Because data for these situations are limited, the surgeon must make the decision with the patient grade of recommendation C. Stablishing standards, besides reducing the differences in patient care, can also make possible to provide options based on evidence, allowing the physician to make decisions about treatment or diagnostic methods, thus reducing the strain on patients, doctors and on the healthcare system.
These guidelines reflect the best scientific information published about the subject to the date of its preparation. Nevertheless, we must be careful when interpreting these data, since the outcome of future studies can lead to changes in recommendations. In some cases, it may be necessary not to follow these guidelines, always keeping in mind patients' well-being , as well as other special circumstances.
Melanoma skin cancer diagnosis and treatment statistics
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Local recurrence in malignant melanoma: long-term results of the multi institutional randomized surgical trial. Excision margins in high-risk malignant melanoma. Evidence and interdisciplinary consensus-based German guidelines: surgical treatment and radiotherapy of melanoma. Melanoma Res. Revised U. Cancer Council Australia. Sydney, N. Guidelines for clinical practice. Standards, options and Recommendations for the management of adult patients exhibiting an M0 cutaneous melanoma, full report.
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[Full text] Improving outcomes in patients with melanoma: strategies to ensure an | PROM
The use of diagnostic tools in the evaluation of suspicious pigmented lesions was investigated. The most common tool used was the magnifying lens Dermatologists in practice for longer than 17 years were more likely to use a magnifying lens for the clinical diagnosis of MIS Also, physicians Physicians practicing in a group or solo practice used the dermoscope less than those in an academic setting However, dermoscope use did not differ with respect to the number of years in practice.
The biopsy methods most commonly used by the respondents were excision The survey showed that respondents A majority of the respondents However, when the pathology report returned with a benign diagnosis but there was a clinical suspicion of MIS, most respondents would take further action Table 2. Only 96 respondents Clinical margins used by respondents for the resection of MIS were elicited Table 3. Furthermore, 19 respondents 3. Surgical treatment of MIS was also assessed by questions regarding the practice of Mohs surgery for lentigo maligna or MIS on the face and not on the face.
Mohs surgery was used at least occasionally by Physicians were asked questions regarding the proper management and follow-up for histologically confirmed MIS lesions. The majority of physicians Of those who ordered additional tests, Overall, This screening should begin at age 11 to 20 years according to respondents Although respondents The results of this survey of a cross-sectional population of US dermatologists indicate that there is variability concerning the entity of MIS and its diagnosis, treatment, and management.
The need for a more uniform approach is underlined by an increasing incidence of MIS in the United States. Early melanoma can be difficult to differentiate clinically from other pigmented lesions. In addition, respondents who had practiced for more than 17 years were more likely to use magnifying lenses. It is unclear whether this increase in magnifying lens use among the more experienced dermatologists was a function of the nature of the training they received, or merely the fact that these dermatologists were compensating for age-related decreased visual acuity.
These findings are of interest since there is a paucity of literature regarding the use of the magnifying lens for assistance in diagnosing skin cancer. The addition of dermoscopy to the visual examination, on the other hand, has been reported to improve the diagnostic accuracy of melanoma 6 - 9 and has even been suggested by some to be the cornerstone of such a diagnosis.
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A likely explanation for the limited use of dermoscopy is the lack of training. Concerning the most commonly used biopsy method for clinically suspected MIS excluding the face, most dermatologists reported the use of excisional surgical techniques. Excisional and saucerization biopses are the best approaches for obtaining an accurate histologic diagnosis. In these select cases, a partial biopsy may be the most reasonable approach to obtain a diagnosis.
Histologic examination of biopsy specimens of pigmented skin lesions is used to reach an exact diagnosis. However, several studies have shown that there is variability between pathologists in the interpretation of pigmented skin lesions. Furthermore, recent literature has questioned the reliability of the histologic diagnosis of lesions such as MIS with routine stains such as hematoxylin-eosin. MART-1 stands for melanoma antigen recognized by T cells. Although most trained pathologists can perform immunohistochemistry, a dermatopathologist may be more likely to use these more specific techniques to render a more precise analysis of diagnostically challenging melanocytic lesions.
In our study, most respondents demonstrated greatest confidence in the diagnostic abilities of dermatopathologists for obtaining accurate diagnoses. Clinical impressions, however, tempered reliance on histologic diagnosis. Although other therapies have been used, 25 - 30 excisional surgery remains the standard of care for definitive treatment of histologically proved MIS lesions. It is not surprising that the respondents in our study were divided between supporting a surgical margin of 5 mm or less It is clear that further prospective research is required to address the optimal surgical margins for MIS, with long-term follow-up to determine local recurrence rates as well as disease-free and melanoma-related survival.
As with surgical margins, there are few data to support the appropriate depth to which MIS should be definitively excised. Currently, there are no widely accepted guidelines for the depth of excision of MIS. This fact may explain the variability in the responses in our survey. The majority of respondents reported removal of lesions at least down to the superficial fat.
This surgical practice may stem from the fact that it is generally necessary to excise at least to the level of the subcutaneous fat for primary wound closure. The present survey also addressed the issue of Mohs micrographic surgery for the treatment of MIS. Although controversial, the Mohs technique offers an alternative to excisional surgery, with complete examination of all margins and possible tissue conservation.
Case series have supported the efficacy of Mohs surgery for MIS, with long-term cure rates equaling or exceeding historical cure rates with conventional wide local excision. This differential practice in treating facial vs nonfacial MIS is likely due to the finding that recurrence rates on the head and neck are especially high after local excision. Most respondents This conservative approach for the follow-up of patients with histologically proved MIS is in keeping with the Melanoma Consensus Conference of It is well known that patients with a history of melanoma are at a higher risk than the general population for developing additional melanomas and nonmelanoma skin cancers.
It is therefore not surprising that clinical follow-up of patients with MIS was deemed important by respondents.
Overall, respondents were also inclined to promote the screening of family members of patients with MIS. Increasing evidence for the genetic basis of melanoma 53 may underlie this relative consensus for familial screening. Variation occurred, however, in the age at which to begin screening, with most recommending screening in the pubertal years of 11 to Finally, some of the most telling, yet inconsistent, responses were those dealing with the clinical concept of MIS.
To date, there remains considerable uncertainty regarding the histologic predictive value for biological behavior with regard to MIS. In vitro studies have demonstrated that in situ lesions are biologically unable to produce immortal cell lines in tissue culture. However, a significant proportion of respondents In addition, These numbers reflect the uncertainty that exists among dermatologists with regard to the natural course and potentially fatal outcomes associated with MIS.
Further research such as genomic profiling needs to be undertaken to gain a better understanding of the biological behavior of MIS. This study gives some indication as to how US dermatologists are currently diagnosing and managing MIS. Responses to this survey affirm the diversity of beliefs and practices of dermatologists with regard to MIS. The low percentage of respondents using dermoscopy underscores the need for more teaching in this area. Excision and saucerization are acceptable means of making a diagnosis. The majority of respondents preferentially use dermatopathologists but do not blindly accept a benign histologic diagnosis when there is a clinical suspicion of MIS.
There is a great need for further studies to investigate appropriate margins, which may differ for lesions on the torso and face. While the overall approach demonstrated by the respondents of this survey seems to identify MIS as a true malignancy, the uncertainty regarding its invasive potential if left untreated warrants additional studies of the biology and the natural course of this disease. Correspondence: Allan C. All Rights Reserved. Table 1. View Large Download.
Related Handbook of Cutaneous Melanoma: A Guide to Diagnosis and Treatment
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