The new 8th edition of TNM staging and its implications for skin cancer: a review by the British Association of Dermatologists and the Royal College of Pathologists, U.K.

The 8th edition of TNM (tumour, node and metastasis) has numerous and important changes compared with the 7th edition. Public Health England and the Royal College of Pathologists, U.K., have adopted the 8th edition of TNM (TNM8) published by the Union for International Cancer Control for skin cancer staging. These changes will have an impact on the management and commissioning of melanoma and nonmelanoma skin cancer (NMSC). The T1-T3 categories for NMSC staging require the clinician to measure the maximum dimension (usually diameter) of every potential invasive cancer. For squamous, basal and adnexal carcinomas, but not Merkel cell carcinoma (MCC), the T1-T3 categories are defined by new 20-mm and 40-mm divisions based on the maximum dimension of the lesion. In addition, new risk factors upstage T1 or T2 to T3. For melanoma, mitotic index no longer influences separation of pathological stage (pT1). There is a new, additional stratification level at 0·8-mm Breslow thickness. Subdivision pT1b, with a negative sentinel lymph node biopsy (SLNB) of pN0, is now stage IA compared with the previous IB. For MCC, SLNB is now included specifically in the pN staging system. The pT1 subdivision requires clinical information as to whether histologically involved nodes were clinically occult or detectable. For both melanoma and MCC the clinician must state whether the lymph nodes are occult or clinically detectable. Eyelid carcinoma continues to have a staging system different from that in general skin and the system is substantially revised in TNM8.

Subacute cutaneous lupus erythematosus associated with radioiodine treatment.

Subacute cutaneous lupus erythematosus (SCLE) is characterized by nonscarring, photodistributed, annular or papulosquamous plaques with antibodies to Ro/SS-A antigen. We report a case of SCLE associated with radioiodine treatment.

Dermatitis artefacta of the lip in an adolescent.

UNLABELLED: Self-inflicted trauma is found in several patient groups including those with learning and developmental delay, the very young and those suffering from psychiatric disturbance. The diagnosis of artefactual disease can only be made when all possible organic disease has been excluded by specific investigations. The case presented is that of a 15-year-old girl complaining of persistent bleeding and crusting of her lips. Investigations provided no real information as to the cause of the allegedly spontaneous bleeding. The diagnosis of artefactual disease was finally decided upon and a referral to a child and adolescent psychiatrist made. CLINICAL RELEVANCE: Patients with unusual clinical signs may be examined regularly by their GDP. This case clearly illustrates the importance of considering a psychological disorder and referral in the differential diagnosis of conditions appearing with unusual clinical signs.

Skin cancer. Recognition and treatment.

There is a worldwide increasing incidence of all forms of skin cancer among Whites as a result of increased sun exposure. Basal cell and squamous cell carcinomas, the most common tumours of the head and neck, are relatively benign neoplasms of elderly individuals. Malignant melanoma, however, has the potential for early metastasis and may occur in early adult life. The increase in malignant melanoma is particularly disturbing, and is a clear indication for skin screening clinics. Although surgical excision is the primary treatment of choice for skin tumours, various drugs may be of therapeutic value. Fluorouracil cream is a useful treatment for solar keratoses. Retinoids are particularly suitable for patients with large numbers of nonmelanoma skin cancer lesions and solar keratoses. For malignant melanoma, arterial limb perfusion with high concentrations of cytotoxic drugs may be performed both as an adjunctive and therapeutic manoeuvre. Treatment of metastatic melanoma with cytotoxic agents is associated with low response rates and high toxicity. However, trials with combined interferon-alpha, interleukin-2 and cytostatic drugs have produced promising preliminary results.

Smoking, eicosanoids and ulcerative colitis.

In this study, which is the first of its kind using normal tissue samples that are very difficult to obtain, we have investigated the hypothesis that smoking protects against ulcerative colitis by altering the colonic mucosal formation of prostaglandins and related substances. Colonic mucosa biopsied from healthy young men produced prostaglandin E, 6-keto-PGF1 alpha (formed from PGI2), leukotriene B4 and leukotriene C4/D4/E4 as determined by radioimmunoassay. With each substance, the median yield was lower in the group of smokers who smoked 3 cigarettes in the 2 h before biopsy, than in the non-smokers. However, with each eicosanoid the statistical probability approached only the 10% level, but the fact that the trend was the same for all eicosanoids somewhat strengthens the possibility of a real difference between the groups.

Quality and outcomes management in the primary care practice.

In response to the trend away from thinking of health care as a commodity to one in which quality is a differentiating feature among providers, primary care practices must focus on outcomes management. This article reviews the various clinical and office-based processes that influence practice outcomes. These include patient management, chart management, practice guidelines, clinical pathways, case management, and patient information. The key to a quality program and successful outcomes management is a commitment on the part of physicians to managing these processes so that best outcomes are achievable.

Cowpox presenting with sporotrichoid spread: a case report.

We describe a patient with cowpox infection who presented with a sporotrichoid pattern of cutaneous lesions. This is the first report of a sporotrichoid pattern of spread in cowpox infection.

The use of meshed advancement flaps in the treatment of lesions of the lower leg.

We describe the use of meshed local advancement flaps to repair surgical defects of the lower leg. The procedure produces a lattice of small cutaneous defects that heal rapidly by second intention. The technique is simple to perform and is suitable for large defects of the lower leg. Only minimal supervision is required post-operatively, and the wound causes virtually no pain.

Micrographic surgery for basal cell carcinoma.

Mohs' micrographic surgery is the most effective method of ensuring complete removal of basal cell carcinoma. It is particularly indicated for recurrent tumours and tumours in critical anatomical areas of the face. This article describes the technique and contrasts it with conventional surgical excision and tissue processing.