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This month, I share a useful review article on the often vexed topic of dysplastic naevi. The article summarises new understandings about the genetic makeup of benign and dysplastic naevi, as well as melanoma.
The summary by Ardakani is well worth reading for everyone, and if you want to explore issues around dysplastic naevi more, read the whole article.
In short, what Ardakani shows is that there does seem to be a subset of dysplastic naevi that has a distinct genetic makeup that is different from other dysplastic naevi. However, it is not clear what the genetic changes mean in a biological or clinical way.
So, while our understanding of the detailed biology of naevi continues to grow, we (as GPs) can continue to manage dysplastic naevi as we do now.
That is, any suspicious pigmented skin lesion should be biopsied by excision biopsy (2mm margins). If the pathology report is of mild or moderate dysplasia, no further treatment is needed. If the report is of severe dysplasia, the lesion should be treated as melanoma in situ, and a re-excision with 5mm margins done.
Professor David Wilkinson
Read more from Professor David Wilkinson on recent research:
- What to do when a partial biopsy of a suspected melanoma is performed
- Artificial Intelligence in clinical practice
- Prof David Wilkinson on melanoma guidelines: Dermoscopy
- How will artificial intelligence benefit GPs in skin cancer medicine?
- The problem of dysplastic naevi
Interested in skin cancer medicine?
The HealthCert Professional Diploma programs offer foundation to advanced training in skin cancer medicine, skin cancer surgery or dermoscopy and provide an essential step towards subspecialisation. All programs are university quality-assured, CPD-accredited and count towards multiple Master degree pathways and clinical attachment programs in Australia and overseas. The programs are delivered online and/or face-to-face across most major cities of Australia.
This month, we consider what to do when a partial biopsy of a suspected melanoma is performed.
The general advice is that if a punch or shave (partial) biopsy has been done, then an excision biopsy should be done before a formal wide-local excision. This is so that complete staging (of Breslow thickness) can be assured before the excision is done. Continue reading “[3 min read] What to do when a partial biopsy of a suspected melanoma is performed”
In this month’s skin cancer update video, Professor Giuseppe Argenziano talks about atypical melanocytic lesions: lesions that are histopathologically in between a melanoma and a naevus, with subtle melanoma criteria that are not enough for the pathologist to diagnose the lesion as a melanoma. Continue reading “[7 min watch] Skin Cancer Update with Prof Giuseppe Argenziano [March 2019]”
We all continue to be plagued by the problem of dysplastic naevi, and especially what to do if we biopsy these lesions and the pathology report comes back with “margins involved”. What should we do? Continue reading “[3 min read] The problem of dysplastic naevi”
Pathology reports of basal cell carcinoma biopsies often contain comments of positive or negative margins, with only one to two per cent of the margin evaluated. A recent study sought to determine the negative predictive value of basal cell carcinoma biopsy margin status on the absence of residual basal cell carcinoma in the corresponding excision.
25 – 28 July 2018 | Brisbane
The 10th Skin Cancer Summit & Masterclasses saw international thought leaders in skin cancer medicine converge in Brisbane to collaborate with GPs from across Australia. The 2018 program once again covered a broad range of topics relevant to doctors working in primary care skin cancer medicine. The Masterclasses focused on core day-to-day material, as a way to reinforce and extend knowledge. The two-day Summit opened up new areas of study, enquiry and interest.
Dermoscopy Masterclass: 25 July 2018
Dr Lallas used the concept of false positive and false negative diagnoses to reinforce our diagnostic accuracy. Clearly, as morphology overlaps the distinction between what is a cancer, and what is not, can provide confusion.
This broad concept was beautifully extended by Prof Marghoob through his presentation on difficult to diagnose melanomas. As we all know, the easy ones are easy. It is the hard-to-diagnose that we risk missing!
The session then moved into important body sites – the face and acral areas, which are important because the morphology of lesions on these sites is different from morphology on other sites. If we don’t understand this and know how the appearances differ, then we can’t accurately recognise cancers.
Our presenters then extended these important concepts to difficult to diagnose non-melanoma skin cancers, as it is not just melanomas that can be tricky. And, as always, we finished with a series of interactive cases.
Surgery Masterclass: 26 July 2018
The second Masterclass covered surgery of the ear. The ear, of course, is a common site for skin cancer because it is so exposed to solar damage. Ear surgery is important because cosmetic results are very visible to the patient and others. So, it is essential to get the surgery right, cure the cancer, and repair the defect as sympathetically as possible.
Dr Con Pappas and Dr Tony Azzi provided a comprehensive overview of how to prepare for and conduct surgery of the ear, across almost all imaginable lesions.
Summit: 27-28 July 2018
The Summit program is deliberately designed to be a mix of very practical, everyday material that supports our daily practice.
This year, key examples of these sessions were those on ‘effectiveness of dermoscopy’, ‘why we miss melanoma’, and ‘radiation oncology’. We also ran sessions that we hope will keep you and your patients safe, including ‘what interests the watchdog’ and ‘monitoring tips and traps’.
We deliberately moved into the future and sought to explore and speculate on what might be. It is clear that artificial intelligence is already with us, and yet most of us don’t really see what is happening and what might be coming. As educated and interested professionals, it is worth being aware of these trends.
We also like to keep you across what is happening outside clinical practice, in areas that are relevant to running your business. So, our sessions on how to run a successful business, and how others organise their own practices, are always very popular.
The Skin Cancer Summit closed with a Gala Dinner at the Queensland Cricketers’ Club. Hosted by the Skin Cancer Institute, the inaugural ‘White Out Skin Cancer’ Gala Dinner donated all proceeds to QIMR Berghofer. The delegates’ generosity and support will make a difference to many lives as we take a step closer to our vision of a world where nobody dies from skin cancer.
Plans are well underway for the 11th Skin Cancer Summit & Masterclasses in 2019! Save the date for 21-24 August 2019 and learn more here.
How can computer vision aid in melanoma detection? A study recently published in the Journal of the American Academy of Dermatology compared the diagnostic accuracy of computer algorithms to dermatologists using dermoscopic images.
The study involved 100 randomly selected dermoscopic images comprising of 50 melanomas, 44 naevi, and six lentigines. Researchers used both non-learned and machine learning methods to combine individual automated predictions into “fusion” algorithms. In a companion study, eight dermatologists classified the lesions in the 100 images as either benign or malignant. Continue reading “How can computer vision aid in melanoma detection?”
Our paper this month comes from Elmore et al, published in the BMJ. The authors set out to determine the accuracy and reproducibility of pathology diagnosis of melanocytic skin lesions. The study was done across the USA and included 240 skin biopsies, and almost 200 pathologists viewed the slides twice, eight months apart.
A recent research article from Nosrati et al, reports on the outcomes of patients with melanoma in situ, treated by either wide local excision or Mohs micrographic surgery (MMS).
Now, most Australian doctors would not consider this surgery for melanoma in situ – we would follow our national guidelines and excise melanomas with 5mm clinical margins. Many GPs do exactly this – measure out 5mm margins and excise and close, usually with an elipse, or with a flap or graft if necessary.
“Well, here it is. After teaching my foundations of skin cancer course with HealthCert for 10 years, and with almost 3000 alumni, Paul and I have finally written the book! Many, many doctors ask me “which is the best book for me?”. Well, if you are a mainstream GP, this is it – in my view.
We wrote this because, as far as we could see, there is no such book on the market. And, most patients with skin cancer are treated by GPs. And, it is not easy. The book is simple and straightforward. All evidence based, clear and basic one to keep on your desk.
I hope you like it.”