Faculty Bibliography

This article discusses that much of what has been taught over the years concerning the Pathology of melanoma clearly may have little validity. Melanoma is viewed simply as a malignant neoplasm comprised initially of a proliferation of atypical melanocytes within the surface epithelium (epidermis). It has many features in common, regardless of anatomic site. It spreads within the epidermis first for months, possibly years or even for decades. At this stage (in situ) it is wholly curable if completely surgically excised. What determines how long a given melanoma remains in situ is not clear. Once a given neoplasm penetrates into the subjacent dermis, there are whole ranges of ill-defined events that act on its ability to continue to grow and develop the competence for metastasis

The risk of malignant melanoma developing in an American in the United States has now reached 1 in 87 (up more than 1800% since the 1930s). This rising incidence of malignant melanoma is, in fact, real because (1) it is not due to increased surveillance; (2) it is not due to better cancer-counting methods in general; (3) it is not due to changes in histologic diagnostic criteria; (4) it is being noted worldwide; and (5) most importantly, despite rising survival percentages, the mortality rate from malignant melanoma also continues to rise. On the basis of these trends, incidence rates for malignant melanoma will continue to rise for at least the next 10 to 20 years, although the demographics of those affected may change. Effective programs to improve public and professional education must be developed to enhance early clinical detection and behavioral changes. An establishment of a National Melanoma Registry is needed to more effectively assess the magnitude and impact of future incidence and the success of prevention program efforts into the next century

OBJECTIVE: To evaluate intraocular pressure (IOP) control and surgical complications following trabeculectomy with 5-fluorouracil (5-FU) or mitomycin at the inferior limbus. METHODS: The charts of all patients undergoing trabeculectomy at the inferior limbus from July 1984 to March 1993 were reviewed. Surgical success was defined as IOP greater than 4 mm Hg and less than 22 mm Hg and at least a 20% reduction from preoperative IOP. PATIENTS: All 101 eyes of 101 patients had undergone prior intraocular surgery at the superior limbus. Mean patient age was 57.5 +/- 2.0 (+/-SE) years; mean follow-up was 23.4+/-2.3 months; mean preoperative IOP was 32.8+/-0.9 mm Hg; and mean number of preoperative antiglaucoma medications was 2.8+/-0.1. RESULTS: Ninety-four eyes (93.1%) received postoperative 5-FU (mean total dose, 36.3+/-1.7 mg) and seven eyes (6.9%) received intraoperative mitomycin (0.5 mg/mL). Cumulative success for all eyes at 2 and 5 years was 56% and 38%, respectively. Intraocular pressure control without medications was achieved in 39% and 15% of eyes at 2 and 5 years, respectively. Complications included 5-FU epitheliopathy (34.0% of eyes receiving 5-FU), early wound leak (26.7%), choroidal effusion (25.7%), late bleb leak (12.9%), and late bleb-related endophthalmitis (11.9%). CONCLUSION: Although trabeculectomy at the inferior limbus offers the opportunity for surgical success in eyes at high risk of failure, this procedure carries an increased risk for late complications and should be reserved for cases in which the therapeutic options are extremely limited

BACKGROUND: During the past few decades there has been increasing interest and training in dermatologic surgery. OBJECTIVE: Our purpose was to determine to what extent members of the American Academy of Dermatology (AAD) are involved in the surgical management of patients with malignant melanomas (MMs), comparing 1982 with 1992. METHODS: Members of the AAD practicing in the United States (N = 7412) were sent a questionnaire that surveyed their role in the definitive treatment of patients with MMs and the surgical margins of normal-appearing skin that they used or recommended for melanomas of various thicknesses. RESULTS: Sixty-four percent of the respondents stated that they performed the definitive surgery for in situ melanoma in 1992, a 14% increase from 1982. Although a significantly greater percentage of dermatologists were performing the definitive surgery for invasive melanoma in 1992 (28%) compared with 1982 (14%), the majority continued to refer their patients to surgical colleagues for definitive treatment. There has been a narrowing of surgical margins recommended or used for melanomas of all thicknesses. In addition, regional differences of the role of the dermatologist in surgical management of patients with MM were observed. CONCLUSION: An increasing proportion of dermatologists are involved in the surgical management of patients with MMs. Most dermatologists appear to be in accord with the guidelines for surgical margins currently recommended in the literature

BACKGROUND: The incidence of malignant melanoma (MM) has rapidly increased during the past five decades. Relatively little information is available on whether the role of the dermatologist has increased concomitantly in the surgical management of this cancer. OBJECTIVE: Our purpose was to learn how members of the American Academy of Dermatology (AAD) treat patients with lesions highly suspected as being MM and how the management of these patients may have changed over the past decade. This, the first of a two-part series, concerns biopsies. METHODS: The data for the study were collected by means of a questionnaire that was sent to all members of the AAD practicing in the United States (N = 7412). RESULTS: A total of 2991 valid questionnaires were returned, a response rate of 40%. The majority of respondents (89% in 1982; 90% in 1992) stated that they performed the biopsies of pigmented lesions suspected of being MMs. Excisional biopsy was the preferred technique (58% in 1982; 68% in 1992). The type of biopsy and who performed the initial biopsy of a suspected MM were associated with the following factors: (1) the number of years in practice, (2) the type of practice, and (3) whether the dermatologist subsequently performed the definitive surgery for the MM. Regional variations in biopsy practices were also noted. CONCLUSION: Most AAD dermatologists who responded to the questionnaire perform the biopsies of lesions highly suspected of being MM. During the last decade an increasing proportion of dermatologists are performing excisional biopsies rather than other types of biopsies for such lesions