Observational study of type of surgical training and outcome of definitive surgery for primary malignant melanoma
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7375.1276 (Published 30 November 2002) Cite this as: BMJ 2002;325:1276All rapid responses
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We thank Anindya Lahiri for the useful comments on our study of
primary treatment of melanoma and initial surgical training.
Not surprisingly, there were statistically significant differences
between mean clearance margins in the three groups. Dermatologists had a
mean margin of 2.6mm, general surgeons 4.7mm and plastic surgeons 8.8mm (p
< 0.001). However initial excision margin was not a significant
predictor of prognosis (p = 0.86).
3016 of our our 4159 patients (75.2%) had a minimum follow-up of 5
years.
Competing interests:
None declared
Competing interests: No competing interests
I read the article by MacKie et al with great interest. It supports
my personal belief that the speed of treatment of melanomas is probably
more important than the choice of surgical speciality.
As the authors rightly mention at the beginning of the article, the
margin of excision is one of the most important and certainly one of the
most discussed questions in the primary management of melanoma. As the
authors had the use of the excellent Scottish Melanoma database, it would
be of great interest to know if excision margins were noted and if there
were any differences in the excision margins chosen by different
specialities and more importantly whether that had any correlation with
the prognosis.
I would also like to mention that as the survival for malignancies
tends to be expressed as five or ten year survival rate, a minimum of five
or ten years of follow-up is probably clinically more relevant than any
average follow-up period. The authors mention that the average follow-up
period was 10 years. I wonder if they noted what was the minimum follow-up
period for this patient cohort or how many patients actually had a minimum
of five years follow-up.
I would like to thank the authors for a very useful study and would
entirely agree with their final recommendation that a patient with a
suspected primary malignant melanoma should be referred to the appropriate
surgical speciality with the shortest waiting time.
Competing interests:
None declared
Competing interests: No competing interests
Surgical training in treatment of cutaneous malignant melanoma
The study by MacKie et al in the BMJ examined a cohort of cutaneous
malignant melanoma patients studied by the Scottish Melanoma Group and
found, as measured by survival, that outcome was independent of the type
of surgeon carrying out the initial excision1. This provides valuable
information on the likelihood of survival once a diagnosis has been made
but does not appear to take into account the relative accuracy of
different specialists in making the diagnosis itself. On this basis it
would not be appropriate to conclude that referral of suspected primary
melanomas should be to the dermatological, plastic surgery and general
surgical service with the shortest waiting time.
Cutaneous malignant melanoma can masquerade clinically as benign lesions
(False Negative Rate, FNR), and benign pigmented lesions can clinically
simulate malignant melanoma (False Positive Rate, FPR). A number of
studies comparing the diagnostic accuracy of dermatologists versus non-
dermatologists have shown that dermatologists consistently recognise
malignant melanoma with greater accuracy2, and this accuracy increases
with experience3. Studies have found that general surgeons were less
likely to make the correct clinical diagnosis, and were more likely to
perform unnecessarily wide excisions for thin melanomas when compared to
dermatologists working in conjunction with plastic surgeons4. This is
likely to lead to an excessive number of benign lesions being excised by
general surgeons. Furthermore, general surgeons or those who are carrying
out only few melanoma excisions are less likely to be entirely up to date
with the guidelines produced jointly by dermatologists and plastic
surgeons. It remains unproven that it is equally appropriate to refer
patients to general surgeons who have higher FNR and FPR diagnoses and
may perform unnecessarily wide excisions for thin melanomas, and may
possibly be less informed in relation to guidelines for melanoma care
compared to dermatologists.
The emergence of Pigmented Lesion Clinics (PLCs) in the 1980s has
significantly reduced the delay interval between referral to the GP and
presentation to hospital, the diagnostic accuracy and the time to initial
surgery. Such PLCs also have a low FNR for melanoma, which is important
because it is responsible for a delay in excision. A recent study found
the FNR was lower in PLCs (10%) than in either ordinary dermatology (29%)
(P<0.0001) or plastic surgery clinics (54%)5.
Surely it is preferable for patients that they are referred to
dermatology or plastic surgery clinics specialising in melanoma where
diagnostic accuracy will increase the quality and appropriateness of care
given to the patient.
1. MacKie RM, Bray CA & Hole DJ. Observational study of type of
surgical training and outcome of definitive surgery for malignant
melanoma. BMJ 2002; 325: 1276-7.
2 Wagner RF, Wagner D, Tomich JM et al. Diagnoses of skin disease:
dermatologist’s vs. non dermatologists. J Dermatol Surg Oncol 1985; 11:
476-9.
3 Morton CA, MacKie RM. Clinical accuracy of the diagnosis of
cutaneous malignant melanoma. Br J Dermatol 1998; 138: 283-7.
4 Williams HC, Smith D, du Vivier A. Melanoma. Differences observed
by general surgeons and dermatologists. Int Dermatol 1991; 30: 257-61.
5 Osborne JE, Chave TA, Hutchinson PE. Comparison of diagnostic
accuracy for cutaneous malignant melanoma between a pigmented lesion
clinic and other clinics.
Br J Dermatol 2003; 148: 252-8.
Competing interests:
None declared
Competing interests: No competing interests