Australian Doctor 3rd November 2023 3rd Nov 23 | Page 33

CF

LEARN MORE ONLINE Visit our Therapy Update

Figure 10 . Stitches in a man ’ s ear after Mohs surgery to remove a melanoma .

Figure 11 . Dermatoscopic view of a melanoma .

The GP recommends an excisional biopsy . Amy is nervous about this as she is fearful of needles and concerned about having an obvious scar on her arm . She asks if monitoring

1 . Which TWO statements regarding the epidemiology of melanoma are correct ? a Queensland has the highest incidence of melanoma in the world . b The incidence of invasive melanoma in Australia continues to increase across all age groups . c Melanoma is predominantly a skin malignancy . d Melanoma incidence does not vary between men and women .

2 . Which THREE are well-recognised risk factors for the development of melanoma ? a UVR exposure . b Low number of naevi . c Individual phenotypic traits . d Family history of melanoma .

3 . Which TWO statements regarding the risk factors for melanoma are correct ? a The use of tanning beds does not confer an increased risk for melanoma . b Intense , intermittent UVR exposure contributes most significantly to the risk of melanoma . c Most melanomas are associated with a pre-existing naevus . d Skin sensitivity to sunlight is a well-recognised risk factor for melanoma .

4 . Which THREE statements regarding the risk factors for melanoma are correct ? a Most people diagnosed with melanoma have a family history of the condition . this lesion is an option and what is the point of cutting it out when she has “ lots of moles anyway ”.

Her GP explains that today , the lesion on her right arm is specifically

b Patients with one melanoma are at higher lifelong risk of further melanomas . c The incidence of melanoma increases with advancing age . d Immunosuppressed patients are at increased risk of melanoma .

5 . Which TWO are implicated in the pathogenesis of melanoma ? a Accelerated development of melanoma in dysplastic or atypical naevi . b UVA and UVB radiation . c The MAPK pathway . d Melanoma risk does not correlate to total body naevus count .

6 . Which THREE statements regarding the diagnosis of melanoma are correct ? a Melanoma survival is strongly correlated with tumour thickness at diagnosis . b Dermatoscopy allows detailed examination of the colours and structures of naevi not visible to the naked eye . c SSM is the most common melanoma subtype . d NM typically displays the ABCD characteristics .

7 . Which TWO statements regarding the diagnosis of melanoma are correct ? concerning as it is different and “ stands out ” from her other naevi . They also discuss that Amy ’ s large number of naevi place her in a group of patients considered high risk for

GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat

a Acral lentiginous melanoma is the common subtype seen in patients with fair skin phototypes . b Lentigo maligna are rapidly and aggressively invasive . c Consider a naevus that is new or changing in an adult suspicious for cutaneous melanoma . d Desmoplastic melanoma may present as amelanotic and have a scar-like appearance .

8 . Which THREE statements regarding the diagnosis and staging of melanoma are correct ? a SLNB is the gold standard for assessment and staging of regional lymph node involvement in melanoma . b Excisional biopsy is the preferred biopsy technique for the diagnosis of melanoma . c Partial biopsy yields similar outcomes to excision biopsy in terms of diagnosis of melanoma . d Accurate staging is essential to guide decisions on treatment and assessment of prognosis .

9 . Which TWO approaches may be appropriate in the management of melanoma ?

EARN CPD OR PDP POINTS

• Read this article and take the quiz via ausdoc . com . au / how-to-treat

• Each article has been allocated one hour by the RACGP and ACRRM .

• RACGP points are uploaded every six weeks and ACRRM points quarterly .

the development of cutaneous melanoma . In addition , the GP discusses her family history of a first-degree , and multiple second-degree relatives , with melanoma diagnosed at a

MELANOMA

a Wide local excision with an adequate surgical margin in primary cutaneous melanomas . b Adequate surgery alone , in localised disease with regional lymph node or distal metastatic involvement . c For lesions that are highly suspicious for melanoma , a wide local excision should be completed in the first instance to attempt to clear the lesion . d Immunotherapy and targeted molecular therapy in more widespread disease .

10 . Which THREE of these statements are correct ? a Clinical and dermatoscopic examination will always allow the clinician to differentiate between melanoma and dysplastic naevus . b For a lesion where the differential diagnosis includes both pigmented BCC and melanoma , the presence of blue ovoid nests and lack of a pigment network is more suggestive of a diagnosis of BCC . c It can be challenging to clinically distinguish between solar lentigo and lentigo maligna on the face ; biopsy for histopathology may be required . d Clinically , nodular / desmoplastic melanomas may mimic dermatofibroma . Any lesion that fits the criteria of “ elevated , firm and growing ” should undergo diagnostic biopsy , even if it resembles dermatofibroma on clinical examination . young age ; this increases her risk of having melanoma . While monitoring her other moles is indicated through regular full skin examinations , the concerning features identified in her right arm lesion indicate it should not be left alone .

Amy agrees to an excisional biopsy and consents , after having been warned about the risks of a scar and a benign result on histology .

The histopathology returns five days later and describes a “ moderately dysplastic compound naevus ”. Amy returns to her GP to discuss these results . She is relieved the lesion is not a melanoma and , after their detailed discussion about the reasons for biopsy , she agrees that it was necessary , despite the final diagnosis of a benign lesion .

Amy is referred by her GP to her nearest total body photography service for baseline images , and organises a repeat full skin examination in six months .

CONCLUSION

GPs are at the forefront of diagnosis and management of cutaneous melanoma . This is a common cancer that can affect any age group , so primary prevention is very important . Offer all adult patients routine full skin examinations , the frequency of which is dictated on their individual risk factors .

Refer patients with melanomas with Breslow thickness greater than 0.8mm to a melanoma surgeon for discussion of SLNB . Refer patients with thick melanomas ( greater than 2mm Breslow thickness ) to the local public hospital melanoma multidisciplinary team .

RESOURCES

• Melanoma Institute Australia bit . ly / 3UROXJF — Melanoma risk calculators bit . ly / 3VcH8Of

• Melanoma Patients Australia ( Patient support and information ) bit . ly / 3EhluBG

• Cancer Council Australia Clinical practice guidelines for the diagnosis and management of melanoma bit . ly / 2DWzuje

References Available on request from howtotreat @ adg . com . au