Predictors of patient satisfaction with initial diagnosis and management of malignant melanoma.

BACKGROUND: Malignant melanoma (MM), accounts for around 10% of skin cancers. To date, there have been few data on patient satisfaction with initial management of MM. OBJECTIVE: To identify the predictors of patient satisfaction with initial diagnosis and management of MM. METHODS: Data on 214 patients were collected using a questionnaire filled in by a clinician during a face-to-face interview when the patient attended an appointment at a tertiary melanoma centre. Age, gender, ethnic origin, date of diagnosis, site of lesion, and overall stage at diagnosis and at interview were obtained from the hospital notes. Patients were asked about their satisfaction level at the end. RESULTS: In total, 64 (29.9%) patients were dissatisfied with the time they had to wait to receive a diagnosis. Patients whose initial biopsy was taken by a dermatologist were more satisfied than those whose biopsy was taken by a general practitioner (GP) (P < 0.003) and women were more dissatisfied than men (P = 0.04). Delay in diagnosis (P < 0.001) and number of visits (P < 0.001) were found to be predictors for dissatisfaction in univariate analysis, but in multivariate analysis, only the number of visits (P < 0.001) was a significant predictor of patient satisfaction. For each additional visit made by the patient, the odds of dissatisfaction increased by 3.5 times, irrespective of who did the initial biopsy, any delay in diagnosis, and the age and gender of the patient. CONCLUSIONS: Patients whose initial biopsy was taken by dermatologist were more satisfied than those with a biopsy taken by a GP. The number of visits was an important predictor of patient satisfaction.

Informational needs of patients with melanoma and their views on the utility of investigative tests.

BACKGROUND: The aim of the study was to identify the informational needs of patients with melanoma on disease status and prognosis, and to ascertain their views on the utility of positron emission tomography (PET) and sentinel node biopsy (SNB). PATIENTS AND METHODS: Patients attending the weekly melanoma outpatient clinic at St Thomas' Hospital London UK between February and August 2007 participated in this cross-sectional survey. Views of 106 melanoma patients were elicited using a face-to face semi-structured questionnaire. RESULTS: The majority of participants wanted to know everything about their disease (88%). Prognostic information (> 85%) and information on palliative care input (97%) were highly valued. More than 50% expected the doctor to impart this information without negotiation. Nearly 70% of the responders who had previously had a PET scan felt they should decide if and when the scans should be performed. Fifty three percentage had undergone the SNB because the doctor had suggested it. CONCLUSIONS: Patients with melanoma want detailed and prompt information about their disease including prognosis. Regular PET scans provide reassurance. The role of SNB is not clear to all patients.

Comparison of positron emission tomography scanning and sentinel node biopsy in the detection of micrometastases of primary cutaneous malignant melanoma.

PURPOSE: Sentinel node biopsy (SNB) is a surgical technique for detecting micrometastatic disease in the regional draining nodes. 2-fluorine-18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scanning is an imaging technique that can detect clinically undetectable metastases. This prospective study was undertaken to compare the sensitivity of FDG-PET scanning with SNB in the detection of micromatastatic malignant melanoma. PATIENTS AND METHODS: Fifty consecutive patients (23 women, 27 men; mean age, 53 years) with primary melanoma >1 mm thick or lymphatic invasion were recruited (mean, 2.41 mm). Primary lesions had been narrowly excised (<1 cm). Patients underwent PET scanning followed by SNB, using a dual technique. Preoperative lymphoscintigraphy was used to identify the draining basin. Lymph nodes were examined histologically and immunostained for S100 and HMB 45. RESULTS: The sentinel node (SN) was identified in all patients. Fourteen patients (28%) had positive SNBs, including eight patients with melanoma <1.5 mm thick. In none of these 14 patients did PET scans identify metastatic disease in the SN or draining basin. In seven patients, the PET scans were positive in other locations, and in four cases, this was suspicious of metastatic disease. However, no patient has developed recurrent melanoma (mean follow-up, 15 months). All patients with positive SNBs underwent therapeutic lymph node dissection. Further lymph node involvement was found in two patients (primary lesions, 1.3 mm and 3.5 mm thick). CONCLUSION: This study demonstrates the limitations of FDG-PET scanning in staging patients with primary melanoma. SNB is the only reliable method for identifying micrometastatic disease in the regional draining node.

The gene for Naegeli-Franceschetti-Jadassohn syndrome maps to 17q21.

Naegeli-Franceschetti-Jadassohn syndrome is a rare autosomal dominant form of ectodermal dysplasia affecting sweat glands, nails, teeth, and skin. We have studied a multigeneration family of Anglo-Saxon British descent using microsatellite markers to screen candidate loci, including the epidermal differentiation complex on 1q, the keratin gene clusters on chromosomes 12q and 17q and the desmosomal cadherin gene cluster on chromosome 18q. Significant genetic linkage to chromosome 17q was observed using marker D17S 1787, with a maximum two-point LOD score of 4.166 at a recombination fraction of theta = 0. Recombination events in the family place the gene in a 26.97 cM interval between markers D17S798 and D17S957, a region known to contain the type I keratin gene cluster and other genes expressed in epithelia. Keratins K15, K19, and K20, plakoglobin, and MEOX1 were excluded as candidates by direct sequencing of genomic polymerase chain reaction products.

Does deprivation of area of residence influence the incidence, tumour site or T stage of cutaneous malignant melanoma? A population-based and clinical database study.

This study aimed to document the incidence of malignant melanoma at specific subsites in men and women, stratified by deprivation of area of residence in southeast England, and to explore the association between deprivation and tumour thickness at diagnosis. Data were extracted on 6468 cases from the Thames Cancer Registry for the years 1998 to 2002, and data on, and 508 cases were extracted from the clinical database of the Skin Tumour Unit, St Thomas' Hospital, for the years 1996 to 2004. The postcode of residence was used to assign quintiles of deprivation based on the income domain stated in the Indices of Deprivation 2000. For both males and females, the incidence was higher for those living in the most affluent areas. The trunk was the most common site in males and the lower limbs in females. All sites showed an affluence gradient, although this was least pronounced for head and neck tumours. Distribution of T stage at diagnosis did not differ by deprivation of area of residence.

Lasers for the dermatologist.

This article reviews the current uses of lasers in dermatological practice. It outlines safety issues and legislation and attempts to summarize the relevant physics and light interactions. The article is divided into sections pertaining to selective photothermolysis of structures containing the major skin chromophores: haemoglobin, melanin and water. The lasers used and conditions treated are discussed with reference to a literature review.

Sentinel node biopsy in the management of malignant melanoma.

The technique of sentinel lymph node (SLN) biopsy has been in use for almost a decade, but its effect on survival has not yet been established. It is however the most accurate method for staging patients with primary cutaneous melanoma who lack clinical evidence of metastatic disease. This article discusses the rationale and logistics of SLN biopsy, and the management strategies that can be employed in those patients who are SLN positive. Future therapeutic trial in patients with primary cutaneous melanoma will only be meaningful if the SLN status of the subjects is established.

Striae formation in two HIV-positive persons receiving protease inhibitors.

Steroidal side effects such as "buffalo hump" and visceral abdominal fat accumulation have been reported in association with protease inhibitors. We report two cases of severe disfiguring striae formation in patients with HIV who recently started indinavir therapy. These changes occurred within 3 months of starting treatment.

Unusual giant comedo naevus.

Comedo naevi are usually well circumscribed, and although extensive cases have been reported individual lesions crossing the midline are rare. Associated neurological, skeletal and ophthalmological abnormalities are also recognized. thus, the patient now reported is unusual in that she had an extensive systematized comedo naevus with crossing of the midline but no associated abnormalities. Topical tretinoin was helpful in improving the texture and appearance of the comedones, and various larger lesions responded to curettage.

Cutaneous infection with Alternaria alternata complicating immunosuppression: successful treatment with itraconazole.

We report an immunosuppressed patient who presented with unusual leg ulceration caused by Alternaria alternata infection. Alternaria is a common saprophyte that is not usually pathogenic in humans. However, infections have previously been documented. Most cases occur in immunocompromised patients and the skin manifestations may vary considerably. The diagnosis is often missed initially as it is not frequently suspected. The treatment is controversial both in choice of agent used and in duration of therapy.

Persistent ulcerated necrobiosis lipoidica responding to treatment with cyclosporin.

We report two patients with severe ulcerated necrobiosis lipoidica (NL) who responded to cyclosporin. One patient had suffered persistent ulceration for a period of 7 years and the other had NL of recent onset. In both cases, ulceration healed completely after 4 months of therapy, and both patients have remained free of ulceration since discontinuing therapy. The possible mode of action of cyclosporin in the context of this debilitating disease is discussed.

The value of positron emission tomography scanning in the detection of subclinical metastatic melanoma.

We have undertaken a retrospective analysis of all positron emission tomography (PET) scans carried out at St Thomas' Hospital, London, since 1994 to establish the sensitivity and specificity of this radiologic technique in cutaneous malignant melanoma. In particular, we have identified those patients with primary cutaneous malignant melanoma in whom PET scanning revealed in-transit or regional spread to nodes and those patients with known regional spread in whom PET scanning revealed distant metastases. We defined our false-negative results as a negative scan result with positive histology or subsequent clinical progression of disease. False-positive results were defined as a suspect scan with negative histology or no subsequent progression of disease. PET scanning had an overall sensitivity of 78% and specificity of 87%; however, subset analysis (M. D. Anderson staging system) showed a sensitivity of 50% for stage I disease (34 patients and 35 scans) and 33% for stage II disease (9 patients and 9 scans) with specificities of 87% and 100%, respectively. For stage III disease (16 patients and 17 scans), PET showed a sensitivity of 93% and specificity of 50%. Overall, 35% of patients with true-positive scans had their disease restaged. We can conclude therefore that PET is valuable as a staging procedure in patients with known regional spread but is suboptimal in the prediction of outcome in stage I or stage II disease.

Staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant Staphylococcus aureus.

We report the first adult case of staphylococcal scalded skin syndrome (SSSS) due to methicillin-resistant Staphylococcus aureus (MRSA). This case is particularly unusual as the MRSA produced toxic shock syndrome toxin 1 and enterotoxin, but not exfoliatoxin. SSSS was originally described in neonates and is thought to result from exfoliatins which produce subcorneal splitting of the epidermis and are only produced by certain strains of S. aureus. This case reflects the range of toxins that can be associated with SSSS and the clinical manifestations of MRSA infection in adult patients.