A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.     

Evaluating invasive cutaneous melanoma: is the initial biopsy representative of the final depth?

BACKGROUND: An accurate initial biopsy of the deepest portion of the melanoma is vital to the management of patients with melanomas. OBJECTIVE: Our goal was to evaluate the accuracy of preliminary biopsies performed by a group of predominantly experienced dermatologists (n = 46/72). METHODS: A total of 145 cases of cutaneous melanoma were examined retrospectively. We compared Breslow depth on preliminary biopsy with Breslow depth on subsequent excision. Was the initial diagnostic biopsy performed on the deepest part of the melanoma? RESULTS: Of nonexcisional initial shave and punch biopsies, 88% were accurate, with Breslow depth greater than or equal to subsequent excision Breslow depth. Both superficial and deep shave biopsies were more accurate than punch biopsy for melanomas less than 1 mm. Excisional biopsy was found to be the most accurate method of biopsy. CONCLUSIONS: Deep shave biopsy is preferable to superficial shave or punch biopsy for thin and intermediate depth (<2 mm) melanomas when an initial sample is taken for diagnosis instead of complete excision. We found that a group of predominantly experienced dermatologists accurately assessed the depth of invasive melanoma by use of a variety of initial biopsy types.     

Prognosis for cutaneous melanoma according to surgical department: comparative study at a tertiary care hospital

IntroductionSurgical treatment of melanoma is performed by dermatologists and general or plastic surgeons. It is not known whether the type of specialist treating the melanoma results in a different prognosis for these patients.Material and methodsA retrospective study was carried out on the epidemiological, clinical/histological and evolutional characteristics of all patients diagnosed with melanoma at Hospital Gregorio Marañón over a 10-year period (1994--2003). The differences by hospital department where the patients were treated (dermatology, general surgery and plastic surgery) were noted.ResultsOver 90 % of the patients with melanoma were treated by the Dermatology Department. The thickness of the tumors and the presence of histologic ulceration were significantly higher in the melanomas treated by general and plastic surgeons (p < 0.05). The differences in overall average survival (105, 55 and 77 months) and disease-free time (88, 24 and 51.3 months) in the melanomas operated on by dermatologists, general surgeons and plastic surgeons, respectively, were significant (p < 0.001).ConclusionsThis study confirms that there are significant differences in the clinical and histological characteristics and the life prognosis of patients with cutaneous melanoma treated by different specialists. The melanomas treated by general or plastic surgeons have usually been developing for a longer time, and therefore are thicker and more often ulcerated than those treated by dermatologists, resulting in a lower survival period. With appropriate medical and surgical training, dermatologists are the most suitable specialists for early diagnosis and treatment.     

Cutaneous melanoma in childhood and adolescence: an analysis of 36 patients

Analysis of data of 6931 patients with cutaneous melanoma seen at the Department of Dermatology and Allergology at the Ludwig-Maximilians-University of Munich between 1977 and 1998 identified 36 patients in whom cutaneous melanomas developed during childhood or adolescence (age <18 years). Clinical courses of all patients and histopathologic characteristics of the lesions were reviewed. Seventeen patients were boys and 19 patients were girls. The median ages of the boys and girls were 15 and 16 years, respectively (range, 2-17 years). Thirty-one patients presented with nonmetastatic primary melanomas and 5 patients presented with metastatic melanoma. Forty-seven percent of the primary lesions were associated with a nevus (22% with congenital nevi and 25% with acquired nevi). Tumor thickness ranged from 0.24 to 7.0 mm, with a median of 1.29 mm (mean, 1.67 mm). All patients with primary melanomas received surgical therapy; patients with metastatic disease received chemotherapy, radiation therapy, or both. Relative 5-year survival was 87.5% for the group of patients younger than 18 years. Similar to experience in adult patients, survival strongly correlated with tumor thickness and clinical stage at the time of diagnosis. The data emphasize that a high index of suspicion for cutaneous melanoma is needed by clinicians assessing melanocytic lesions in children and adolescents for early diagnosis. Reduction of the melanoma mortality rate in children and adolescents will be achieved through identification of patients at increased risk.     

Melanoma in private practice: Do dermatologists make a difference?

Malignant melanoma is a major contributor to Australian morbidity and mortality. In this era of resource rationalisation, we seek to address the issue of whether routine full-skin examination by a dermatologist, rather than focussed examination of flagged lesions, will increase melanoma diagnosis. A retrospective chart review was undertaken between 1 July 2007 and 30 June 2008 in a private dermatology group practice in order to ascertain the number and characteristics of incidentally detected melanomas on routine skin examination. A total of 94 melanomas were detected during this 12-month period. Of these, 57 (60.6%) were incidentally detected by the dermatologist, 41 (71.9%) were in situ melanomas and 16 (28.1%) were invasive melanoma. Of the invasive lesions, 15 (94%) were 'thin' (less than 1.0 mm Breslow thickness). The majority of melanomas were found in men, and were distributed in areas of high cumulative sun exposure. Nine (9.6%) lesions were clinically misdiagnosed by the dermatologists and picked up on histopathology. This audit reaffirms the usefulness of routine full-skin examination by dermatologists in detecting de novo melanoma as part of the global strategy in reducing the burden of melanoma in Australia.     

Changes from mid-1980s to late 1990s among clinical and demographic correlates of melanoma thickness

Tumour thickness is the most relevant prognostic factor for cutaneous melanoma. Although the increasing incidence of melanoma is currently attributable to "thin" lesions, the incidence rates of "thick" melanomas have not declined. We want to identify the clinical and demographic characteristics of patients that are associated with diagnosis of thick (> 3 mm) cutaneous melanoma and whether they had changed from mid-1980s to late-1990s. Cutaneous malignant melanomas incidence in 1985-87 and in 1995-97 were retrieved from the Tuscany Cancer Registry, central Italy. Only cases with Breslow-thickness information (182/260 in 1985-87 and 387/490 in 1995-97) were included. Thickness was categorised in < = 1 mm, 1-3 mm and > 3 mm. Thickness was evaluated for each period of time according to gender, age, histological type, site and residence. For cases diagnosed in 1995-97 the effect of such variables in predicting the risk of a thick tumour (vs. a thin one) was analysed in a logistic model. In 1985-87 patients with thick melanoma were more likely to be - with a statistically significant difference - males (38.1 % of thick tumours) than females (19.4 %), over 70 (57.7 % of thick tumour), with nodular melanoma (62.1 %) and residents far from the city of Florence (30.3 %); no differences were evidenced according to site. From 1985-87 to 1995-97 there was a global shift towards thinner melanomas. In 1995-97 nodular type and old age were the only variables significantly associated with thick melanomas when other factors were taken into account in a multivariate analysis. According to most recent data, early detection activities should be focused on older patients and on nodular histotype. Male sex and residence was no longer found to be associated with late melanoma diagnosis.     

Disease progression in patients with thin cutaneous melanomas (tumour thickness < or = 0.75 mm): clinical and epidemiological data from the Tumour Center Munich 1977-98

BACKGROUND: Although survival in patients with thin melanomas (tumour thickness < or = 0.75 mm) is usually excellent, thin melanomas have the potential to metastasize. OBJECTIVES: To determine risk factors for the development of disease progression in patients with thin cutaneous melanomas. METHODS: A retrospective study was performed between 1977 and 1998 to identify risk factors for the development of disease progression in 2302 patients with cutaneous melanoma with tumour thickness < or = 0.75 mm, diagnosed and treated at the Department of Dermatology and Allergology, Ludwig-Maximilians University, Munich, Germany. The Kaplan-Meier method was used to estimate the influence of different clinical characteristics for the occurrence of first progression during 10 years of follow-up. RESULTS: An analysis of the data from 6298 patients with cutaneous melanoma identified 2302 patients (37%) who presented with cutaneous melanoma with a tumour thickness < or = 0.75 mm, without clinical signs of metastasis at initial diagnosis (clinical stage Ia). A small subgroup of our patients (77 of 2302) developed metastatic disease during the follow-up period. The estimated rate of occurrence of metastasis after 10 years of follow-up was 4.7%. The mean follow-up time was 62 months (median 46). Of these 77 patients, 16 experienced progression at the primary tumour site and 32 presented with regional lymph node metastases. Twenty-eight patients primarily developed systemic metastases (seven patients with and 20 without regional lymph node metastases, one patient with regional lymph node metastases and local recurrence). In one patient the primary site of metastatic disease was not reported. Clinical characteristics included age, sex of the patient and different subtypes of cutaneous melanoma: superficial spreading melanoma, nodular melanoma, acrolentiginous melanoma (ALM) and lentigo maligna melanoma (LMM). Male patients and patients with LMM or ALM were significantly over-represented (P = 0.02 and P = 0.002). In the group of 77 patients with thin melanomas (< or = 0.75 mm), local recurrence was over-represented as compared with those with melanomas > 0.75 mm. No difference in group was found for overall survival after the occurrence of lymph node metastasis as the first manifestation of disease progression. CONCLUSIONS: Thorough follow-up and skin examination is recommended for a subgroup of patients with thin tumours, which consists of male patients with LMM or ALM located in the head and neck region.     

Case Reports of Fatal or Metastasizing Melanoma in Children and Adolescents: A Systematic Analysis of the Literature

Childhood melanoma (ChM) is rare, with clinical and epidemiologic characteristics that differ from those of adult melanomas. The objective of the current study was to systematically identify and analyze case reports and case series of fatal and metastasizing ChM in the medical literature. ChM case reports with a fatal outcome or metastases were identified using a Medline search and subdivided into ChM developing in the absence of a congenital melanocytic nevus (ChM without CMN) and ChM associated with a CMN (ChM with CMN); 258 cases of ChM without CMN (206 cutaneous, 52 noncutaneous) were identified. In cutaneous ChM without CMN with a fatal outcome (n = 155), the mean age at diagnosis was 13.1 years (median 14 yrs). The mean Breslow index in this group was 8.5 mm for children ages 0 to 10 years and 3.7 mm for children ages 11 to 18 years. In ChM with CMN (n = 178; 112 cutaneous, 66 central nervous system [CNS]), the mean age at diagnosis was 5.8 years for cutaneous melanoma (median 3 yrs) and 5.5 years for CMN‐associated CNS melanoma (median 3 yrs). The majority of CMN‐associated cutaneous melanomas developed in small and giant CMN (vs medium and large); 53.9% of CNS melanomas developed in patients with multiple medium CMN. This study represents the largest and most complete synopsis of ChM case reports in the medical literature. Our analysis supports the view that cutaneous ChM without CMN (or associated with smaller CMN) differs in several important aspects from ChM associated with large or giant CMN.     

The performance of SolarScan: an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma

OBJECTIVE: To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma. DESIGN: Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan. SETTING: Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners. PATIENTS: Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy. MAIN OUTCOME MEASURES: Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility. RESULTS: The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80). CONCLUSIONS: SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.     

Developing indications for the use of sentinel lymph node biopsy and adjuvant high-dose interferon alfa-2b in melanoma

OBJECTIVES: To convene a multidisciplinary panel of dermatologists, surgical oncologists, and medical oncologists to formally review available data on the sentinel lymph node (SLN) biopsy procedure and high-dose adjuvant interferon alfa-2b therapy for patients with melanoma and to rate the "appropriateness," "inappropriateness," or "uncertainty" of the procedure and therapy to guide clinical decision making in practice. PARTICIPANTS: The panel comprised 13 specialists (4 dermatologists, 4 oncologists, and 5 surgeons) from geographically diverse areas who practiced in community-based settings (n = 8) and academic institutions (n = 5). Participants were chosen based on recommendations from the relevant specialty organizations. EVIDENCE: A formal literature review was conducted by investigators at Protocare Sciences Inc, Santa Monica, Calif, on the risks and benefits of performing an SLN biopsy in patients with stage I or II melanoma and adjuvant interferon alfa-2b therapy in patients with stage II or III disease. The MEDLINE database was searched from 1966 through July 2000, and supplemental information was obtained from various cancer societies and cancer research groups. Panel participants were queried on additional sources of relevant information. Unpublished, presented data were included in abstract form on 1 recently closed clinical trial. CONSENSUS PROCESS: The RAND/UCLA Appropriateness Method was used to review and rate multiple clinical scenarios for the use of SLN biopsy and interferon alfa-2b therapy. The consensus method did not force agreement. CONCLUSIONS: The panel rated 104 clinical scenarios and concluded that the SLN biopsy procedure was appropriate for primary melanomas deeper than 1.0 mm and for tumors 1 mm or less when histologic ulceration was present and/or classified as Clark level 4 or higher. The SLN biopsy was deemed inappropriate for nonulcerated Clark level 2 or 3 melanomas 0.75 mm or less in depth and uncertain in tumors 0.76 to 1.0 mm deep unless they were ulcerated or Clark level 4 or higher. Interferon alfa-2b therapy was deemed appropriate for patients with regional nodal and/or in-transit metastasis and for node-negative patients with primary melanomas deeper than 4 mm. The panel considered the use of interferon alfa-2b therapy uncertain in patients with ulcerated intermediate primary tumors (2.01-4.0 mm in depth) and inappropriate for node-negative patients with nonulcerated tumors less than 4.0 mm deep. Specialty-specific ratings were conducted as well.     

CONJUNCTIVAL MELANOMAS

Background. The nomenclature and the clinical and pathologic features of cutaneous and conjunctival melanomas are different. A comparison is made to familiarize dermatologists and ophthalmologists with these differences. Methods. Five cases of conjunctival malignant melanoma from December 1983 to December 1990 were reviewed. Results. The nomenclature of primary acquired melanosis is not used for cutaneous melanomas, and terms such as dysplasia and Clark's nevus are not used for conjunctival melanomas. Technical difficulties exist in orienting thin conjunctival tissues because of a tendency to curl during fixation, resulting in tangential sectioning and making a false diagnosis of a prognostically ominous pagetoid spread for an otherwise banal basilar hyperplastic pattern. Excision, cryotherapy, and rarely exenteration are the therapeutic measures in managing conjunctival melanomas; these have far more serious consequences for the patient compared with the excision of a skin melanoma. Conclusion. Differences exist in several aspects between melanomas located in the skin and the eye.     

Management of Spitz nevi: a survey of dermatologists in the United States

BACKGROUND: There is no consensus concerning management of Spitz nevi. OBJECTIVE: This study was carried out to ascertain how dermatologists manage Spitz nevi. METHODS: A questionnaire was sent to 997 fellows of the American Academy of Dermatology, 284 pediatric dermatologists, and 27 directors of pigmented-lesion clinics. The results are based on the 381 questionnaires returned. RESULTS: The vast majority of responding dermatologists (93%) recommend biopsies of suspected Spitz nevi. Of this group, 43% recommend total biopsies and 55% recommend partial biopsies; 2% would recommend either total or partial biopsies, depending on the clinical situation. Sixty-nine percent of physicians would completely excise a lesion that was histologically diagnosed as an incompletely removed Spitz nevus. Seventy percent of general dermatologists and 80% of pediatric dermatologists would recommend excision with a 1- to 2-mm margin of normal-appearing skin around a Spitz nevus. Nine percent of general dermatologists would recommend margins of 4 mm or more; however, all pediatric dermatologists surveyed would recommend margins less than 4 mm. Physicians were less likely to monitor patients whose Spitz nevi were completely removed. Three fourths (74%) of respondents believe Spitz nevi are entirely benign, 4% believe they are precursors to melanoma, and 22% are not sure. Seven percent of general dermatologists and 4% of pediatric dermatologists have seen metastatic melanomas arise at sites of lesions initially diagnosed histologically as Spitz nevi; 40% of pigmented-lesion clinic directors have seen such lesions. CONCLUSIONS: We believe that the lack of consensus, both in our survey and in the medical literature, reflects to some extent the lack of certainty in the histologic differentiation of Spitz nevi from melanomas and that concern about melanoma influences management. At the pigmented-lesion clinic of the New York University Skin and Cancer Unit, because of this concern about melanoma, it is usually recommended that Spitz nevi be completely excised.     

Clinical and dermatoscopic diagnosis of small pigmented skin lesions

Small pigmented skin lesions represent a new challenge for all physicians devoted to the early diagnosis of melanoma. The purpose of this prospective study was to establish the diagnostic value of the clinical and the dermatoscopic examinations in a population of 157 consecutive patients with 161 small (< or = 6 mm) pigmented lesions, recruited in a short time. Of these 161 lesions, 13 were thin melanomas (median thickness 0.49 mm). In this population, clinical evaluation produced a diagnostic sensitivity of 77% and a specificity of 74%. Dermatoscopy resulted in a sensitivity of 77% and in a specificity of 72%. Combining clinical and dermatoscopic evaluations all the melanomas were preoperatively recognised. The results of the present study stress the complementary role of clinical and dermatoscopic examinations. In particular, clinical evaluation remains of utmost importance in diagnosing melanoma. This concept must be stressed in the education and training of young dermatologists.     

Seasonal pattern of the diagnosis of cutaneous melanoma: a hospital-based study in a Mediterranean country

BACKGROUND: Several investigators have described a seasonal variation in the diagnosis of cutaneous melanoma. Limited data exist on the seasonality of melanoma diagnosis in Southern European countries. PATIENTS AND METHODS: The seasonal pattern of diagnosis was analyzed in 404 Greek patients diagnosed with cutaneous melanoma (CM) between 1996 and 2004. A summer-to-winter ratio was determined overall and in relation to gender, age, anatomic site, histopathologic type, and tumor thickness. RESULTS: The summer-to-winter ratio was 1.53 for all patients (95% CI [confidence interval]: 1.15-2.02) with a ratio of 1.83 for women (95% CI: 1.20-2.78) and 1.28 for men (95% CI: 0.87-1.88). A seasonal pattern of melanoma diagnosis was observed for patients younger than 50 years of age (1.70, 95% CI: 1.05-2.74) and between 50 and 69 years (1.64, 95% CI: 1.05-2.56), for melanoma located on the upper or lower extremities (2.50, 95% CI: 1.12-5.56 and 2.23, 95% CI: 1.19-4.18, respectively), for superficial spreading and nodular melanomas (1.73, 95% CI: 1.12-2.69 and 1.52 95% CI: 0.96-2.41) and for melanomas with a tumor thickness of 1-2 mm (1.69, 95% CI: 0.91-3.12) and > 4 mm (2.13, 95% CI: 1.04-4.35). CONCLUSIONS: No major differences were seen in the seasonal distribution of CM diagnosis in a Mediterranean population compared to previously reported results. A better ascertainment of the skin during the summer and an increased awareness due to the melanoma screening campaigns are the more likely reasons for the seasonality of melanoma diagnosis in Greece.     

Características clínico-patológicas de los melanomas cutáneos diagnosticados en un hospital terciario mediterráneo entre 1990 y 2004: comparación entre sexos,por grupos de edad y evolución a lo largo del tiempo

BackgroundThe incidence of malignant melanoma has increased over recent decades. Early diagnosis continues to be essential for effective treatment. Our objective was to analyze cutaneous malignant melanomas diagnosed over a 15-year period in a tertiary hospital for trends towards earlier diagnosis and to identify subgroups with poorer prognosis.Material and methodsRetrospective analysis of primary cutaneous melanomas analyzed in the pathology department of Hospital La Paz, Madrid, Spain, between 1990 and 2004.ResultsIn total, 526 melanomas were diagnosed. The mean (SD) Breslow thickness was 2.63 (4.84) mm and the median thickness was 0.98 mm (range, 0-65 mm). The mean size (widest point) was 16.59 (12.11) mm. The most common histological type was surface-spreading melanoma and the most common site was the trunk. Melanomas detected in men were generally larger and thicker than in women (P = 0.05). Individuals aged over 60 years consulted for significantly thicker and larger tumors than younger individuals. The incidence of malignant melanomas has increased steadily over the years whereas the mean Breslow thickness and size have decreased.ConclusionsDiagnosis of melanoma in Spain is made increasingly earlier, although locally advanced tumors are still sometimes seen in men and in individuals aged over 60 years.     

Patient education and regular surveillance results in earlier diagnosis of second primary melanoma

BACKGROUND: As the incidence of cutaneous melanoma continues to rise, more individuals will be at risk for developing second primary melanomas. We hypothesize that patient education and follow-up surveillance will lead to the early detection of subsequent primary melanomas as demonstrated by a decrease in Breslow thickness at diagnosis. METHODS: A computer-based investigation was performed to identify patients who had developed a second primary melanoma following treatment of in situ and American Joint Commission on Cancer (AJCC) Stage I or II melanoma. Patients are routinely educated on the increased risk of developing a second primary lesion and characteristic clinical features of melanoma. Patient surveillance was performed on a regular basis. Differences in Breslow thickness between the initial and subsequent primary melanomas were analyzed by a paired t-test. RESULTS: Among 877 individuals identified in the Mount Sinai School of Medicine Department of Dermatopathology database with in situ or AJCC Stage I or II melanoma, 111 developed a second primary melanoma. The mean thickness was 0.239 +/- 0.661 mm for the initial melanoma and 0.1135 +/- 0.319 mm for the subsequent melanoma. By paired t-test, the difference in tumor thickness was statistically significant (P = 0.019). CONCLUSIONS: Upon analysis of our data, subsequent primary cutaneous melanomas were found to be significantly thinner than initial primary melanomas at the time of diagnosis. This suggests that earlier diagnosis may be the result of patient education and careful follow up. Counselling on the risk of developing a second primary melanoma, education regarding clinical characteristics of melanoma, and routine lifelong follow up should be provided to all patients diagnosed with a cutaneous melanoma.     

How well do physicians recognize melanoma and other problem lesions?

The alarming increase in the incidence of cutaneous malignant melanoma in the United States emphasizes the importance of its early detection and treatment. Early detection requires accurate clinical recognition of both malignant and precancerous skin lesions (dysplastic nevi). This study presents data on dermatologists' and nondermatologists' ability to diagnose skin lesions. A total of 105 nondermatologist physicians, from first-year residents to practicing physicians, and forty-eight dermatologists were asked to identify color slides or photographs of eleven cutaneous lesions, including malignant melanomas, dysplastic nevi, and innocuous lesions such as seborrheic keratoses and common moles. Diagnosis of cutaneous lesions was generally inaccurate among nondermatologists. Only 38% correctly identified four or more of the six melanomas as melanoma of any type, and 58% were unable to diagnose dysplastic nevi. Only 17% categorized their relevant training as excellent or good. Improved training in the diagnosis of skin lesions for practicing physicians and house staff is required if mortality from malignant melanoma is to be decreased in the United States.     

Invasive cutaneous melanoma in elderly patients

Clinical and pathologic variables were compared between "older" (greater than or equal to 70 years) and "younger" (30 to 39 years) patients with primary invasive cutaneous melanoma. Older patients had more nodular melanomas and acral lentiginous melanomas (58%); superficial spreading melanomas predominated in younger patients (74%). Mean tumor thickness was greater in the older patients (3.95 vs 2.02 mm). Invasive levels 2 and 3 occurred more often in younger patients (41.1% vs 13%); level 5 occurred more often in older patients (30.4% vs 5.3%). Microscopic ulceration occurred more often in older (46.4%) than in younger patients (19.4%). Older patients classified as clinical stage I at presentation or with primary lesions 1.50- to 3.00-mm thick had poorer survival. Younger women survived longer than younger men; this was not true of older patients. The elderly patients with cutaneous melanoma were more likely to have poor prognostic features and thus more likely to die from melanoma than the younger patients.     

Small diameter melanoma: a follow-up of the Norwegian Melanoma Project

BACKGROUND: Melanoma prognosis is dependent upon early recognition and treatment. There is a need for good clinical guidelines that focus on the early signs of melanoma. The ABCD (asymmetry, border, colour and diameter) rule states that most melanomas are more than 6 mm in diameter. Critics crave a modification, arguing that small diameter melanomas are not infrequent. OBJECTIVES: The aim of the present study was to describe the frequency and prognosis of melanomas less than 7 mm in a clinical setting. METHODS: The Norwegian Melanoma Project was conducted as a multicentre, prospective study with inclusion criteria. Patients were recruited from five dermatological departments in Norway from 1990 to 1993. RESULTS: The frequency of small melanomas was 11.4% (18/158). One-third was in situ melanoma, the rest invasive with a median thickness of 0.8 mm. Four small melanomas were T2 lesions, with a Breslow thickness of more than 1 mm. One nodular T2 melanoma recurred locally 2 years after diagnosis and the patient died of distant metastasis only months later. CONCLUSIONS: The ABCD rule remains a practical guide for early recognition of melanoma. Clinicians must be aware of its limitations.