The new 8th edition of TNM staging and its implications for skin cancer: a review by the British Association of Dermatologists and the Royal College of Pathologists, U.K.

The 8th edition of TNM (tumour, node and metastasis) has numerous and important changes compared with the 7th edition. Public Health England and the Royal College of Pathologists, U.K., have adopted the 8th edition of TNM (TNM8) published by the Union for International Cancer Control for skin cancer staging. These changes will have an impact on the management and commissioning of melanoma and nonmelanoma skin cancer (NMSC). The T1-T3 categories for NMSC staging require the clinician to measure the maximum dimension (usually diameter) of every potential invasive cancer. For squamous, basal and adnexal carcinomas, but not Merkel cell carcinoma (MCC), the T1-T3 categories are defined by new 20-mm and 40-mm divisions based on the maximum dimension of the lesion. In addition, new risk factors upstage T1 or T2 to T3. For melanoma, mitotic index no longer influences separation of pathological stage (pT1). There is a new, additional stratification level at 0·8-mm Breslow thickness. Subdivision pT1b, with a negative sentinel lymph node biopsy (SLNB) of pN0, is now stage IA compared with the previous IB. For MCC, SLNB is now included specifically in the pN staging system. The pT1 subdivision requires clinical information as to whether histologically involved nodes were clinically occult or detectable. For both melanoma and MCC the clinician must state whether the lymph nodes are occult or clinically detectable. Eyelid carcinoma continues to have a staging system different from that in general skin and the system is substantially revised in TNM8.

Subacute cutaneous lupus erythematosus associated with radioiodine treatment.

Subacute cutaneous lupus erythematosus (SCLE) is characterized by nonscarring, photodistributed, annular or papulosquamous plaques with antibodies to Ro/SS-A antigen. We report a case of SCLE associated with radioiodine treatment.

Dermatitis artefacta of the lip in an adolescent.

UNLABELLED: Self-inflicted trauma is found in several patient groups including those with learning and developmental delay, the very young and those suffering from psychiatric disturbance. The diagnosis of artefactual disease can only be made when all possible organic disease has been excluded by specific investigations. The case presented is that of a 15-year-old girl complaining of persistent bleeding and crusting of her lips. Investigations provided no real information as to the cause of the allegedly spontaneous bleeding. The diagnosis of artefactual disease was finally decided upon and a referral to a child and adolescent psychiatrist made. CLINICAL RELEVANCE: Patients with unusual clinical signs may be examined regularly by their GDP. This case clearly illustrates the importance of considering a psychological disorder and referral in the differential diagnosis of conditions appearing with unusual clinical signs.

Treatment of acrodermatitis continua of Hallopeau with oral propylthiouracil and methotrexate.

A 71-year-old man with acrodermatitis continua of Hallopeau was treated successfully with a combination of oral propylthiouracil and methotrexate. After 14 weeks, he developed acute pancytopenia, an uncommon idiosyncratic side-effect of propylthiouracil, and presented with a life-threatening methicillin-resistant Staphylococcus aureus pneumonia. This illustrates the potential value and associated risks of propylthiouracil in the management of this difficult condition.

Lupus erythematosus/lichen planus overlap syndrome with scarring alopecia.

Lupus erythematosus (LE) and lichen planus (LP) may occur as an overlap syndrome (LE/LP). The term comprises a heterogeneous group of patients who have clinical, histological and/or immunopathological characteristics of both diseases at the same time. The disease occurs so infrequently as to limit clinical cases for study. We present a case of scarring alopecia due to LE/LP overlap syndrome. Initial biopsy of the scalp showed scarring alopecia only, with subsequent biopsies showing histological features of LE. Direct immunofluorescence was negative for the LE band, but showed features consistent with LP. We report this case as an uncommon cause of scarring alopecia illustrating the importance of multiple biopsies in the diagnosis of LE/LP overlap syndrome.

Quality and outcomes management in the primary care practice.

In response to the trend away from thinking of health care as a commodity to one in which quality is a differentiating feature among providers, primary care practices must focus on outcomes management. This article reviews the various clinical and office-based processes that influence practice outcomes. These include patient management, chart management, practice guidelines, clinical pathways, case management, and patient information. The key to a quality program and successful outcomes management is a commitment on the part of physicians to managing these processes so that best outcomes are achievable.

Skin cancer. Recognition and treatment.

There is a worldwide increasing incidence of all forms of skin cancer among Whites as a result of increased sun exposure. Basal cell and squamous cell carcinomas, the most common tumours of the head and neck, are relatively benign neoplasms of elderly individuals. Malignant melanoma, however, has the potential for early metastasis and may occur in early adult life. The increase in malignant melanoma is particularly disturbing, and is a clear indication for skin screening clinics. Although surgical excision is the primary treatment of choice for skin tumours, various drugs may be of therapeutic value. Fluorouracil cream is a useful treatment for solar keratoses. Retinoids are particularly suitable for patients with large numbers of nonmelanoma skin cancer lesions and solar keratoses. For malignant melanoma, arterial limb perfusion with high concentrations of cytotoxic drugs may be performed both as an adjunctive and therapeutic manoeuvre. Treatment of metastatic melanoma with cytotoxic agents is associated with low response rates and high toxicity. However, trials with combined interferon-alpha, interleukin-2 and cytostatic drugs have produced promising preliminary results.

Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery.

Details of presentation and treatment were obtained prospectively by questionnaire for 1366 patients with basal cell carcinoma, first attending under the care of 166 consultant dermatologists in the U.K., during a 2-week period. One thousand five hundred and ninety-seven tumours were reported in these patients (median age 71 years). Most were situated on the head and neck, and their median size was 9 mm. Excision was the most common treatment used in 58% of tumours, curettage and cautery was used in 24%, cryotherapy in 8%, and radiotherapy in 8%. On average, one in four tumours were referred to other specialists for treatment (range 0-70%). Very few patients (2%) were referred to a combined dermatology/radiotherapy/plastic surgery clinic, calling into question its value and availability. There was considerable variation in practices between dermatologists, demonstrating a clear need for individual, local audit of the management of this common dermatological problem. The data collected in this study form a suitable measure with which local performance may be compared.