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MELANOMA

Early diagnosis is vital to outcome. Thickness of a melanoma when it is removed is the major factor determining prognosis: it is vital to detect melanomas when they are in the thin stage and look like an unusual freckle. An irregular border or margin is characteristic of the tumour.

Clinical features

  • Typical age range 30–50 yrs (av. 40)

  • Can occur anywhere on the body. More common:

    • – lower limb in women

    • – upper back in men

  • Often asymptomatic

  • Can bleed or itch

Change The sign of major importance is a recent change in a ‘freckle’ or mole:

  • change in size: at edge or thickening

  • change in shape

  • change in colour: brown, blue, black, red, white, incl. combinations

  • change in surface

  • change in the border

  • bleeding or ulceration

  • other symptoms (e.g. itching)

  • development of satellite nodules

  • lymph node involvement

Beware of the non-pigmented melanoma, esp. on the sole of the foot.

Pitfalls/traps in diagnosis

  • Nodular melanomas

  • Small melanoma

  • Amelanotic melanoma

  • Regressing melanoma

  • Rapidly growing melanoma

The early nodular melanoma problem The ABCD rule often does not apply. Early nodular melanomas tend to be symmetrical, non-pigmented, even in colour, small diameter, firm and grow vertically, i.e. elevated. They are often mistaken for a haemangioma or a pyogenic granuloma. Refer if suspicious.

Management

  • Early diagnosis and referral to specialist unit is vital.

  • Surgical excision with a narrow but significant margin is the treatment.

  • Guidelines for excision margins:

    • – suspicious lesion—margin 2 mm

    • – melanoma in situ—margin 5–10 mm

    • – melanoma <1 mm thick—margin 1 cm

      1–4 mm thick—margin 1–2 cm

      >4 mm thick—margin 2 cm

  • Follow-up is based on the tumour thickness:

    • – ≤1 mm—6 mthly for 2 yrs

    • – >1 mm—regularly for 10 yrs

    • – yearly chest X-ray.

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Table M1 Features and associations of melanoma subtypes

Melanoma subtype

Frequency %

Location

Average age

Superficial spreading

70

Trunk (back), limbs (legs)

Middle-aged

Nodular

20

Trunk, limbs

Middle-aged

Lentigo maligna

7.5

Head, neck

Elderly

Acral lentiginous

2.5

Palms, soles, mucosae

Not known

Reproduced with permission of J Kelly

MELASMA (CHLOASMA)

Treat with topical 2% hydroquinone in sorbolene cream (long course). Limit sun exposure.

MÉNIÈRE SYNDROME

image 194

MENOPAUSE SYNDROME

The menopause is the cessation of the menses for longer than 12 months. Up to 80% of women experience vasomotor symptoms for an average of 5 yrs (range 1–10); 20% will be severely affected.

Symptoms

  • Vasomotor, e.g.:

    • – hot flushes (80%)

    • – night sweats (70%)

    • – palpitations (30%)

  • Psychogenic, e.g.:

    • – tearfulness/depression

    • – irritability

    • – anxiety/tension

  • Urogenital (60%), e.g.:

    • – atrophic vaginitis

    • – vaginal dryness ...

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