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These guidelines for the management of cutaneous melanoma present an evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiology, diagnosis, investigation, and follow-up., (Copyright 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons and British Association of Dermatologists. Published by Elsevier Ltd.. All rights reserved.)

Background: In England and Wales, patients with suspected skin cancer are referred to specialists within 2 weeks ('two-week rule', TWR) by tick-box proforma., Objectives: To evaluate proforma details that might be amended to improve sensitivity and specificity., Methods: Five hundred and six TWR referrals were evaluated. Potential proforma changes were criteria for melanoma, and guidance that most squamous cell carcinomas (SCCs) measure >or= 1 cm. We compared melanomas vs. benign pigmented lesions using seven-point, and amended (10-point), checklist scores. We examined sizes of 82 SCCs and investigated influence of size on TWR referral., Results: Of 506 TWR referrals, 381 (75%) were suspected melanoma [30 (7.8%) correct], and 125 (25%) were suspected SCC [22 (17.6%) correct]. Fifty per cent of melanomas were referred by TWR, but only 8% of SCC. No combination of seven-point checklist criteria had discriminatory value for melanoma; total scores (seven- or 10-point) were not significantly different between melanomas and nonmelanomas. No total score, using either system, had acceptable sensitivity and specificity. Measured size of SCCs varied from 4 to 30 mm; 88% were >or= 1 cm. Reducing the 'cut-off' to 7 mm identified only another 3.5%. Even at 2.5-3 cm, only 50% of SCCs were referred by TWR., Conclusions: The seven-point checklist for melanoma, when used in TWR format, does not have discriminatory value for melanoma. Altering the suggested cut-off size for SCC is unlikely to alter referrals. Education may be a more important factor in refining use of the TWR.

Background: In 1997 the U.K. government introduced the target that all patients seen in primary care, and whose general practitioner suspected a possible diagnosis of any cancer, would be seen by a specialist within 2 weeks. Several individual departmental reports suggest that this has generated a high volume of 'urgent' referrals and has been unachievable without impact on other patients., Objectives: To determine the views of dermatologists, with audit and database information where possible, on the overall impact of the 2-week rule referral standard for suspected skin cancers., Methods: A questionnaire was sent to consultant dermatologists in the U.K. requesting views and numerical data., Results: There were 139 responses, some on a departmental basis, representing 272 individuals (nearly two-thirds of all consultant dermatologists in post in the U.K). Based on 52 formal audit studies or database information, the overall proportion of confirmed skin cancers among 2-week rule referrals was 12%, but only 42% of tumours were referred by this route. Correct suspicion of melanoma was generally better than that of squamous cell carcinoma. Information on standard referral proformas was only considered to be 'usually adequate' by 34% of departments. Considering all replies, only 27% of respondents felt that the 2-week rule works well; the major problems are an excess of benign lesions, the lack of opportunity to prioritize referrals and the displacement of other urgent problems., Conclusions: There are significant problems with the perception and application of the 2-week referral standard for possible skin cancers, including a high volume of nonrelevant lesions and displacement of other urgent conditions. Increasing the specificity of referral guidelines, and increased education regarding recognition of benign lesions, are the favoured options for improvement.

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the U.K., they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery., (Copyright 2002 The British Association of Plastic Surgeons and the British Association of Dermatologists.)

Background: Abnormal melanosomes occur in naevus spilus (NS)., Objective: To determine whether melanoma arising in NS contains abnormal melanosomes., Methods: Light and electron microscopy of melanoma within NS and congenital naevus (Case 1), and of blue naevus within NS (Case 2). Light microscopy of additional naevi and melanomas., Results: The melanoma and NS (Case 1) both had large numbers of giant pigment granules (GPGs), demonstrated ultrastructurally to be melanosome macrocomplexes. These were not observed in a congenital naevus (Case 1), or in the blue naevus within NS (Case 2). Small numbers of GPGs were observed in 0/2 NS, 8/16 benign naevi and 11/16 malignant melanomas (MMs)., Conclusion: NS may be associated with other melanocytic tumours including MM and blue naevi; abnormal melanosomes in NS may also be present in the associated tumour. The prognostic importance of these is unknown, but occasional GPGs in melanocytic lesions are a frequent finding.

A study of 953 invasive cutaneous malignant melanomas of the head and neck was performed to determine differences between lentigo maligna melanoma and other histogenetic types with regard to patients and sites affected; prognosis was analysed in 595 of these cases. The cases studied comprised all head and neck melanomas registered with the Scottish Melanoma Group between 1979 and 1992, apart from the 3% of cases that were unclassifiable or rare histogenetic types. The histogenetic types of melanoma were 498 (52%) lentigo maligna melanoma (LMM), 237 (25%) superficial spreading melanoma (SSM) and 218 (23%) nodular melanoma (NM). All types increased in incidence throughout the study period. Patients with LMM (mean age 73 years) and NM (mean 68 years) were significantly older than those with SSM (mean 57 years). There were significant anatomical subsite differences related to sex of patients and histogenetic type of melanoma; melanomas on the face were more frequent in females and 90% of LMM occurred at this site, whereas melanomas on the scalp, neck and ears were more frequent in men. Kaplan-Meier estimates of the probability of survival were produced for the 595 of these 953 patients with 5 year follow-up details. In this group of patients the prognostic significance of tumour thickness, Clark level of invasion, ulceration, histogenetic type of melanoma and number of mitoses were studied using stepwise variable selection of procedures. Each of these possible prognostic factors attained individual significance but the tumour thickness was the dominant risk factor in the proportional hazards analysis. When patients were divided into four sex/ulceration subgroups (male/ulcerated, female/ulcerated, male/non-ulcerated, female/non-ulcerated) and analysed by proportional hazards analysis, no variable other than the tumour thickness had any further prognostic effect. Histogenetic type did not remain an independent prognostic variable at this stage. Despite sex and subsite differences, the prognosis for invasive lentigo maligna melanoma does not differ from that for other histogenetic types after controlling for tumour thickness.

Four hundred and eighteen cases of primary cutaneous malignant melanoma of the head and neck were registered with the Scottish Melanoma Group between 1979 and 1985. Distribution of histogenetic types of melanoma was lentigo maligna melanoma 50 per cent, superficial spreading melanoma 24 per cent, nodular melanoma 20 per cent, unclassifiable 6 per cent. Annual registrations of all types increased over the seven-year period but were less for lentigo maligna melanoma than for the other types. Patients with lentigo maligna melanoma were older, and those with superficial spreading melanoma younger, than the overall average. These two features support the hypothesis that the former may be more closely related to cumulative sunlight exposure than are other histogenetic types of melanoma. The sex ratio (F:M) was 1.7:1 for lentigo maligna melanoma, 1.5:1 for superficial spreading melanoma, but 1:1 for nodular melanoma. All types of melanoma were seen most commonly on the cheek. The proportion of lentigo maligna melanoma on the cheek was significantly greater than nodular melanoma or superficial spreading melanoma. Superficial spreading melanoma was significantly increased in frequency on the neck and scalp, and nodular melanoma on the ear. Melanomas of the scalp were significantly more frequent in male patients than female. The anatomical site distribution of nodular melanoma showed considerable differences between the sexes: nodular melanoma of the ear or neck occurred more commonly in male patients and nodular melanoma of the cheek was significantly more frequent in female patients. Five-year mortality data for head and neck melanoma derived from patients registered between 1979 and 1981 revealed that mortality was greater in male than in female patients, but there was no significant difference in prognosis between the three histogenetic types of melanoma when these were stratified according to tumour thickness.

The article offers information on the 2010 review and revision of Great Britain guidelines related to the aspects of cutaneous melanoma management, including its prevention, diagnosis, and initial treatment. It mentions several measures to prevent melanoma, such as the limit of sun exposure in people at risk of the disease. It discusses several factors that can help in the prognosis of melanoma, including perineural infiltration, detection of microsatellites, and presence of melanocytic naevus.