to treat a large steroid resistant haemangioma of the lower face and neck. At the time of treatment the lesion had shown no signs of involution. The haemangioma was not life threatening but extension within the mouth was associated with bleeding and ulceration, which was impairing feeding and speech development. A significant improvement was seen with vincristine treatment.

Free dermis—fat graft to correct the whistle deformity in patients with cleft lip

Vermilion notching or 'whistle deformity' is a common secondary deformity of the vermilion in patients with cleft lip. The free border of the lip is a composite structure consisting of the orbicularis oris and the overlying tissues, namely subcutaneous fat, vermilion and mucosa. A deficiency of all or one of these structures is responsible for the vermilion notch. An absolute shortage of the muscle or subcutaneous tissue necessitates the use of tissue from another source to correct the deformity. Dermis fat grafts have been used to augment the free border of the lip and correct this deformity. The technique is simple and reliable. The tissue is available in plenty, easy to harvest and could be repeated if necessary, i.e. in case of resorption. From June 1996 until January 2000 the technique was used in 10 patients. Of these 10, one was a bilateral cleft and nine were unilateral cleft lip deformities. A degree of graft resorption was seen in one patient, one had a partial graft loss due to ulceration and exposure. The first patient had a further augmentation.

"Now you see it...now you don't." Carmoisine vital dye facilitates complete removal of cutaneous neoplasia by intraoperative visual enhancement

Patients presenting for excision of squamous cell carcinomata, including Bowen's disease, in sun-damaged skin often present with poorly defined, morphoeic or multifocal neoplasms, the extent of which can be difficult to identify intraoperatively. Use of vital staining has been commonly used to aid identification and appropriate excision of squamous lesions of the oral cavity and upper aerodigestive tract but has not been readily adopted for cutaneous lesions. We report a case of a morphoeic squamous cell neoplasm of the web space and fingers to illustrate the merits of vital staining cutaneous squamous neoplasms with the simple dye Carmoisine E122. This assists with intraoperative tumour identification and facilitates adequate oncological resection and appropriately planned reconstruction. By comparison with other methods such as Mohs, it is a simple, cheap, and rapid aid that may be used by surgeons of all grades to improve identification of the extent of the neoplasm, without special equipment.

U.K. guidelines for the management of cutaneous melanoma

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the U.K., they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

UK guidelines for the management of cutaneous melanoma

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

Dispersal of radioisotope labelled solution following deep dermal injection in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is the commonest inherited disorder of connective tissue, affecting around 10 000 patients in the UK. Patients with EDS have reported that local anaesthetic is often ineffective. Patients with less severe skin laxity often have the most problems. We have postulated that this resistance to local anaesthetics is not due to the lax connective tissues as is often assumed. This study used radioactively labelled solution ((99m)Tc-pertechnetate) administered as a deep dermal injection in the forearm. The rate of dispersal of isotope was measured over 60 min and found to be identical between six patients with EDS and three controls. The effects of local anaesthetics are complex and depend on the individual chemical properties of the agent and a number of tissue factors. This study would suggest that the lack of effectiveness of local anaesthetic solutions is not due to rapid dispersal of solution. It is unlikely therefore that its lack of effect can be compensated for by simply increasing the amount used. The diagnosis of EDS should be considered in any patient who complains unexpectedly of pain during their procedure, particularly when the surgeon knows that an adequate volume of local anaesthetic has been used.

The impact of antenatal diagnosis on the effectiveness and timing of counselling for cleft lip and palate

Birth of a cleft child is emotionally distressing to the parents. The opportunity for forewarning the parents is now possible with antenatal ultrasound diagnosis of the cleft. This has opened up a new chapter of antenatal counselling. We present a retrospective postal study of 124 primary cleft lip and/or palate repairs operated over the last 5 years. In our study, 30% were diagnosed antenatally and received antenatal counselling. The rest received postnatal counselling. Of those who had an antenatal diagnosis 85% felt that the diagnosis prepared them psychologically for the birth of the cleft child. A total of 92% (n = 23) of parents who had antenatal as well as postnatal counselling, as compared with 71% (n = 46) of those counselled only postnatally, said the information given to them by the counselling cleft team was detailed and satisfactory. The majority of those who felt counselling was confusing had only postnatal counselling. Of those who had antenatal diagnosis 92% said that they had never contemplated termination of pregnancy. Only one parent had actually terminated her pregnancy due solely to the antenatal diagnosis of a bilateral cleft lip and palate. Our study has highlighted the importance of antenatal diagnosis of cleft and the importance of antenatal counselling for the delivery of a cleft child to be a positive experience.

Meningococcal septicaemia and plastic surgery--a strategy for management

Meningococcal septicaemia is a severe life threatening illness that is part of the spectrum of meningococcal disease. It is of particular concern to the plastic and reconstructive surgeon because as the medical and intensive care of these patients improves, more are surviving the acute phase of the septicaemia and suffering from the associated complications such as skin necrosis and extremity loss. Recently there have been several reports in the literature concerning the management of skin infarction with both skin grafting and free flap surgery. This paper will provide an update on the proposed pathophysiological mechanisms involved, summarise the present data on plastic surgical care and suggest a stratagem for future management of these difficult cases.

Therapeutic trends in cutaneous melanoma

Many advances in the management of melanoma have occurred in the last few years. These make this an exciting time for clinicians and allows them to offer glimmers of hope for patients with this disease. This article looks at the therapeutic aspects of the treatment of cutaneous melanoma.

Cutaneous melanoma: diagnosis and at risk patients

Malignant melanoma is a condition which kills many young people, yet early recognition can lead to cure. There are, however, new approaches to diagnosis and management of disease at high risk of recurrence, which raise glimmers of hope in this most capricious of conditions.

Skin replacement in Dupuytren's disease

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren's disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren's disease requiring reoperation and as a primary procedure when there is significant skin involvement.

The submental island flap

The submental island flap is a reliable source of skin of excellent colour, contour and texture match for facial resurfacing and leaves a well hidden donor site. The flap is safe, rapid and simple to raise. We report on its use in 12 cases of facial or intraoral reconstruction. Complications were few. However, there was one case of complete flap loss following its use in a reverse flow manner, due to the presence of an unreported, but constant, valve in the venous system of the face. We believe this flap to be a worthwhile addition to the existing surgical armamentarium.

Computer screening for early detection of melanoma--is there a future?

Computer image analysis in the study of pigmented lesions is critically examined and discussed in the light of the current published data. The potential for objective analysis by computers as a possible screening aid for the inexperienced clinician is discussed. The future for this technology is exciting if handled with care.

Analysis of 100 upper limb injuries using the Merseyside Accident Information Model

More than 2 million upper limb injuries occur each year in Britain. Information about the precise sequence of events leading up to an accident may help prevention of similar injuries by alteration of the work environment or through safety education. The first impression of the cause of an accident may not identify the key event triggering it. The Merseyside Accident Information Model (MAIM; Manning, 1987) provides a structured questionnaire, based on a menu-led computer programme. This not only allows the first unforeseen event to be identified from the history, but is also the basis of a database. Pooled data can then be analyzed. We present an analysis of 100 consecutive cases presenting to one Plastic Surgery Unit.

Shape analysis for classification of malignant melanoma

Melanoma is a malignant skin tumour. If detected and surgically removed early whilst residing in the superficial part of the skin the prognosis is excellent. A seven-point check-list of signs and symptoms has been adopted by the Cancer Research Campaign to help non-dermatologists distinguish benign pigmented lesions from melanoma. The presence of irregularity in shape or outline of a mole is one of these important signs. However, it has recently been shown that not only patients, but also clinicians have difficulty in agreeing upon whether a mole exhibits irregularity or not. Computer image analysis methods have been developed to derive quantitative measures of those shape parameters which dermatologists appear to use in their assessment of shape irregularity. The overall shape of the lesion is expressed by the 'bulkiness' measure. Irregularity of the border is expressed by two fractal dimension measures, one for the 'structural' aspect of the shape and the other for the 'textural' aspect. These measures were used in combination to classify melanomas in the study containing silhouettes of 43 melanomas and 45 benign lesions producing correct classification with 91% sensitivity and 69% specificity. This paper describes computer image analysis aspects of the study.

Breast implant materials: sense and safety

Cosmetic breast augmentation, and post-mastectomy breast reconstruction surgery using synthetic implants, have become established in surgical practice over more than 20 years. The operative technique for implant placement have changed somewhat during this time, as many different implant presentations have become available, but the same basic materials have remained in use. We have reviewed the present state of knowledge about breast implant materials with particular reference to the possible connection between polydimethylsiloxane and polyurethane to the so-called "Human Adjuvant Disease", and to carcinogenesis. Problems related to capsular contracture and mammography are also discussed.

Evaluation of herniography in the diagnosis of an occult abdominal wall hernia in symptomatic adults

Outpatient herniography as a means of confirming or refuting the presence of an occult abdominal wall hernia was performed in 50 symptomatic patients, including 13 who had previously undergone hernia repair. Altogether 30 occult hernias were detected in 27 patients, only one of which was considered to be unrelated to the presenting symptoms. On the basis of herniography, 17 patients were spared surgical exploration and, of these 17, 16 obtained a good result. One further patient with a clinically apparent hernia on one side but with contralateral symptoms was spared unnecessary surgery because the contralateral side was radiologically normal. There was one false negative and no false positive examinations. There were three minor complications: two cases of sigmoid colon puncture and one of abdominal wall haemorrhage (all managed conservatively). There were two technical failures. These results support the Scandinavian experience that herniography has a useful role in the management of patients who may have occult hernias as the underlying cause of abdominal wall symptoms.

Mesh grafts--an 18 month follow-up

Thirty-four patients, who had received either sheet or mesh grafts during surgery at the McIndoe Burns Unit, were reviewed, with a minimum follow-up period of 18 months. Expert observers were able to identify 1:1.5 mesh after close examination, but no group found the cosmetic result inferior to that of sheet graft. 1:4 mesh was uniformly identified, and cosmesis was judged unsatisfactory by all observers.