Seasonal variation in high-risk phenotypes of cutaneous malignant melanoma diagnosed in Eastern England: An observational study.

BACKGROUND: Despite seasonal variation in malignant melanoma diagnosis being well described, data on the annual variation in high-risk melanomas are scarce. OBJECTIVES: We set out to investigate the relationship between seasonality, the incidence of melanoma, and the distribution of melanoma characteristics, including Breslow thickness, ulceration, mitotic rate, lymphovascular and perineural invasion, and the presence of microsatellites. METHODS: Primary cutaneous malignant melanomas diagnosed between 2011 and 2019 in Eastern England were identified from our prospectively maintained melanoma database (n = 2199). These were analysed by year and season of diagnosis, patient demographics, and melanoma characteristics. RESULTS: There was a variation in rates of melanoma diagnosis across the year, with Summer having the highest incidence (p < 0.0001). There was a significant trend towards more male than female diagnosis in Winter (p = 0.0354). There were no significant seasonal trends in Breslow thickness, ulceration, tumour infiltrating lymphocytes, or mitotic rate. Multivariate analysis showed that microsatellites were more likely to be diagnosed in the Winter (OR=2.00 (1.19-3.43), p = 0.010), lymphovascular invasion significantly more likely to be diagnosed in Autumn (OR=1.78 (1.16-2.76), p = 0.009), and perineural invasion was more likely to be diagnosed in the Summer (OR=0.44 (0.23-0.79), p = 0.007). CONCLUSIONS: These data confirm that high-risk phenotypes are associated with increasing Breslow thickness and mitotic rate. However, season variability as an independent risk factor for the phenotypes is a novel finding.

Optical transfer diagnosis differentiating benign and malignant pigmented lesions in a simulated primary care practice.

BACKGROUND: The detection of melanoma poses a substantial challenge, particularly for primary care providers (PCPs) who may have limited training in discriminating between suspicious and benign melanocytic lesions. The noninvasive optical transfer diagnosis (OTD) method was designed to be used by PCPs in their decision-making process. OBJECTIVES: To assess the potential of the OTD method by developing, training and validating an OTD indication algorithm for automated discrimination between benign melanocytic lesions and malignant lesions, based on a set of 712 lesions. METHODS: The authors performed in vivoOTD capture and subsequent analysis of 712 pigmented lesions. Of the lesions, 415 were clinically and dermoscopically benign and 297 were dermoscopically suspicious or equivocal. After image capture, all suspicious or equivocal lesions were biopsied and examined histopathologically. RESULTS: Of the 297 suspicious or equivocal lesions, histopathological findings revealed 80 to be malignant (64 melanomas, 13 basal cell carcinomas and 3 squamous cell carcinomas). OTD misdiagnosed one of the 80 malignant lesions as benign (sensitivity, 99%). OTD specificity was 93% for the dermoscopically benign lesions, 73% for all lesions included in the study and 36% for the clinically suspicious but histopathologically benign lesions. CONCLUSIONS: High sensitivity and specificity, as provided by OTD in this preliminary study, would help PCPs reduce the number of referrals for dermatology consultation, excision or biopsy. Further studies are planned for screening patients in a primary care setting, with comparisons of OTD results with biopsy or dermoscopy results.

False-negative rate of intraoperative frozen section margin analysis for complex head and neck nonmelanoma skin cancer excisions.

INTRODUCTION: Intraoperative frozen section analysis (IFSA) is traditionally performed for complex and high-risk non-melanoma skin cancer (NMSC) resections, particularly when surgery under a general anaesthetic and a complex reconstruction is required, and where Mohs micrographic surgery (MMS) is not available. METHODS: A retrospective audit of 253 cases between 1999 and 2009 was undertaken, investigating the accuracy and efficacy of IFSA for the treatment of NMSC in our tertiary skin tumour unit based in a university hospital setting. RESULTS: The combined incomplete and very narrow (<1 mm) excision margin rates were 28.7% and 27.5% for basal cell and squamous cell carcinoma, respectively. Unrepresentative sampling of the excision margins intraoperatively was the overwhelming cause of error (94%). CONCLUSION: After a thorough audit of our data, IFSA has been abandoned for the treatment of NMSC in our unit. MMS is practised intraoperatively, even in advanced cases. We believe that IFSA no longer has any role in our complex, multidisciplinary skin cancer practice.

Setting up an effective and efficient sentinel node biopsy service for malignant melanoma within the NHS.

Sentinel lymph node biopsy provides prognostic information for melanoma patients, and the Department of Health states that it should be available across the country by 2012. We review the setting up of a melanoma sentinel lymph node biopsy service with specific consideration to resources, service implications and patient outcomes. In total, 164 patients underwent sentinel lymph node biopsy for melanoma from August 2008 until March 2010. The median time for sentinel lymph node excision was 26 min. The median total operative time, which includes melanoma excision and sentinel node biopsy was 65 min, compared with 22 min for excision of the melanoma performed during the previous 19 months. The complication rate was 8.5%, with only 1.2% requiring operative treatment. After the initial outlay for two gamma probes, it was possible to deliver a cost neutral service within the National Tariff. Despite a significant increase in demand for the service in the second half of the study period, and 106% increase in the number of regional lymphadenectomies, only 1 patient (0.6%) breached the 'Going Further on Cancer Waits' target. In conclusion, a sentinel lymph node biopsy service for malignant melanoma can be effectively delivered within the majority of UK plastic surgery departments.

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

BACKGROUND: Cellulitis is responsible for over 400,000 bed days per year in the English National Health Service (NHS) at the cost of £96 million. OBJECTIVES: An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists. METHODS: Review of patient details and work diaries from the first 40 months of implementation of the new model of care. RESULTS: Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty-eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment. CONCLUSIONS: This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.

A randomized, double-blind, negatively controlled pilot study to determine whether the use of emollients or calcipotriol alters the sensitivity of the skin to ultraviolet radiation during phototherapy with narrowband ultraviolet B.

BACKGROUND: There is contradictory evidence suggesting that emollients increase, decrease or have no effect on minimal erythema dose (MED) or minimal phototoxic dose values prior to phototherapy. Few studies have looked at the in vivo use of emollients or calcipotriol prior to narrowband ultraviolet (UV) B (NB-UVB) treatment. OBJECTIVES: To investigate whether emollients or calcipotriol alter MED readings of skin on the back of healthy subjects prior to NB-UVB irradiation. METHODS: Topical agents were applied to the backs of 20 healthy volunteers for 30 min prior to MED testing. These agents were aqueous cream, 50:50 white soft paraffin and liquid paraffin, Diprobase(®) (Schering-Plough, Welwyn Garden City, U.K.), Epaderm(®) (Medlock, Oldham, U.K.) and calcipotriol ointment and cream. A control MED strip was used with no topical agent applied prior to testing. MED readings were recoded as integer steps between 1 and 9 (one is lowest MED dose for skin type; eight is highest; nine is no response, i.e. a higher MED). RESULTS: The median MED was between step 5 and 6 for all treatments and control. There was no significant difference at the 5% level between control and each topical agent. The study was powered to detect a median difference of approximately 0·4-0·6 steps. CONCLUSIONS: This has important implications at a practical level when advising patients not to apply creams prior to treatment with NB-UVB. Studies where agents are applied immediately prior to phototherapy have been more likely to show that emollients block transmission of UV radiation. If they are applied at least 30 min prior to treatment, they have no effect.

A comparison of narrowband (TL-01) UVB-induced erythemal response at different body sites.

In most dermatology centres where phototesting is performed, the starting dose is calculated as a proportion of the minimal erythema dose (MED). Previous studies have found significant differences in MED readings between forearm and back skin with both broadband and narrowband (NB) UVB. Our objective was to compare MEDs obtained from three body sites, the forearm, back and abdomen, to see if there was a significant difference in individuals. We recruited 20 healthy volunteers who were exposed to our standard dose series for phototesting with NB-UVB to three body sites: forearm, back and abdomen. MEDs were assessed 24 h post exposure. The median MED for the abdomen was 0.79 J/cm2, the back 0.95 J/cm2 and the arm 1.11 J/cm2. Friedman's analysis of variance by ranks showed that these differences were significant (P = 0.003). There was no correlation between skin type and MED for any of the three anatomical sites. Our results support phototesting for all patients prior to treatment with NB-UVB. Furthermore, we have shown that the abdomen is the anatomical site of choice for phototesting, as this will result in a reduced risk of burning episodes.