Ensuring universal assessment and management of vitamin D status in melanoma patients at secondary care level: a service improvement project.

BACKGROUND/AIMS: Melanoma is the most aggressive skin malignancy with an ever-increasing caseload, especially in the western world. Recently developed immunotherapeutic modalities have substantially improved the prognosis of advanced melanoma. The association between serum levels of vitamin D and prognosis of melanoma has been a focus of ongoing research, with some evidence of vitamin D's potential as an adjunctive modality to immunotherapy. The National Institute for Health and Care Excellence guidelines clearly recommend that assessment of vitamin D levels and relevant advice should be an inherent aspect of the management of patients with melanoma at the secondary care level. METHOD: A service improvement project was conducted to ensure full compliance of practice in the authors' skin unit with the current National Institute for Health and Care Excellence guidelines on the management of vitamin D status in patients with melanoma. RESULTS: After two reaudits the unit's practice complied with National Institute for Health and Care Excellence guidelines by using a multidisciplinary team approach. CONCLUSIONS: The authors propose that the simple and reliable pathway used to achieve and sustain the results could be easily adopted to ensure universal adherence to these guidelines.

Assessment of Accuracy of an Artificial Intelligence Algorithm to Detect Melanoma in Images of Skin Lesions.

Importance: A high proportion of suspicious pigmented skin lesions referred for investigation are benign. Techniques to improve the accuracy of melanoma diagnoses throughout the patient pathway are needed to reduce the pressure on secondary care and pathology services. Objective: To determine the accuracy of an artificial intelligence algorithm in identifying melanoma in dermoscopic images of lesions taken with smartphone and digital single-lens reflex (DSLR) cameras. Design, Setting, and Participants: This prospective, multicenter, single-arm, masked diagnostic trial took place in dermatology and plastic surgery clinics in 7 UK hospitals. Dermoscopic images of suspicious and control skin lesions from 514 patients with at least 1 suspicious pigmented skin lesion scheduled for biopsy were captured on 3 different cameras. Data were collected from January 2017 to July 2018. Clinicians and the Deep Ensemble for Recognition of Malignancy, a deterministic artificial intelligence algorithm trained to identify melanoma in dermoscopic images of pigmented skin lesions using deep learning techniques, assessed the likelihood of melanoma. Initial data analysis was conducted in September 2018; further analysis was conducted from February 2019 to August 2019. Interventions: Clinician and algorithmic assessment of melanoma. Main Outcomes and Measures: Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of the algorithmic and specialist assessment, determined using histopathology diagnosis as the criterion standard. Results: The study population of 514 patients included 279 women (55.7%) and 484 white patients (96.8%), with a mean (SD) age of 52.1 (18.6) years. A total of 1550 images of skin lesions were included in the analysis (551 [35.6%] biopsied lesions; 999 [64.4%] control lesions); 286 images (18.6%) were used to train the algorithm, and a further 849 (54.8%) images were missing or unsuitable for analysis. Of the biopsied lesions that were assessed by the algorithm and specialists, 125 (22.7%) were diagnosed as melanoma. Of these, 77 (16.7%) were used for the primary analysis. The algorithm achieved an AUROC of 90.1% (95% CI, 86.3%-94.0%) for biopsied lesions and 95.8% (95% CI, 94.1%-97.6%) for all lesions using iPhone 6s images; an AUROC of 85.8% (95% CI, 81.0%-90.7%) for biopsied lesions and 93.8% (95% CI, 91.4%-96.2%) for all lesions using Galaxy S6 images; and an AUROC of 86.9% (95% CI, 80.8%-93.0%) for biopsied lesions and 91.8% (95% CI, 87.5%-96.1%) for all lesions using DSLR camera images. At 100% sensitivity, the algorithm achieved a specificity of 64.8% with iPhone 6s images. Specialists achieved an AUROC of 77.8% (95% CI, 72.5%-81.9%) and a specificity of 69.9%. Conclusions and Relevance: In this study, the algorithm demonstrated an ability to identify melanoma from dermoscopic images of selected lesions with an accuracy similar to that of specialists.

Use of Integra dermal substitute to prevent implantable device extrusion in an Olympic athlete.

We present a challenging case of imminent metallic implant extrusion in a Paralympic athlete managed with a single-stage procedure using 'Integra' dermal substitute. The patient had hereditary spastic paraparesis, for which a baclofen pump delivering intrathecal medication was vital in the management of his condition. The device had been most recently implanted into the thigh after previous complications. Integra provided robust soft-tissue coverage over the implanted baclofen pump in the thigh. Different operative management strategies were considered but the use of Integra was felt to offer the least morbidity and a quick recovery. The patient was able to successfully compete in a Paralympic canoeing qualifying event the week following surgery and achieve medal success. To the authors' knowledge, this is first case in which Integra has been used in such circumstances.

Marjolin's ulcer: a rare entity with a call for early diagnosis.

Marjolin's ulcer (MU) is an umbrella term covering squamous cell carcinoma (SCC), basal cell carcinoma and malignant melanoma that develop in chronic wounds, sinuses or scars. Cutaneous (non-MU) SCC is related to excessive sun-exposure, with Fitzpatrick skin types I and II being more susceptible. Radiation, genetic disorders (eg, Xeroderma pigmentosum) and immunosuppression, are other important risk factors often involved in the development of cutaneous malignancies and may also be involved in the development of MU. MU, first described by Jean-Nicholas Marjolin in 1828, is more aggressive than non-MU SCC, with a higher potential for early metastasis. A high index of suspicion and early histological diagnosis in chronic wounds and unstable scars with recent changes in characteristics offer the best prognosis with treatment. We present a case alongside a literature review contrasting the characteristics of MU and non-MU SCC, and suggest a management plan for early MU identification and prevention.

Gyrate erythema and melanoma-a new clinical association.

The authors present the case of a 65-year-old gentleman with a 2.6-mm Breslow thickness melanoma on the lower limb. During his treatment, he underwent several operations including a partial foot amputation. At clinical review, he was noted to have developed an unusual rash. This rash, an annular and gyrate erythema, has never been described before in relation to melanoma, and is sometimes seen in the presence of paraneoplastic processes. Highlighting this new association may enable clinicians to understand and appreciate melanoma better in the future.

Soft fluted silicone drains: a prospective, randomized, patient-controlled study.

BACKGROUND: For some patients, removal of surgical drains can be the most painful part of surgery. The authors present a prospective, randomized, patient-controlled study comparing soft fluted silicone (Blake) drains with conventional rigid (Portavac) drains. METHODS: After ethical committee approval, 43 patients undergoing bilateral breast reduction surgery were recruited into the study. A Blake drain was inserted on one side and a Portavac drain was inserted on the contralateral side; the patients therefore acted as their own controls. Pain scores were measured on a descriptive scale 10 minutes before, during, and 10 minutes after drain removal. Statistical analysis was carried out using the Wilcoxon signed ranks matched pairs test. RESULTS: The results show that Blake drains are less painful before (p = 0.05), during (p = 0.01), and after removal (p = 0.009). Of those patients who expressed a preference, 27 preferred the Blake drain and 10 preferred the Portavac drain. CONCLUSION: The authors advocate the use of a silicone fluted (Blake) drain for any wound requiring drainage, especially if large-caliber drains are indicated.

Free flap neovascularization: myth or reality?

The blood supply of 17 free flaps was studied several months after surgery. The aim was to see whether or not the free flaps acquired blood flow through vessels across the flap inset independently of the main vascular anastomoses. A color Doppler flowmeter was used to identify the original arterial and venous anastomoses, the vessels in the margin of the flap, and also across the flap inset. The main vascular pedicle was then manually compressed for 2 min and blood flow was again examined in the vessels at the margin of the flap. The flap vessels (post-anastomotic), the anastomoses, and the recipient vessels (pre-anastomotic) could be identified in every case. There was no evidence of anastomotic stenosis. No vessels (neo-vascularization) greater than 0.5 mm could be identified across the flap inset. Small arteries could be identified in the flap near the inset. These vessels emptied completely on manual compression of the vascular pedicle for 2 min and did not refill until the compression was released. This evidence suggests that the free flaps do not receive significant blood flow through vessels across the flap inset, and are therefore significantly dependent for vascularity on the original anastomoses even 1 year after surgery.