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Rapid Responses: Rapid Responses published:
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Photos and pigmented lesions. No suprise to me.
- Robert I. Rudolph, M.D., FACP (15 August 2003)
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Science not Art
- Gerry E Burns (15 August 2003)
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what about the dermatoscope?
- Stephen F Hayes (18 August 2003)
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Another chance for the algorithm
- Felipe C Cepeda, Ella J Ariza ellariza@yahoo.com (19 August 2003)
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Publicity is good
- Adam Dangoor (23 August 2003)
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Objective assessment of skin lesions
- Dalvi Humzah (30 August 2003)
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Robert I. Rudolph, M.D., FACP, Clinical Professor of Dermatology, University of Pennsylvania, Philadelphia, PA USA 1134 Penn Avenue, Wyomissing, PA, 19610, USA
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I read the article on photographs and melanoma with great interest. I thought it was nicely done. As a dermatologist (especially one affiliated with a major dermatology department which has always had a strong interest in melanoma [Wally Clark started the Pigmented Lesion Clinic years ago at Penn, and I was fortunate to count him as a friend and colleague]) I was always taught that photos were a good aid in helping to detect changes and/or malignancy within pigmented lesions or on patients with many lesions. Despite this, however, I've never really found over the years that photos (even if taken properly by a professional at the PLC) were of any real help to me in determining whether a lesion needed to be removed or not. I've always felt that "the computer in my head" - honed and tuned by years of experience and visualising thousands upon thousands of pigmented lesions - was much more valuable to me than photos or formal algorithms. I see my patients with melanomas and other pigmented moles regularly, and train them in skin examination, and what to look for in pigmented lesions. They get very good at noticing changes. When I see something that "looks funny to my discerning diagnostic eye" I take it off. It is truly amazing - and humbling - what the pathology reports say on many an occasion. I much prefer to leave lesions alone, but as I get older I'm becoming ever more cautious about pigmented lesions. To be sure, I do photograph patients, and do use diagnostic aids such as a dermatoscope, but, as I always tell students and residents: "if the lesion looks suspicious or atypcial enough for you to actually pull out your dermatoscope then you are, by defintion, concerned about the lesion, and unless you are truly convinced after close examination that no malignancy is present, it's prudent to remove it." This advice has served me well, and the number of highly atypical and melanomatous lesions I've removed over 29 years of practice continues to increase, and astound me. Bottom Line: if it "looks funny", take it off! (EBMer's and policy people will most certainly ululate - and execrate me - for this philistine and practical approach, but I'll bet a case of good wine that if I detected a peculiar or funny looking lesion on one of them, they sure as hell would want it off "now", and in a bottle!) Cheers to all, and please keep the vilification down to a minimum. Competing interests: I'm a skin doc who is seeing an ever increasing number of patients with melanomas |
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Gerry E Burns, GP principal 165 duncairn gdns belfast bt15 2ge
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editor, the results found by English et al are not surprising considering the litiginous world we all live in now where it is deemed prudence is a better course than valour. The ratio of benign to malignant lesions does seem high compared to a ratio of roughly 10:1 in N. Ireland. Speaking with local dermatologists reveals their ratio to be 2:1, albeit in a pre-selected group. I am currently working on a mathematical model to determine malignant risk in pigmented lesions. This model could be used in those wihout the benefit of years of experience in a dermatological department. This is similar to the formula used to determine the cardiovascular risk in patients whose BP cholesterol and age are known. Obviously in the case of melanoma we are looking at the absence or presence of asymmetry, the degree of colour change , the size of the lesion etc Armed with such a tool hopefuly it will be easier to reassure patients their lesion is indeed benign. Dr Gerry Burns Competing interests: Macmillan GP facilitator |
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Stephen F Hayes, Hospital Practitioner, dermatology Isle of Wight
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As a result of this paper I will have to change one of my PowerPoint presentations, since I had been quoting the earlier Del Mar study on melanoma diagnosis which this one appears to overturn. However, I was going to change it anyway after having been introduced to the dermatoscope. This inexpensive device magnifies features visible to the naked eye and reveals features not visible to it. My clinic letters already contain references to findings such as blue-white veil, scar-like depigmentation, radial streaming and irregular dots and globules which taken together enable the diagnose of thinner melanomas. Also, absense of a melanin pigment network and presence of positive features of benignity revealed dermatoscopically can save patients from needless surgery. On the day this edition of the BMJ came out I was able to confidently reassure a patient who presented with a new, dark, bleeding lesion on the back-to the naked eye it looked nasty but the 'scope revealed it as a benign haemangioma. Melanoma is now killing more people in the UK than cancer of the cervix. Massive resources are dedicated to screening for the latter cancer, while it is difficult for GPs to access training in dangerous mole recognition. By the way, lesion (a) on the front cover, listed as a superficial spreading melanoma, is very obviously a nodular melanoma arising from a superficial spreading, and from it's apparent depth will have probably metastatised by now. The only evidence based way to avoid mortality in this catastrophically malignant cancer is excision before it has spread, the dermatoscope can help here but even more, better training for all frontline healthcare workers. Competing interests: None declared |
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Felipe C Cepeda, General Practitioner Bogotá, Colombia, Ella J Ariza ellariza@yahoo.com
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To the Editor: In the article English and Burton 327:375 (16 August) are not specific about the training and adherence of the practitioners to the algorithm. Because, even though this is an aid for clinical practice, the usefulness of this is bound to the success of the implementation. In our experience we know that there are some variables which should be measured in the application of algorithms like the physician’s agreement with algorithm, training in using it , comfortably and closely, which are not mentioned in materials and methods.2 This may be an important variable at the moment of obtaining the results, in our point of view it could be a confusion of variable. Furthermore, the algorithm has not followed international standards in their paper which includes specific boxes for clinical skills; (rectangle of round boards), decision (hexagon), and action (rectangle).
We are general practitioners, and we worked in our internship in the utility of algorithm in clinical practice, and as Carmi Margolis says in one of his book, one important point in the implementation of the guidelines which is missed some times is the “sense of beauty and utility” of this guidelines, by the physicians the flowcharts could be present in different ways, we are sending another idea of the same algorithm, using, some academic tools and international rules mentioned before In other words in the objective of the article determining whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice 1for us the null hypothesis is that the aid to the diagnosis of pigmented skin lesions does not help to reduce the ratio of excised benign melanomas. In the conclusion they accept the null hypothesis saying that provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners 1and in epidemiology that definitions which we had learned the null hypothesis either will or will not be rejected as a viable but no to be accepted , this affirmation is confuse to us because our training on basics of epidemiology, and it could be a side effects of the confusion of variables mentioned before. 1. English D, Burton R, Del Mar C, Donovan R, Ireland P, Emery G. Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice BMJ 2003;327:375 2. Margolis C, Cretin S. Implementing clinical practice guidelines. Chicago, IL:AHA Press;1999. Competing interests: None declared |
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Adam Dangoor, Oncology Registrar Christie Hospital, Manchester, M20 4BX
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The photographs of melanomas on the BMJ cover and the paper by English et al are beneficial as they remind doctors how difficult melanoma is to diagnose and how high the index of suspicion should be. In a melanoma oncology clinic we regularly see patients who have been reassured about skin lesions, or even treated for other conditions such as verucca, before the true diagnosis is reached. Unfortunately melanoma can occur in unexpected places - the soles of the feet, under toe nails; not just the sun exposed areas we might expect. This needs to be remembered, suspicious lesions need close review and if in doubt cut them out. Competing interests: None declared |
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Dalvi Humzah, Consultant Plastic & Reconstructive Surgeo Wordsley Hospital DY8 5QX
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The paper by English et. al., confirms a view held by many that serial photography does not alter the final diagnosis of a skin lesion. A suspicious lesion that remains following an interval will eventally require an excision biopsy to confirm a pathological diagnosis. The main problem in using serial photography, and in particular colour photographs is the difficulty in obtaining a standard image (i.e. colour saturation) between different periods. The ambient lighting and other external factors all change the view of the skin lesion - thus objective comparisions are not possible. Furthermore photographs may not easily differentiate skin lesions e.g deeply pigmented seborrhoeic keratoses and melanomas. The weakness of this study is that a simple objective skin examination technique was not used. The Dermatoscope (Epi-luinescence Microscopy) is mandatory in evaluating a skin lesion and is invaluable in helping differentiate a benign and suspicious lesion. Although it is possible to assess lesions purely by visual examination, what is required is an objective (descriptive)asessment of a lesion that can be recorded in the notes or photographed through the dermatoscope (derma-phot)(1). If English et al had performed this study using the dermatoscope the results would have been of major interest - unfortunately this study purely contradicts that by Del Mar et. al (2),and does not contribute in helping primary care workers differentiate between benign and suspicious lesions. The dermatoscope is simple and safe to use and is a technique that must be used when examining a skin lesion. Ackerman stated that "no one should die of melanoma" as this cancer mostly arises on the external skin. Therefore the main principles to be kept in mind when examining a patient with one skin lesion is that the skin is an organ and therefore the whole organ must be examined; and a simple illuminated contact-plate magnification (dermatoscope)is a safe, non-invasive and cheap method which is invaluable in differentiating suspicious lesions. These two principles will be of major benefit to those looking at skin lesions and enable a thorough evaluation of the patient. Ref: 1. Clinics in Dermatology - Dermoscopy of Pigmented Skin Lesions Vol 20 (3) 2002. 2 Del Mar CB, Green AC. Aid to diagnosis of melanoma in primary medical care. BMJ 19995; 310:492-5. 3. Ackerman. AB. No one should die of malignant melanoma. J Am Acad Dermatol 1985; 12: 115-6. Competing interests: None declared |
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