Surgical excision of skin cancer: the importance of training

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3‐month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21·5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.     

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.     

A retrospective study comparing the accuracy of prehistology diagnosis and surgical excision of malignant melanomas by general practitioners and hospital specialists

A retrospective study was carried out to compare the overall standard of surgical excision of malignant melanomas (MMs) between general practitioners (GPs) and hospital specialists before and after the introduction of the UK melanoma guidelines between 1989 and 2006. In total, 213 melanoma excision reports were examined and surgical excision margins recorded. The results showed a significant difference in the rate of adequate surgical excision margins (at all levels of Breslow thickness) between GPs and hospital specialists, with hospital specialists excising melanomas with safe surgical excision margins at a significantly higher rate compared with GPs. Since the introduction of the guidelines in 2002, GPs showed a significant improvement in the completeness of melanoma excision but remained poor at prehistology diagnosis and in particular at taking adequate excision margins. Implementation of the guidelines has not produced significant improvements in adequacy of excision margins in both primary and secondary care. The results show that hospital specialists maintained a high standard of prehistological diagnosis and completeness of excision throughout the time of the study, performing at a significantly higher standard compared with GPs. Our conclusions concur with the UK melanoma guidelines and the National Institute for Health and Clinical Excellence guidelines, which suggest that lesions suspicious for melanoma should be urgently referred to a dermatologist or plastic surgeon for surgical excision and should not be surgically excised in primary care, particularly if lesions have a Breslow thickness > 2 mm. We suggest that the new guidelines need to be more aggressively implemented in primary care and guidance introduced to improve the accuracy of diagnosis, with better training provided for GPs.     

Factors influencing skin cancer excision rates in Scottish primary care

Skin cancer incidence rates are rising in the UK, yet many areas are experiencing a shortage of dermatologists. We sought to compare skin cancer excision rates between general practice (GP) surgeons to identify factors associated with good practice, through a retrospective analysis of GP skin cancer histopathology reports in three Scottish Health Boards over a 4‐year period. Postal questionnaires were used to explore factors affecting surgeons’ excision rates. GPs excised 895 skin cancers (4.5% of the 19 853 regional total) during the period. Of the basal cell carcinomas, 308 would be classified as low‐risk by current National Institute for Health and Care Excellence criteria. Of the returned questionnaires, 58 accounted for 631 (70.5%) of the excised skin cancers. Analysing completeness of skin cancer excision, there was a statistically significant difference between GPs performing excision on ≥ 11 lesions/month compared with those performing excision on ≤ 10/month. Policymakers may wish to consider systems to facilitate low‐risk patients being treated by GPs who undertake frequent surgical procedures.     

Dermatological surgery: a comparison of activity and outcomes in primary and secondary care

Background  Dermatological surgery is carried out by a variety of practitioners in primary and secondary care.
Objectives  To explore the activity and histopathological outcomes among different groups of dermatological surgeons dealing with skin cancers.
Methods  Reports for all new skin tumour specimens processed by our histopathology department over a continuous 3-month period were reviewed retrospectively.
Results  One thousand, one hundred and eleven new skin tumour specimens were identified. General practitioners (GPs) were least accurate in clinical diagnosis, with 42·8% (59/138) of their request forms including the eventual histological diagnosis, compared with 69·5% (328/472) for dermatologists (odds ratio, OR 0·33, 95% confidence interval, CI 0·22–0·48). Inappropriate procedures were most often performed by plastic surgeons, usually involving large excision biopsies for benign lesions in elderly patients [6·6% (20/305) of their specimens vs. 0% for dermatologists, exact P  <   0·001]. Excision biopsies performed by GPs had the highest rate of margin involvement by tumour of any specialty [68% (15/22) of such specimens vs. 8% (9/116) for dermatologists; OR 25·47, 95% CI 8·26–78·53]. As per National Institute for Health and Clinical Excellence guidance, 13·8% (19/138) of tumours operated on by GPs should instead have been referred to secondary care for initial surgical management.
Conclusions  This study presents a strong case for dermatologists to continue to provide the lead in diagnosis of skin lesions, and in selection and execution of dermatological surgical procedures.     

Diagnostic ability of general practitioners and dermatologists in discriminating pigmented skin lesions

BACKGROUND: Early recognition of melanoma is the key in preventing metastatic disease. OBJECTIVE: The aim of this study was to evaluate diagnostic ability of general practitioners (GPs) and dermatologists concerning pigmented skin lesions in general and melanoma in particular. We also investigated whether the diagnostic ability of GPs changed after a lecture on melanoma. METHODS: A test set of 13 pigmented skin lesions on 35-mm color slides was presented to 160 GPs and 60 dermatologists during educational courses. RESULTS: GPs correctly evaluated biologic behavior of the pigmented skin lesions in 72% of the evaluations. In 71% of these evaluations they correctly identified the lesions. The proportion of lesions correctly identified was positively correlated with the frequency of pigmented skin lesions in everyday practice. Dermatologists made a correct identification of the lesions in 88% of all evaluations, and they correctly evaluated biologic behavior in 94% of these. Recognition of melanoma was proportional to melanoma exposure in everyday practice. Thick melanomas were better recognized than thin melanomas in both physician groups. After a lecture on melanoma, sensitivity of GPs to recognize malignant disease increased from 72% to 84%, without a significant decrease in specificity. The proportion of lesions correctly identified also rose significantly (66% vs 52%).     

Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients

BACKGROUND: In the Irish health system, dermatology patients present to their family practitioner for diagnosis and treatment, and are referred to a dermatologist for a second opinion where diagnosis is in doubt or when there has been therapeutic failure. The level of expertise in dermatology amongst family practitioners varies considerably. AIM: To compare the diagnoses of general practitioners and dermatologists over a selected period in patients with a possible diagnosis of skin cancer. METHODS: Four hundred and ninety-three patients were seen by one of two dermatologists over a 1-year period at a rapid referral clinic for patients suspected by their family practitioners of having unstable or possibly malignant skin lesions; 213 of these patients had a diagnosis made on clinical examination by the dermatologist, while 264 had diagnostic or therapeutic biopsies performed; 16 patients defaulted on surgery. RESULTS: The diagnoses of the family practitioners agreed with the diagnoses of the dermatologists on patients diagnosed clinically in 54% of cases. Thirty-eight patients had histologically proven skin malignancy. These were diagnosed accurately by the referring family practitioner in 22% of patients, while the dermatologists made the correct diagnosis prior to biopsy in 87%. CONCLUSIONS: In over 50% of cases diagnosed clinically, the dermatologist and family practitioner agreed. Histologically proven skin cancers were diagnosed accurately in only 22% of cases by family practitioners, compared to 87% of cases by dermatologists. Specific areas of diagnostic difficulty for family practitioners include benign pigmented actinic and seborrheic keratoses, squamous cell carcinoma, and melanoma. Postgraduate education for family practitioners should be directed towards these areas of deficiency. Dermatologists had difficulty distinguishing pigmented actinic keratoses from melanoma.     

Diagnostic and surgical accuracy and economic aspects of dermatological surgery - a pilot study

BACKGROUND: Good skin care for oncological dermatological patients includes efficacious excision to achieve tumour control and economically reasonable costs. This field concerns dermatologists as much as other surgical specialities. METHODS: Of 944 excisions and biopsies, we studied 114 epidermal carcinomas excised by plastic surgeons and dermatologists. This allowed us to compare the accuracy concerning oncological surgical aspects as well as the extrapolated costs produced by these two specialities. RESULTS: Dermatologists are significantly more accurate concerning total excision of epidermal tumours compared to plastic surgeons. CONCLUSION: From an economic point of view, plastic surgeons are increasingly more expensive than dermatologists. Most expenses are due to the use of a hospital operating room.     

Management of naevus sebaceous: a national survey of UK dermatologists and plastic surgeons

Naevus sebaceous (NS) is a congenital cutaneous hamartoma, which typically occurs on the head and neck. Historically, the treatment of choice was excision in infancy because of the potential for malignant transformation; however, recent studies suggest that this risk is < 1% and unlikely in childhood. We sent a questionnaire to UK dermatologists and plastic surgeons to investigate current management practice of NS. We found that almost a third of dermatologists still recommend excision for malignancy prevention, while over 90% of plastic surgeons consider excision, with 64% citing malignancy prevention as the reason. Plastic surgeons most commonly recommended excision in childhood, whereas dermatologists waited until adulthood. We have shown there is significant variation in practice across the UK in the management of naevus NS. It is important that patients across the UK receive the same standard of care, and therefore we advocate the development of evidence‐based guidance for treatment of naevus NS.     

Clinical validation of an automated system for supporting the early diagnosis of melanoma

BACKGROUND: Early diagnosis and surgical excision is the most effective treatment of melanoma. Well-trained dermatologists reach a high level of diagnostic accuracy with good sensitivity and specificity. Their performances increase using some technical aids as digital epiluminescence microscopy. Several studies describe the development of computerized systems whose aim is supporting dermatologists in the early diagnosis of melanoma. In many cases, the performances of those systems were comparable to those of dermatologists. However, this cannot tell us whether a system is able to support dermatologists. Actually, the computerized system might correctly recognize the same lesions that the dermatologist does, without providing them any useful advice and therefore being useless in recognizing early malignant lesions. PURPOSE: We present a novel approach to enhance dermatologists' performances in the diagnosis of early melanoma. We provide results of our evaluation of a computerized system combined with dermatologists. METHODS: A Multiple-Classifier system was developed on a set of 152 cases and combined to a group of eight dermatologists to support them by improving their sensitivity. RESULTS: The eight dermatologists have average sensitivity and specificity values of 0.83 and 0.66, respectively. The Multiple-Classifier system performs as well as the eight dermatologists (sensitivity range: 0.75-0.86; specificity range: 0.64-0.89). The combination with the dermatologists shows an average improvement of 11% (P=0.022) of dermatologists' sensitivity. CONCLUSION: Our results suggest that an automated system can be effective in supporting dermatologists because it recognizes different malignant melanomas with respect to the dermatologists.     

Mohs micrographic surgery: a review of indications,technique, outcomes,and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.     

Changing trends in melanoma treatment and the expanding role of the dermatologist

As the incidence of melanoma continues to increase, so does the role of the dermatologist as both medical and surgical oncologist for these patients, especially those with stage I disease. The dermatologist holds a key role in all phases of care, including prevention, diagnosis, treatment, and follow-up. The dermatologist is best trained to complete a full and thorough skin examination and is best able to recognize a melanoma at its earliest stages of radial growth. In large part because of advances in dermatology, the dysplastic nevus syndrome has been identified as an important marker and precursor lesion for melanoma; the dermatologist has the best knowledge base for the recognition and management of both sporadic and familial dysplastic nevi. Dermatologists also have the unique opportunity (by virtue of their patient population concerned with skin problems) to prevent melanoma through patient education concerning sun protection, self-examinations, and the ABCDs of melanoma recognition. The dermatologist is well trained to obtain an appropriate, full-thickness skin biopsy specimen and is also knowledgeable to interpret the pathologist's report, understanding the significance of the various histologic prognostic indices. Because of the changing trends in excisional margin size and fewer recommendations for ELND, the dermatologist is becoming more active in the surgical management of melanoma patients. In the MDMC, the dermatologist was clearly recognized as a capable surgeon to perform the wide local excisions for stage I patients. Almost one half of the patients seen (49%) were surgically treated in the department of dermatology. Of group I patients, 78% were treated by dermatologists. The dermatologist as surgeon should be capable of performing a wide local excision to the level of deep subcutaneous tissue or muscle fascia with an appropriate primary layered closure, local flap, or graft. Our experience confirms that the majority of patients present with local disease and a thin Breslow depth and thus can be skillfully treated in an outpatient setting under local anesthesia by a dermatologic surgeon. In follow-up, the dermatologist should provide continuity of care and should be knowledgeable in appropriate interval examinations and tests. The dermatologist is thoroughly skilled at the cutaneous examination and has the knowledge base to perform a careful and competent lymph node examination. As primary medical oncologist to these patients, the dermatologist needs to recognize stage II and stage III disease and be able to comprehensively discuss with the patient the options for treatment and how they affect their prognosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

Melanoma

A retrospective review of 182 cutaneous melanomas seen at King's College Hospital from 1970 to 1987 showed that surgeons saw much thicker melanomas (median 3.64 mm) when compared to dermatologists (median 1.14 mm). Surgeons saw a greater proportion of nodular melanomas, less superficial spreading melanomas, were less likely to make the correct clinical diagnosis, and were more likely to perform wide excisions for thin melanomas (less than 2 mm) when compared to dermatologists. General surgeons see a different group of melanoma patients compared to dermatologists and manage them differently from dermatologists working with plastic surgeons. There is a need for a combined approach for the diagnosis and management of cutaneous melanoma between specialists.     

Is sentinel node biopsy the standard of care in melanoma management? The opinions and practices of Australian specialists

Background/Objective: There is international debate over the role of sentinel node biopsy (SNB) in invasive melanoma management. There is currently evidence that SNB offers prognostic information; however, the therapeutic benefit of SNB is yet to be elucidated. Many experts describe SNB as the standard of care in the management of patients with melanoma. Labelling a procedure as a standard of care has consequences from the perspectives of both patient care and cost. This study aims to determine the opinions of Australian dermatologists and plastic surgeons on the role of SNB, to compare these opinions between specialties and to compare self‐reported practices with current evidence. Methods: An online survey of 10 questions was distributed to members of the Australasian College of Dermatologists and the Australian Society of Plastic Surgeons. Results: A total of 137 responses were received (66 dermatologists and 71 plastic surgeons), representing 16% of the dermatologists and 20% of the plastic surgeons in Australia. Just over half of the respondents (51%) said SNB should not be the standard of care. More dermatologists than plastic surgeons held this view. In total 15% of specialists were counselling patients outside current guidelines. Conclusions: Australian specialists are divided on the role of SNB in the management of patients with melanoma. There are differences in opinion on the role of SNB in melanoma management between speciality groups and regions. A significant percentage of specialists are counselling patients outside current guidelines.     

Melanoma excision by general practitioners in North–East Thames region, England

A retrospective study of pathology reports of melanomas excised by general practitioners (GPs) was undertaken in the course of a population-based study of melanoma, with a telephone survey of the current practice of those GPs who had excised melanomas. The objectives of this study were to identify all cases of cutaneous melanoma excised by GPs in the North-East Thames Region between 1989 and 1993, and to review the management of those patients. The main outcome measures of the study were: (i) the patterns of distribution of GP excisions within the region; (ii) the histological subtypes of melanomas excised, the accuracy of the pre-excision clinical diagnosis and the adequacy of treatment of the GP-treated tumours compared with the control group; and (iii) the reported current practice in the management of pigmented skin lesions by the GPs who had excised melanomas. Eight hundred and nineteen melanomas were excised in the region during the study period, of which 59 were excised by GPs. The Breslow thickness of tumours was similar in both GP-excised and non-GP-excised groups. Tumours were more likely to be amelanotic in the GP-excised group (P < 0.001). Incomplete excision was significantly more likely in the GP group (P < 0.001). The GPs made a confident clinical diagnosis of melanoma in only 17% of patients prior to surgery. The reported referral rate to specialists by this subset of GPs of patients with pigmented lesions was low, and at interview half of the GPs reported that they felt confident enough to manage patients with suspected skin cancers on their own. The majority of the GPs did not routinely obtain histological examination of skin lesions they believed to be benign. In conclusion, there are problems with the accuracy of clinical diagnosis and inadequacy of excision of melanomas removed in primary care. In the majority of cases, however, patients were subsequently appropriately treated by referral to specialist units. There was an under-usage of pathological examination of samples by the GPs interviewed.     

Knowledge and management of scabies in general practitioners and dermatologists

Scabies is an infectious skin disease with an increasing incidence during the past decade. A survey was conducted among general practitioners (GPs) and dermatologists in the region of Ghent, Belgium, to explore their knowledge on scabies. Information on the treatment advice given and the frequency of reporting scabies to the Health Inspection was also collected. The scores on the knowledge test were of an acceptable level in both GPs and dermatologists (median score 59% and 79% respectively). We found that profession (dermatologist versus GP), the number of years of experience and the estimated number of scabies patients per year had a significant effect on this score. Permethrin cream, currently regarded as the standard treatment, is prescribed as the only treatment for scabies by half of the GPs and dermatologists. Almost 50% of the GPs and dermatologists indicated they rarely or never report scabies to the Health Inspection. As a result the correct incidence of scabies in Belgium, as in many other countries, is not known.     

Complications of cutaneous laser surgery. A survey

We surveyed a selected group of 139 dermatologists and plastic surgeons about their experience with the complications of cutaneous laser surgery. Reported complication rates varied from 0% to 35%, with means of 3.2% for dermatologists and 6.2% for plastic surgeons using the argon laser, and 4.2% for dermatologists and 2.8% for plastic surgeons using the carbon dioxide laser. Hypertrophic scarring was the complication noted most frequently; 69% of physicians using the argon laser and 64% of physicians using the carbon dioxide laser have seen at least one case of hypertrophic scarring. Complications noted less frequently include infection, pain, atrophic scarring, intraoperative or postoperative hemorrhage, and prolonged wound healing. Environmental accidents were few. No procedure-related deaths, ocular damage, or secondary cutaneous malignant neoplasms were reported. We conclude that cutaneous laser surgery has an acceptable risk profile but that complications are not uncommon.     

The concept of safer face-lifting

Face-lifting is now a common aesthetic procedure, performed mainly by plastic surgeons but increasingly also by ENT surgeons, oral surgeons, general surgeons and dermatologists. The level of expertise is dependent on training and exposure to patients, in addition to basic surgical skills. With cosmetic surgery clients, a holistic approach to patients is becoming increasingly important and, with increasing demands from the Care Standards Committee, there should be less demand for part-time aesthetic surgeons. This paper describes the working practice and thought processes of a single surgeon, based on 14 years of a busy aesthetic surgery practice. There are numerous types of face-lift described in the literature but, in practical terms, the simplest technique often gives the best result, with little risk of morbidity. Undoubtedly, some clients need an aggressive approach but, in most cases, the vertical pull mini-face-lift gives consistently good results in cases that are carefully assessed preoperatively and managed by skilled aesthetic/plastic nurses in the postoperative period. This paper is unique in its holistic approach to assessment, technique and aftercare. It is designed for the sensible surgeon, looking for a low-risk technique that reaps professional satisfaction and a happy client base. The more complex face-lift should be referred to recognized specialists in the field.