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World Book of Family Medicine – European Edition 2015 Final histological diagnosis benign premalignant malignant unknown total Clinical diagnosis benign 4302 (96.6%) 34 (0.8%) 100 (2.2%) 16 (0.4%) 4452 premalignant 12 (42.9%) 13 (46.4%) 3 (10.7%) 28 malignant 66 (50%) 11 (8.3%) 54 (40.9%) 1 (0.8%) 132 unknown 441 (89.5%) 12 (2.4%) 35 (7.1%) 5 (1%) 493 total 4821 70 192 22 5105 In the group of benign clinical diagnoses we found 3% (pre-) malignancies. The malignancies occurred over the whole spectrum of clinical diagnoses including epidermal/trichilemmal cyst, seborrhoeic keratosis, naevocellular nevus, verrucous wart and fibroma. This indicates that clinical assessment of skin lesions by family doctors may be insufficiently reliable in allowing some skin excisions to be exempt from histopathological investigation, and that all skin excisions by family doctors deserve to be routinely investigated by histopathology in order not to miss serious malignancies. We compared melanomas excised by family doctors with those excised by dermatologists and surgeons in an academic practice to identify the nature of melanomas missed by family doctors, which may be translated into better clinical practice for family doctors. Of the family doctor melanomas, 64% were clinically considered to be a benign nevus in contrast with 38% of academic melanomas. This does not necessarily mean that family doctors do worse in diagnosing melanoma, since family doctors will usually refer patients with highly suspicious lesions anyway, and the low index of suspicion lesions will be treated by the family doctors (pre-selection bias). A low index of suspicion will usually lead to a narrow primary excision with a higher risk of an incomplete excision. The general consensus is to refer pigmented lesions with a high index of suspicion to a dermatologist or surgeon for a slightly wider local excision followed by reexcision and sentinel node biopsy if indicated. In a study exploring whether the “ugly ducking” (UD) sign is sensitive for melanoma detection it was concluded that melanomas are generally apparent as UDs. It is a common observation that, in a given individual, all the nevi tend to show a similar pattern. A nevus that stands out, the ugly duckling, is suspicious. Translating this knowledge to Family Medicine it seems very important to let patients undress when assessing pigmented skin lesions in order to investigate the overall pattern of the skin moles and to detect the “ugly duckling” if present. The safest approach to skin lesions is to excise them all and submit them for histopathology. However, this would lead to unwanted cosmetic side effects and low cost-effectiveness. Better diagnostic strategies could help family doctors to discriminate between benign lesions that can be left alone and high index of suspicion lesions that need to be excised properly. Dermatoscopy is widespread in secondary care and has been suggested as a tool to improve the diagnostic accuracy and therapeutic management by family doctors as well. Take Home Messages The total yield of (pre-)malignancies in skin excisions submitted for pathology is between 5% and 10%, most of them unexpected, including serious malignancies. Unexpected malignancies in skin excisions performed by family doctors occur across all clinical diagnosis categories, and about 2% of clinically 100% benign lesions are malignant. Lowering the number of unnecessary excisions is a more fruitful approach to cost-saving than omitting histopathology of excised lesions. It seems very important to let patients undress when they present with a pigmented skin lesions to investigate the overall pattern of the skin and to detect the “ugly duckling” if present. Dermatoscopy may be a valuable addition for the diagnostic and management strategy of pigmented skin lesions by family doctors. Original Abstract http://www.woncaeurope.org/content/27-pa-minor-surgery-primary-care-team 44
References: World Book of Family Medicine – European Edition 2015 1. O‘Cathain A, Brazier JE, Milner A, Fall M. The cost-effectiveness of minor surgery in general practice: a prospective comparison with hospital practice. Br J Gen Pract 1992;42:13-17. 2. Lowy A, Brazier J,Fall M, Thomas K, Jones N, Williams B. Quality of minor surgery by general practitioners in 1990 and 1991. Br J Gen Pract 1994;44:364-365. 3. Buis PAJ, Chorus R, Van Diest PJ. Value of histopathologic analysis of skin excisions by general practitioners. BJGP 2005;55:458-460. 4. Buis PAJ, Verweij W, Van Diest PJ. Value of histopathologic analysis of subcutis excisions by general practitioners. BMC Family Practice 2007;8:5. 5. Buis PAJ, van Kemenade F, Frijling BD, van Diest PJ. Skin melanomas excised by General Practitioners: more often unsuspected, of nodular type and less of often radically excised than those excised in an academic setting. Clinical and Experimental Dermatology 2011;2:125.doi:104172/2155-9554.1000125 6. Scope A, Dusza SW, Halpern AC. The “Ugly Duckling” sign. Agreement between observers. Arch Dermatol 2008;144:58-64. © Pieter Buis 45
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