This is the PDF (click on link below) of a presentation I am giving this afternoon (22nd March 2017) for Southampton GPs about how to make best use of the 2 week wait urgent skin cancer pathway.
Please note, while we sometimes can remove skin cancers on the day, and will try to do so in the case of nodular melanomas, we can’t guarantee to do this, so don’t tell patients to expect it. Many tumours, e.g. SCCs on the scalp or BCCs on the noseCCG 2 week wait, require a skin graft which is 90 minutes in Day Theatre with a highly experienced skin surgeon, common sense dictates we can’t just provide this off the peg in a busy clinic setting.
Here’s another mole that you take one look at and think—UGH!!!!!
Its ugly, but so was Neil Shroff’s case I posted a few days ago, and that was a harmless seborrhoiec keratosis. Need to get the dermoscope into action.
Absolute chaos. Even to a complete beginner, you can see multiple colours, multiple structures, even if you can’t name them.
I can see, from the top of the lesion going clockwise, streaks, an eccentric black blotch, irregular network, asymmetric clods, shiny white streaks, and a blue grey veil. That’s 6 out of 7 of Giuseppe Argenziano’s well validated 7 point check list (the only missing feature being atypical vessels, and there are probably some atypical vessels under all that black.)
Melanoma all the way.
Thanks to my friend Dr Neil Shrof for this case.
Very dark ugly duckling. Is it a nodular melanoma? No. Black seb k, also known as melanoacanthoma. Stuck on appearance and keratin pits. Harmless.
The 2017 South Coast Dermoscopy skin lesion recognition and dermoscopy course has just started with a group of about 75 GPs, dermatology trainees, dermatologists, plastic surgeons, nurses and podiatrists assembling at The Holiday Inn Fareham last Friday.
This is the first case I sent out to our on line case discussion group. I like to put up some easy cases to start with. No plain view to hand. In fact I posted this here a few years back, but never mind, its a nice case.
This is an obvious melanoma, at one glance. Professor Peter Soyer calls this the heuristic method, after ‘Eureka!’ which means ‘I have it!’. OK, but why is it a melanoma?
Any of the accepted diagnostic methods will get us there. Let’s start with the 2 step algorithm.
step 1: is it melanocytic? There are brown globules (clods in the new terminology) particularly from 6 to 9 o’clock. Brown globules are a positive feature for melanocytic lesions. Can we see features of any non-melanocytic lesion (i.e. haemangioma, seborrhoeic keratosis, dermatofibroma etc)? No. So it is melanocytic by default and also on positive grounds (brown globules).
step 2; could it be a melanoma? Yes, because of gross asymmetry and multiple patterns and colours. Therefore excision.
The 3 step pathway. In this, we look for asymmetry, blue-white structures, and atypical network. Our lesion here shows the grossest of asymmetry, not so much of shape but of colour and patterns (which are both more important than geometry). We can see blue-white structures (also called blue white veil) and we can also see atypical network, in this case inverse network (the lacy white net-like structure at right and right of centre.) So again positive.
The 7 point check list of Argenziano. Please click on the link for a discussion of this 7 point check list. Again, positive. I can see gross asymmetry, irregular dots and globules, blue-white veil, pseudopods (basically a pseudopod is a blob of the end of a streak) an a few other structures.
Chaos and clues. This is chaotic as it has many structures and colours all mixed up. Step 2 of ‘chaos and clues’ is, having said ‘yes, chaos’ we look for clues, initially to ask the question ‘Is it a seborrheoic keratosis?’ Plainly not, the lesion lacks the fissured keratin, comedo like openings, milia like cysts, cerebriform appearance or looped vessels we expect to see in a seb k. When we look for melanoma clues, they are abundant (see above link to 7 point check list).
using SCOPE, our own mnemonic, we see no Symmetry, many COlours, many Patterns and odd things happening at the Edge.
The lesson being that whichever algorithm or scoring technique we use, this is a melanoma (as proved on histology, 3.5mm Breslow thickness). Professor Harald Kittler has said that experts learn all the algorithms and then invent their own. Sometimes one is better, sometimes another, sometimes a mixture.
Pattern analysis is defined as the simultaneous evaluation of all dermoscopic features of a lesion. The link takes you to a useful discussion on dermnetnz.
A US based study using self photographes and Apple software is trying to see if this can be used to detect melanoma early. A paper in the British Journal of Dermatology by Peter Soyer et al showed that selfies of patient- identified suspicious moles with a cheap smartphone dermoscope was feasible.
In the end though, what really matters is people looking out for new and funny moles and easy access to a trained, capable dermoscopist. I am currently working on a presentation about mole monitoring and will post a summary here. Based on what I have been able to learn, there is a lot to be said for selfie mole mapping and 3 monthly review by a friend or relative, with easy access to an expert opinion in the event of a new or changing mole.
These 2 cases were seen on the same day and had similar stories-a suspicious mole noticed on a middle aged white man’s back. Both are ‘ugly ducklings’, that is to say your eye is drawn to them as the most outstanding mole on the person’s skin.
Are you worried about 1, 2 or both? Perhaps you may agree its not so easy to be sure.
Dermoscopy changes everything.
This is the dermoscopy of the first lesion. It shows an even reticular network, several shades of brown but no additional colours, an overall well balanced structure, and was flat on palpation. Diagnosis: benign junctional naevus which just happens to be the man’s largest naevus. No concerns, advised to self photograph and report any significant change.
Lesion 2 is different.
Multiple colours, multiple structures= chaos. The main colour is light to medium brown, but there is also a black blotch to right of centre and a bluish structureless area. As far as structure is concerned, there are multiple dots and globules of varying sizes and irregular distribution. Diagnosis=probable superficial spreading melanoma. (histology awaited)
PS melanoma confirmed 0.45mm Breslow, should be cured.
Dermoscopy makes a difference to the diagnosis of a solitary questionable mole.