In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

The impact of subspecialization and dermatoscopy use on accuracy of melanoma diagnosis among primary care doctors in Australia.

BACKGROUND: Dermatoscopy improves accuracy of melanoma diagnosis, but the impact of subspecialization in skin cancer practice among general practitioners on melanoma diagnostic accuracy is not known. OBJECTIVE: To assess the impact of dermatoscopy use and subspecialization on the accuracy of melanoma diagnosis by general practitioners. METHODS: We did a prospective study on the Skin Cancer Audit Research Database and measured melanoma 'number needed to treat' (NNT), with 21,900 lesions excised to diagnose 2367 melanomas. RESULTS: Melanoma NNT fell from a high of 17.0 (95% confidence interval [CI] 14.5-20.7) among general practitioners with a generalist practice to 9.4 (CI 8.9-10.1) among those with a specific interest in skin cancer, and 8.5 (CI 8.1-9.0) among those practicing only skin cancer medicine (P < .0001). Melanoma NNT fell from a high of 14.6 (CI 12.0-18.6) among dermatoscopy low/non-users to 10.9 (CI 9.8-12.4) among medium users, and 8.9 (CI 8.6-9.3) among high users (P < .0001). The association between NNT and practice type remained (P < .0001) when adjusted for dermatoscopy use and other variables. The association between NNT and dermatoscopy use disappeared (P = .41) when adjusted for practice type and other variables. LIMITATIONS: There is selection bias with respect to participating doctors and completeness and accuracy of data are not independently verified in the Skin Cancer Audit Research Database (SCARD). CONCLUSIONS: General practitioners who subspecialize in skin cancer have a higher use of dermatoscopy and diagnose melanoma with greater accuracy than their generalist counterparts.

Dermatoscopy in routine practice - 'chaos and clues'.

BACKGROUND: Skin cancer is a major cause of mortality and morbidity in Australia, and primary care doctors can, and should, treat most cases. OBJECTIVE: In this article we outline one method for the effective use of dermatoscopy in diagnosing melanoma and other skin malignancies in general practice. DISCUSSION: The use of a dermatoscope in clinical practice has been shown to increase diagnostic accuracy and is considered the standard of care in assessing patients with pigmented skin lesions. Its use is also being increasingly applied to the diagnosis of nonpigmented skin lesions. Like any clinical tool, training is required for effective use. 'Chaos and clues' is a straightforward method of rapidly assessing suspicious pigmented skin lesions using a dermatoscope; its use can lead to improved diagnosis of melanoma and other skin malignancies.

Dermatology education on the Web.

Conventional dermatology teaching favours a didactic, factual approach, rather than a problem-solving approach. A Web-based education system that uses a problem-solving approach offers many advantages. Several international Websites now provide continuing education to specialist dermatologists. These are all 'discretionary' Websites, that is, they are visited by choice; 'obligatory' educational Websites are those tied to a university medical faculty or postgraduate college and which host either online tasks that must be completed or unique examinable material. An interactive education Website, named Dermconsult, has been established unofficially for fellows of the Australasian College of Dermatologists and registrars in training. However, a successful Website will require backing from certifying organizations. Continuing medical education will need to be compulsory for potential users if an educational Website is to be successful.