Cutaneous Mycobacterium chelonae infection in Edinburgh and the Lothians, South-East Scotland, U.K.

BACKGROUND: We reviewed all cases of Mycobacterium chelonae infection seen in our department between 1 January 2008 and 31 December 2012. OBJECTIVES: To review the epidemiology, clinical features and management of cutaneous M. chelonae in South-East Scotland, and to compare prevalence data with the rest of Scotland. METHODS: The Scottish Mycobacteria Reference Laboratory database was searched for all cases of cutaneous mycobacterial infections. RESULTS: One hundred and thirty-four cases of cutaneous mycobacterial infection were recorded. Sixty-three were tuberculous; of the remaining 71, M. chelonae was the most common nontuberculous organism (27 cases). National Health Service (NHS) Lothian Health Board was the area with highest incidence in the Scotland (12 cases). Three main groups of patients in the NHS Lothian Health Board contracted M. chelonae: immunosuppressed patients (n = 6); those who had undergone tattooing (n = 4); and others (n = 2). One case is, we believe, the first report of M. chelonae cutaneous infection associated with topical corticosteroid immunosuppression. The majority of patients were treated with clarithromycin monotherapy. CONCLUSION: The most prevalent nontuberculous cutaneous mycobacterial organism in Scotland is M. chelonae. The prevalence of M. chelonae in Edinburgh and the Lothians compared with the rest of Scotland is disproportionately high, possibly owing to increased local awareness and established facilities for mycobacterial studies. Immunosuppression with prednisolone appears to be a major risk factor. The first outbreak of tattoo-related M. chelonae infection in the U.K. has been reported. Clinicians should be aware of mycobacterial cutaneous infection and ensure that diagnostic skin samples are cultured at the optimal temperatures.

Trends in skin cancer incidence by socioeconomic position in Scotland, 1978-2004.

BACKGROUND: Non-melanoma skin cancer has been little studied in relation to deprivation. METHODS: Incident cases diagnosed in 1978-2004 were extracted from the Scottish Cancer Register and assigned to quintiles of Carstairs deprivation scores. Age-standardised incidence rates (ASRs) (European standard population) were calculated by deprivation quintile, sex, period of diagnosis, for the three main types of skin cancer. RESULTS AND CONCLUSION: As age-standardised incidence of each skin cancer increased significantly over time across all deprivation categories, rates were consistently highest in the least deprived quintile.

Recent trends in incidence of nonmelanoma skin cancers in the East of Scotland, 1992-2003.

BACKGROUND: Historically, ascertainment of nonmelanoma skin cancer (NMSC) by cancer registries in the U.K. has been shown to be incomplete in several studies. However, recent evidence suggesting that almost all clinically diagnosed NMSCs are verified histologically, coupled with the increasing availability of electronic histopathology data to cancer registries, raises the possibility that this situation may have improved. OBJECTIVES: To assess recent trends in incidence of the main types of NMSC and carcinoma in situ (CIS) of the skin in Scotland. METHODS: The study was restricted to selected health board areas in the East of Scotland for which pathology data have been used routinely to support cancer registration since the early 1990s. Incident cases of squamous cell carcinoma (SCC) of the skin, CIS of the skin, and first ever basal cell carcinoma (BCC) were extracted from the Scottish Cancer Registry covering the period of diagnosis 1992-2003. Sex-specific, age-standardized and age-specific incidence rates were calculated for four consecutive 3-year periods of diagnosis. Estimated annual percentage changes (EAPCs) in incidence were calculated by Poisson regression modelling, with adjustment for age. The percentage distribution of SCC, BCC and CIS of the skin by anatomical site and sex was calculated for the period of diagnosis 1997-2003. RESULTS: The crude incidence of SCC for the period 1995-97 was 34.7 per 100,000, comparable with the best existing Scottish estimate of 32.2 derived from a prospective survey in Glasgow during March 1995. Age-adjusted rates of SCC, first ever BCC, and CIS of the skin have all increased significantly in both sexes between 1992 and 2003 (all P < 0.001), with EAPCs ranging in magnitude from +1.4% (first ever BCC in males) to +5.1% (CIS in males). The majority of lesions arose on the head and neck area, with the exception of CIS, which in females was more commonly located on the limbs. CONCLUSIONS: Ascertainment of NMSC has probably improved since the advent and use of electronic pathology data. Ongoing increases in age-adjusted incidence, combined with ageing of the population, will have major implications for the clinical workload associated with NMSC for the foreseeable future.

Changes in the site distribution of malignant melanoma in South East Scotland (1979-2002).

Scottish Melanoma Group (SMG) data on 2790 melanoma (MM) cases in South East Scotland over a 24-year time period were analysed in four periods each of 6 years duration grouped into frequently exposed, intermittently exposed, and always covered sites. Incidence increased significantly over time with females having a higher incidence rate than males. In both sexes, the proportion of cases seen on the posterior trunk and arm increased significantly (P<0.001), but declines were seen in the proportion of leg tumours in males (P=0.09) and of head tumours in females (P=0.011). Although the proportion of cases decreased for certain sites, the actual MM incidence increased at all sites. A significant increase in incidence occurred at usually and always covered sites (P<0.001 and P<0.001, respectively) in females and at usually covered sites in males (P<0.001).

Thick melanoma: the challenge persists.

BACKGROUND: Considerable resources have been channelled into primary and secondary prevention of cutaneous melanoma over the past 20 years. These efforts have been associated with a significant increase in the proportion of thin, good prognosis lesions and this is felt to be the principal reason for the current overall improvement in melanoma survival. OBJECTIVES: Analysis of Scottish Melanoma Group (SMG) data was carried out to identify the proportion of thick melanomas presenting over time. SMG data were used to characterize the patients presenting with thick melanoma. METHODS: Using data from the SMG database 915 patients (392 male and 523 female) first diagnosed with invasive melanoma > or = 3.5 mm thick in the two decades between 1979 and 1998, inclusive, were identified. The patients were from regions designated South-east Scotland, Tayside, Grampian and Highland, which together form half of all Scottish cases. RESULTS: The analysis shows that, although the proportion of thick, poor prognosis melanomas has decreased over time, the number presenting per year has not significantly altered. In the first decade, 50.5% of registrations were thick lesions and these fell to 31.0% in the second decade. In the first decade there were 419 cases (173 male), median age 66 years (range 5-99). Fifty-five patients were under the age of 40 years. Two hundred and twelve melanomas were nodular, 116 superficial spreading (SSM), 34 acral and 26 lentigo maligna melanoma. Sixty-nine patients had either lymph node involvement or distant spread at presentation. Despite a 93.3% increase in the total number of melanoma registrations by the end of the second decade, there was relatively little change in the absolute numbers of thick lesions. The total number of thick lesions was 496 (220 male), an increase of 18.4%. Median age was greater, at 70 years (range 1-98), and 31 patients were under the age of 40 years. Nodular was still the commonest type but its proportion had dropped significantly compared with the first decade, with a corresponding increase in SSM and acral types. CONCLUSIONS: Over a 20-year period there was little change in the absolute number of patients presenting with thick melanoma each year, though these form a diminishing proportion of the rising number of total melanomas. This thick melanoma group is characterized by an increasingly older age group and a changing type profile, nodular and SSM being the most common types. This work suggests that the resources currently directed at public and professional education on melanoma are having no effect on this group of patients and that alternative strategies may need to be considered.

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma.

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.

A retrospective observational study of primary cutaneous malignant melanoma patients treated with excision only compared with excision biopsy followed by wider local excision.

BACKGROUND: For primary cutaneous malignant melanoma the guidelines recommend an excision biopsy of the suspected lesion followed by wider local excision; the diagnosis can then be confirmed and excision margins planned. OBJECTIVES: To compare retrospectively the clinicopathological features, surgical margins and survival of patients from the Scottish Melanoma Group database whose tumour was removed by excision only (one-stage) or excision biopsy followed by wider local excision (two-stage) surgery. METHODS: The Scottish Melanoma Group database records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. From this 1595 patients were identified over a 19-year interval from 1979 to 1997 with follow-up until the end of December 1999. Overall survival, disease-free survival and recurrence-free interval were examined with univariate and multivariate statistical methods. RESULTS: The patients in the one-stage excision group (n = 547) were statistically significantly older (P < 0.001), had thicker melanomas (P < 0.001), a higher proportion of lentigo maligna melanomas (P < 0.001), head and neck (P < 0.001), and ulcerated lesions (P < 0.003) compared with the two-stage group (n = 1048). The margins of excision were significantly narrower in the one-stage compared with the two-stage group (P < 1 x 10(-5)). Fifty-two percent of all one-stage excisions were performed with a margin < 1 cm compared with 20% of the two-stage group. The excision margin was more positively correlated with the Breslow thickness for the two-stage over the one-stage group (Spearman rho = 0.38, P < 0.001; and 0.27, P < 0.001, respectively). Overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RF) were all statistically significantly better in the two-stage compared with the one-stage excision group, P < 1 x 10(-5), P < 1 x 10(-5) and P = 0.001, respectively (log rank test). After adjusting for the prognostic factors of age, sex, tumour thickness, site, histology and ulceration, OS, DFS and RF were still significantly better in the two-stage compared with the one-stage group [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006; HR 0.75, CI 0.62-0.90, P = 0.002; and HR 0.78, CI 0.62-0.99, P = 0.04, respectively]. CONCLUSIONS: This study showed that one-stage excisions were more common in patients with poorer prognostic features and that excision with margins narrower than those suggested by current guidelines was more likely. Patient survival was statistically significantly better with the two-stage procedure, although the reasons for this were unclear.

Evidence for an association between cutaneous malignant melanoma and lymphoid malignancy: a population-based retrospective cohort study in Scotland.

We analysed the risk of cutaneous malignant melanoma (CM) occurring in patients following a diagnosis of non-Hodgkin's lymphoma (NHL) or chronic lymphatic leukaemia (CLL), and of NHL or CLL subsequently developing in CM survivors. Cohorts of patients with CM, NHL or CLL (index cancer) diagnosed between 1975 and 1997 were identified from the Scottish national cancer registry and followed through the registry for subsequent CM, NHL or CLL. The standardised incidence ratio (SIR) for each cancer was calculated and overall risk, risk in relation to gender and age at diagnosis of the index cancers and time from diagnosis of the index cancer to the diagnosis of the second malignancy were measured. There were 9385 CM patients, 4016 CLL patients and 13 857 NHL patients identified with an index cancer with 56 195, 14 450 and 44 999 person-years of follow-up, respectively. There was an increased risk of both CLL and NHL following a diagnosis of CM (SIR 2.3 and 1.5, respectively) and of CM following a diagnosis of CLL and NHL (SIR 2.3 and 2.1, respectively). The risk was statistically significantly increased for CLL developing in CM patients and for CM occurring in NHL survivors (P<0.05). This study supports an association between CM, CLL and NHL developing in the same patient. Immunosuppression, exposure to ultraviolet radiation and genetic factors may lead to a host environment that is conducive to the development of these malignancies.

The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival.

BACKGROUND: The surgical management of primary cutaneous malignant melanoma usually involves an excision biopsy of the suspected lesion followed by wide local excision. No study has addressed whether a delay between these two surgical procedures influences patient outcome. OBJECTIVES: To determine if the surgical interval (SI) between the diagnostic excision biopsy and wide local excision for primary cutaneous malignant melanoma affects recurrence or survival outcome. METHODS: A cohort of 986 patients who had a diagnostic excision biopsy followed by wide local excision was identified from those registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. The cohort was divided into five arbitrary groups determined by the length of the SI as follows:< or =14 days, 15-28 days, 29-42 days, 43-91 days and > or = 92 days. Overall survival, disease-free survival and recurrence-free interval between the groups were compared univariately and multivariately. RESULTS: The mean age at excision biopsy was 47.4 years and the median period of follow-up was 5 years (range 27 days to 20.7 years). The median SI was 30 days (range 1-468 days). The SI was: (i)< or =14 days for 130 (13%); (ii) 15-28 days for 320 (33%); (iii) 29-42 days for 262 (27%); (iv) 43-91 days for 251 (25%); and (v) > or = 92 days for 23 (2%) patients. The latter group was older, had thinner melanomas, a higher percentage of lesions on the head and neck, fewer superficial spreading malignant melanomas and ulceration present less often compared with patients treated earlier. Univariately, there was no significant difference in overall survival (P = 0.60) or disease-free survival (P = 0.24) between the groups. Although there was a statistically significant difference in the percentage of recurrence-free patients between the groups (P = 0.011), the better recurrence-free rates occurred in the 29-42 and 43-91 day groups. After adjusting for age, sex, tumour thickness, site, histology, ulceration and mitotic activity using Cox's proportional hazards model, there was no statistically significant difference in overall survival, disease-free survival and recurrence-free percentages between the surgical groups (P = 0.88, P = 0.44 and P = 0.084, respectively). CONCLUSIONS: There was no evidence that survival outcome or recurrence was related to the time interval between the diagnostic excision biopsy and wide local excision of melanoma.

Risk of cancer in patients with dermatomyositis or polymyositis, and follow-up implications: a Scottish population-based cohort study.

We conducted a national, retrospective population-based cohort study of 705 patients hospitalized with a first diagnosis of dermatomyositis (DM) or polymyositis (PM) during 1982-1996 based on linkage of hospital discharge, cancer registration, and death records in Scotland. Risks of cancer were assessed by calculating standardized incidence ratios (SIR). A first malignancy was diagnosed concurrently or subsequently in 50 patients with DM (SIR 7.7, 95% CI 5.7-10.1), and 40 patients with PM (2.1, 1.5-2.9). Significantly elevated risks were observed for lung, cervix uteri, and ovarian cancer in patients with DM, and for Hodgkin's disease in patients with PM. The excess risk of cancer was highest around the time of diagnosis, and for patients with DM remained high for at least 2 years. Risks were elevated for both sexes but only significantly so for females, and were highest in patients aged 45-74 years at the time of diagnosis for DM and 15-44 for PM.

Equestrian perniosis associated with cold agglutinins: a novel finding.

Reports of equestrian perniosis are rare in the literature and in the cases previously described there have been no abnormal laboratory investigations. We describe two patients with equestrian perniosis who had persistently elevated titres of cold agglutinins. We discuss the relationship of these cold agglutinins to the pathogenesis of perniosis and other related skin disorders.

Malignant melanoma and lymphoproliferative malignancy: is there a shared aetiology?

We report seven patients who developed malignant melanoma either coincident with or before the diagnosis of non-Hodgkin's lymphoma or chronic lymphatic leukaemia. One patient died secondary to leukaemia, and chemotherapy-induced immunosuppression may have contributed to the development of metastatic melanoma in another patient. Immunosuppression, exposure to ultraviolet radiation and genetic factors may result in a host environment that is conducive to the development of both tumours in these patients.

The gene for hypotrichosis of Marie Unna maps between D8S258 and D8S298: exclusion of the hr gene by cDNA and genomic sequencing.

Hypotrichosis of Marie Unna (MU) is an autosomal dominant hair-loss disorder with onset in childhood. A genomewide search for the gene was performed in a large Dutch family using 400 fluorescent microsatellite markers. Linkage was detected with marker D8S258, and analysis of this family and a further British kindred with additional markers in the region gave a combined maximum two-point LOD score of 13.42, with D8S560. Informative recombinants placed the MU gene in a 2.4-cM interval between markers D8S258 and D8S298. Recently, recessive mutations in the hr gene were reported in families with congenital atrichia, and this gene was previously mapped close to the MU interval. By radiation-hybrid mapping, we placed the hr gene close to D8S298 but were unable to exclude it from the MU interval. This, with the existence of the semidominant murine hr allele, prompted us to perform mutation analysis for this gene. Full-length sequencing of hr cDNA obtained from an affected individual showed no mutations. Similarly, screening of all exons of the hr gene amplified from the genomic DNA of an affected individual revealed no mutations. Analysis of expressed sequences and positional cloning of the MU locus is underway.

'Naevophobia'.

In recent years there has been intensive media interest in pigmented lesions and several skin cancer prevention/early detection campaigns. Pigmented lesions may cause great anxiety, although patients are usually reassured once their moles have been examined by a dermatologist. We describe a case in which a young man with multiple pigmented naevi attempted to remove all the lesions himself. This self-mutilation occurred despite his having attended a dermatology clinic.