Second primary cancers in patients with skin cancer: a population-based study in Northern Ireland.

Among all 14,500 incident cases of basal cell carcinoma (BCC), 6405 squamous cell carcinomas (SCC) and 1839 melanomas reported to the Northern Ireland Cancer Registry between 1993 and 2002, compared with the general population, risk of new primaries after BCC or SCC was increased by 9 and 57%, respectively. The subsequent risk of cancer, overall, was more than double after melanoma.

Reliability testing of a sun exposure questionnaire for the Northern Ireland population.

BACKGROUND: Sunbathing and other types of exposure to ultraviolet radiation are the major preventable risk factors for skin cancer. Due to the continued increase in incidence of melanoma in Northern Ireland, we have conducted a questionnaire survey in an attempt to gather information about sunbathing habits and other forms of ultraviolet light exposure amongst the Northern Ireland population. AIM: The aim of this study was to examine the test-retest reliability of a questionnaire used in a large-scale cross-sectional population survey pertaining to sunbathing habits, use of sun screen, skin types, and frequencies of sunburn and to assess the responses given by the subjects to determine the nature of their sun-related behaviour. METHODS: Thirty control subjects were randomly selected from a population control sample participating in a large case-control study investigating melanoma in the Northern Ireland population. All participants completed the interview questionnaire on two occasions, with a median of 15 days (range, 12-42 days) between interviews. We randomly chose control subjects who had been visited by the same research nurse, thus ruling out interobserver bias in the analyses. We used the test-retest method. Kappa statistics were used to calculate the association between test and retest scores of all the individual items. If the items contained within the questionnaire are reliable, then repeated measurement after a fairly short period of time should result in high within-subject repeatability. RESULTS: Questions pertaining to hours spent in the sun and sun bed usage showed high reliability (kappa > 0.7). Questions about sunscreen usage showed moderately high reliability (kappa > 0.6) in all but one of the 10-year age bands and complete agreement (kappa = 1) in one age category (>50 years). CONCLUSION: This questionnaire is a reliable method of assessing sun-associated behaviour identifying high-risk sun-related behaviour and misconceptions about tanning, which can be targeted for improvement in public health.

Skin cancer trends in Northern Ireland and consequences for provision of dermatology services.

BACKGROUND: The incidence of skin cancer, both melanoma and nonmelanoma skin cancer (NMSC), is rising throughout the world. The evaluation of trends in skin cancer will allow better planning of the future development of skin cancer services. OBJECTIVES: Using data collected from the Northern Ireland Cancer Registry (NICR), the incidence of the three major cutaneous cancers, basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM), was determined and the workload associated with their management assessed. METHODS: The records of patients with a first diagnosis of BCC, SCC or MM occurring between 1993 and 2002 were retrieved from the NICR database. The annual age- and sex-adjusted incidence rates of all three skin cancers were computed per 100 000 person-years by direct standardization according to the European Standard Population. Trends in incidence were estimated by calculating the estimated annual percentage change using Microsoft Excel. For patients registered with the NICR as having BCC, SCC or MM, the number of pathological reports where malignant samples had been examined was counted and then summed to provide the number of specimens examined each year between 1993 and 2004. RESULTS: For all three cancers the age-specific rates for both males and females increased with age, except for MM in men aged 75 years and over, where the rates were seen to decrease. Over the 12-year period there was a 62% increase in the overall number of skin cancer samples processed by local pathology laboratories and a 20% increase in the number of patients. These data highlight the fact that many patients will have more than one skin cancer, which reinforces the benefit in collecting data for both patient and sample numbers in order to obtain a true reflection of the workload. The data have also shown that more affluent men and women have higher rates of BCC and MM than their less affluent counterparts. CONCLUSIONS: In view of the data presented it is clear that management of NMSC and MM will impose significant demands on services in the years ahead. This will impact on the entire multidisciplinary team. Future planning, in terms of manpower and resources, will prove essential if we are to remain in a position to manage our patients with these malignant tumours appropriately.

Follow-up of basal cell carcinomas: an audit of current practice.

BACKGROUND: Follow-up of patients after treatment of basal cell carcinoma (BCC) allows for monitoring of recurrence and detection of new tumours, but adds a significant burden to outpatient clinics. At the skin tumour clinic in the dermatology department, the Royal Hospitals, Belfast, all patients are reviewed for 2 years after surgical excision of a low-risk primary BCC. OBJECTIVES: An audit was undertaken to determine the quality of data set recorded relating to prognostic factors for BCCs to determine the rate of recurrence and number of new primary tumours detected and to determine the completeness of follow-up by patients. METHOD: Patients who had primary BCCs treated by excision were identified from a database held at the clinic. Medical charts were reviewed to determine data recorded about lesions, the number of recurrent BCCs and new tumours detected, and the number of patients completing follow-up. RESULTS: Between January 1999 and December 2000, 114 patients had 121 primary BCCs excised. BCC location and size were recorded in 100% and 35% of cases, respectively. Histological type was stated for morphoeic or multifocal lesions. Two years of follow-up was completed by 53% of patients and 1 year by 78% of patients. The rate of recurrence was low, with 2 BCC recurring within 2 years of excision. The risk of developing a new BCC was 11.6% in the first year and 6.3% in the second year. CONCLUSIONS: Follow-up of patients after excision of a low-risk BCC at the clinic has been reduced to 1 year. A proforma has been developed to encourage documentation of prognostic factors.

Improved survival for melanoma in Northern Ireland: a comparison of two 5-year periods (1984-88 and 1994-98).

BACKGROUND: The incidence of cutaneous malignant melanoma has been rising steadily in Caucasian populations for several decades, with a doubling time of 10-14 years. An increase in incidence of about 5% per year has been reported in most Caucasian populations since the early 1960s. OBJECTIVES: This study was designed to determine the changing incidence of primary cutaneous malignant melanoma in Northern Ireland and to examine changes in survival rates from cutaneous malignant melanoma in two 5-year periods, 1984-88 and 1994-98. METHODS: One thousand three hundred and twenty-six patients with invasive primary cutaneous melanoma were included in the study. RESULTS: The age standardized rate of melanoma rose from 4.3 per 100,000 population per year in men and 8.6 per 100,000 population per year in women to 7.7 and 11.8, respectively, per 100,000 population per year in the 1994-98 period. Overall, the absolute 5-year survival for the 1984-88 period was 71.0% [95% confidence interval (CI) 66.9-75.1%] and 77.4% (95% CI 73.4-81.4%) for the 1994-98 period. Women consistently showed better survival at all ages and within almost all categories of thickness of primary tumour. Younger patients of both sexes showed better survival rates. CONCLUSIONS: When survival rates between the 1984-88 and 1994-98 periods were compared using multivariate analysis, we found that patients diagnosed in the second period had a one-third lower risk of dying than those in the earlier period. Much of this reduction was explained by changes in the number of melanomas of thin Breslow depth and ulcerated melanomas.

Association between long-term acitretin therapy and osteoporosis: no evidence of increased risk.

Osteoporosis has been observed with chronic hypervitaminosis A, leading some authors to hypothesize that systemic retinoids may have an effect on bone mineral density. Two previous small studies identified osteoporosis in patients who received long-term therapy with etretinate. Etretinate has now been superceeded by acitretin in clinical use. We hypothesized that bone mineral density is lower in patients taking long-term acitretin than control cases who had never taken acitretin. Thirty Caucasian patients receiving acitretin for a median of 3.6 years for a variety of dermatoses were studied. Bone mineral density measurements were determined using DEXA scanning at two standard sites, the lumbar spine and Ward's triangle. We did not find an association between daily dose of acitretin, total dose administered or overall duration of treatment and risk of osteopenia or osteoporosis. Acitretin appears to be safe for long-term use in patients with chronic dermatoses.

Clinical and histologic trends of melanoma.

BACKGROUND: Several changing clinical and histopathologic melanoma trends occurred from the 1950s to the 1980s. OBJECTIVE: The purpose of this study was to evaluate melanoma trends during the past decade and to compare present trends to those documented during the past four decades. METHODS: Sex, age at diagnosis, location, tumor thickness, stage, and histologic subtypes were evaluated from 1984 to 1995 and compared with trends during the past four decades. RESULTS: Most changing trends from the past four decades have slowed or stabilized during the past decade. CONCLUSION: Complete reporting of all melanomas to central tumor registries is necessary to accurately analyze present and future melanoma trends. Ongoing and new prevention and control strategies beginning at birth may be necessary to continue the positive efforts to curtail the melanoma epidemic.

Pyoderma gangrenosum of the breast treated with low-dose cyclosporin A.

Pyoderma gangrenosum (PG) is a painful chronic ulcerative skin disorder often occurring in association with systemic disease. It typically affects the lower limbs, but may also involve other sites, or sometimes develop after trauma of surgical procedures. We report the case of a woman with rheumatoid arthritis who developed disfiguring and severe PG of the right breast, a rare site, following biopsy for a benign breast lesion, and who was subsequently successfully treated with low-dose cyclosporin A.

An autosomal dominant syndrome of acromegaloid facial appearance and generalised hypertrichosis terminalis.

We report a family in which a phenotype of acromegaloid facial appearance (AFA) and generalised hypertrichosis terminalis segregates through three generations. Congenital hypertrichosis terminalis and AFA have been previously reported as independent autosomal dominant traits. This is the first report to delineate an autosomal dominant transmission of the combined phenotype.

The value of a baseline liver biopsy prior to methotrexate treatment.

Two patients with severe disabling psoriasis were treated with methotrexate (MTX). As a short course of treatment was envisaged, a pretreatment liver biopsy was not performed. Although both patients developed similarly abnormal levels of hepatic enzymes after low cumulative doses of MTX (440 and 450 mg), subsequent liver biopsies revealed contrasting findings. In one patient the histological features were normal. However, in the second, there was hepatic fibrosis, and the absence of a pretreatment biopsy led to problems with interpretation of these histological findings. As a liver biopsy is by far the most reliable method of detecting liver disease, we suggest that it is still of value to include a baseline liver biopsy in the pretreatment assessment of patients even when only a short course of MTX is planned.

An audit of dermatology in a paediatric accident and emergency department.

Two studies were undertaken of patients with dermatological disorders who attended the Accident and Emergency (A&E) Department of the Royal Belfast Hospital for Sick Children during 1990-1991. The aims were to review diagnostic accuracy and assess the benefits of an open-access consultant dermatology clinic. A retrospective survey of 14,340 new attendances at the A&E department over a 7-month period found that 540 of these (4%) had a primary dermatological disorder. In 26% no diagnosis had been made although only 10% were referred for a specialist opinion. A 2-month prospective study of patients who attended the department and were referred to a consultant dermatology open-access clinic revealed overall diagnostic accuracy of 66% (+/- 2 SEM). Individual rates of diagnostic concordance between junior doctor and consultant were 59% for skin infections and 77% for papulosquamous disorders. The open-access clinic allowed prompt referral for correct diagnosis and initiation of appropriate management.

Serum neurone specific enolase (NSE) levels as an indicator of neuronal damage in patients with cerebral infarction.

A radioimmunoassay has been developed and used to measure serum neurone specific enolase (NSE) concentrations in 24 patients, following cerebral infarction. A significant correlation between cerebral infarct volume and maximum serum NSE concentration was observed (P = 0.047). Serum NSE was also assayed at times 24, 48, 72 and 96 h post ictus. At 72 h a significant correlation existed between serum NSE levels and infarct volume (P = 0.012), and levels appeared to be approaching statistical significance at 48 h (P = 0.067). No correlation existed at 24 and 96 h. In addition serum concentrations of NSE were compared to clinical outcome as determined by the Glasgow Outcome Score. Using the Mann-Whitney U test, there was no significant difference in maximum NSE level between patients graded 1-3 on the Glasgow Outcome Score and those graded 4 and 5. However, further studies are required on a larger population to more completely assess this. NSE may prove to be a useful marker of neuronal damage in the study of stroke, with particular application in the assessment of treatment.