Diagnosis of primary melanoma

As primary melanomas are clearly visible on the surface of the skin, most melanomas are first detected by the patient or a spouse examining the skin and then bought to the attention of the GP. The three major features of melanoma (in terms of diagnostic importance) in a skin lesion are as follows: (1) a change in size of the lesion, (2) the presence of an irregular outline or edge around the lesion and (3) the presence of three or more colours within the lesion. Other minor signs include a lesion with a diameter greater than 7 mm, inflammation, oozing or a change in sensation. The ABCDE guidance formula is another commonly used clinical guide for the diagnosis of early melanoma; see Box 11.1.

Box 11.1 ABCDE guidance to the recognition of melanoma A = Asymmetry B= Border C= Colour D= Diverse structure E= Elevation

It is recommended that patients with a lesion suspicious of melanoma are referred to a doctor trained in the specialist diagnosis of skin cancer, normally a dermatologist (National Institute for Health and Clinical Excellence, 2006a). In England, it is a requirement for patients to be seen within 2 weeks of referral, as early diagnosis and treatment represents the best chance of cure (Department of Health, 2006). In order to meet this target set out in the National Cancer Plan (2000), most hospitals have designated skin cancer clinics.

At the skin cancer clinic an assessment will be undertaken; a clinical history will be ascertained, and the lesion examined, often with the aid of a dermatoscope (see Assessment and planning care). Suspicious lesions should be biopsied with a 2 mm margin of skin often using a local rather than general anaesthetic promptly. The National Cancer Plan (Department of Health, 2000) provides details on the referral arrangements.

A record of the patients treatment plan agreed by the multidisciplinary team (MDT) whose core members should include a dermatologist, a plastic surgeon, a histopathologist, a specialist nurse, a radiotherapist and an MDT coordinator (Department of Health, 2000) should be recorded in the patient’s notes.