At the beginning of each month I shall post a couple of journal articles which might be of interest to members, concentrating on more practical surgical information plus some dermoscopy and melanoma information.  Comments are invited.  As we do not yet have a bulletin board based forum, any comments can be emailed to the treasurer, and I will distribute them to all members. (click on the Board link on the right of this page, then treasurer).

October 01 2010

Variation in the Depth of Excision of Melanoma A Survey of US Physicians
( Arch Dermatol. 2010;146(9):995-999.)

"There is considerable variation among physician groups with regard to depth of excision practices for the treatment of melanoma. Given the current lack of clinical data available, studies assessing depth of excision and patient outcomes are needed to better define our surgical management of melanoma".

Current guidelines, including those of the National Comprehensive Cancer Network (NCCN) Melanoma Panel, the British Association of Dermatologists, and the American Academy of Dermatology (AAD) Guidelines/Outcomes Committee, do not make direct recommendations with regard to depth of excision. The AAD guidelines state that “Excising to fascia may not be necessary for melanoma tumors confined to the upper levels of the skin, but they do not elaborate".

The Australian and New Zealand guidelines, not quoted in the article state "Depth of excision in usual clinical practice is excision down to but not including deep fascia unless it involved".

http://archderm.ama-assn.org/cgi/content/short/146/9/995

Two excellent extensive review articles on the dermoscopy of non pigmented lesions have been published in the September 2010 edition Journal of the Academy of Dermatology

J Am Acad Dermatol. 2010 Sep;63(3):361-74  http://www.ncbi.nlm.nih.gov/pubmed/20708469
J Am Acad Dermatol. 2010 Sep;63(3):377-86  http://www.ncbi.nlm.nih.gov/pubmed/20708470

September 01 2010

Sentinel lymph node biopsy is widely performed by surgeons in Australasia but it's place in melanoma management remains controversial. This editorial from the Australasian Journal of Dermatology argues that it should not be a standard of care.  One of the points raised is that the significance of microscopic cells in the sentinel node has been questioned.
http://onlinelibrary.wiley.com/doi/10.1111/j.1440-0960.2009.00602.x/full

In the same issue, an original paper examines the complication rates of SLN Adrian Ling, Rosie Dawkins, Michael Bailey, Michael Leung, Heather Cleland,
Jonathan Serpell and John Kelly Australasian Journal of Dermatology (2010) 51, 13–17
http://onlinelibrary.wiley.com/doi/10.1111/j.1440-0960.2009.00575.x/full

This letter published in the JAAD also questions the use of SLNB.
Sentinel node biopsy: not the standard of care for melanoma.
Sladden MJ, Foley P, Stanford DG, Zagarella S, Reid C. J Am Acad Dermatol. 2009 May;60(5):872-5.

http://www.ncbi.nlm.nih.gov/pubmed/20227586

A very comprehensive review was recently published in the JAAD and (in my opinion) presents a balanced view of the procedure.
Sentinel lymph node biopsy and melanoma: 2010 update Part I.

Stebbins WG, Garibyan L, Sober AJ.J Am Acad Dermatol. 2010 May;62(5):723-34; quiz 735-6.

http://www.ncbi.nlm.nih.gov/pubmed/20398810

"Sentinel lymph node biopsy for melanoma is a minimally invasive method of pathologically staging regional lymph node basins in patients with clinical stage I/II melanoma.
Numerous studies show that sentinel lymph node evaluation improves accuracy of prognostication, although its
therapeutic role remains in question.
Further research is needed regarding the short- and long-term psychological value of the additional prognostic information provided by sentinel lymph node biopsy."

Part 2 

J Am Acad Dermatol. 2010 May;62(5):737-48  http://www.ncbi.nlm.nih.gov/pubmed/20398811

"Sentinel lymph node (SLN) status still remains the most powerful indicator of prognosis, but there remains a great deal of controversy regarding the therapeutic role of removal of the remainder of locoregional lymph nodes in the case of a positive SLN.
To date, no randomized clinical trial has shown that complete lymph node dissection (CLND) after positive SLN can improve overall survival. However, large, randomized clinical trials are currently underway to assess overall survival benefit of CLND versus observation in patients with positive SLN.
Compared to delayed therapeutic nodal dissection of clinically palpable nodes, CLND is associated with decreased surgical complexity and lower postoperative morbidity."

August 01 2010

Morphologic features and natural history of scalp nevi in children.
Gupta M, Berk DR, Gray C, Cornelius LA, Bayliss SJ.  Arch Dermatol. 2010 May;146(5):506-11.

The message that change in a mole may indicate melanoma is widely known, but for scalp naevi in children change over time is the norm.  Parents frequently present because a mole on the scalp of a child has changed, and this can lead to excision because of either parental or doctor anxiety.  Is this necessary?   A recent article looks at the problem and concludes "This preliminary study does not support excisional biopsies but does support physician evaluation of scalp nevi evolution and serial photography of clinically distinctive lesions".  77% of the naevi studied changed during the study period.  There are some nice photos in the full article.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20479298

Revised U.K. guidelines for the management of cutaneous melanoma 2010
J.R. Marsden, et al  British Journal of Dermatology 2010;163 (2):238–256
http://dx.doi.org/10.1111/j.1365-2133.2010.09883.x

The guidelines include the statement "Melanoma remains relatively uncommon and therefore the opportunity to develop diagnostic skills is limited in primary care. All lesions suspicious of melanoma should be referred urgently under the 2-week rule to local screening services usually run by dermatologists.  In England and Wales, this would be to an LSMDT.(Local Skin cancer Multi Disciplinary Team)".  This reflects the lower incidence of melanoma in the UK as compared to Australia and New Zealand.  There is much mention of Sentinel Lymph Node Biopsy which will be the subject of next month's posting.
ANZ melanoma guidelines can be downloaded from
http://www.cancer.org.au/Healthprofessionals/clinicalguidelines/skincancer.htm


June 01 2010

This month we look at the issue of surgical margins and tissue shrinkage.

Effect of tissue shrinkage on histological tumour-free margin after excision of basal cell carcinoma.

Blasdale C, Charlton FG, Weatherhead SC, Ormond P, Lawrence CM.

Br J Dermatol. 2010 Mar;162(3):607-10.

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19906070

In this study, the authors have set out to provide further information about tissue shrinkage following surgical excision.  The main findings are that tumour tissue shrank by 11% but that the surrounding tumour free skin shrank by 19%, and that most of this shrinkage occurred before the specimen was put into formalin.

"Clinical guidelines quote desirable excision margins. These are not the same as the histological surgical margin but operators are frequently disconcerted to discover that an apparently perfectly adequate clinical margin has shrunk on the histological
margin. Our findings suggest that on average a 19% loss of clinical margin can be explained by tissue shrinkage between excision and histological processing".

One the articles cited by the above authors is the paper by Wold and Zitelli on surgical margins for BCC.  This paper from 1987 is well worth reading by anyone who excises BCCs.

Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol 1987; 123:340–4.

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3813602


The Melanoma Family by Giuseppe Argenziano

This is a classification of melanomas based on biological behaviour and presented by Giuseppe at the 2009 skin Cancer Conference in Brisbane

(1)  slow-growing melanomas, with a strong increase in incidence across time and associated with intermittent sun-exposure, large number of nevi, and BRAF mutations

(2) fast-growing melanomas, with stable incidence and presumably neither associated with sun-exposure, nor with large number of nevi and BRAF mutations