Brown M D, Johnson T M, Swanson N A
Department of Dermatology and Otolaryngology, University of Rochester, New York.
Dermatol Clin. 1991 Oct;9(4):657-67.
As the incidence of melanoma continues to increase, so does the role of the dermatologist as both medical and surgical oncologist for these patients, especially those with stage I disease. The dermatologist holds a key role in all phases of care, including prevention, diagnosis, treatment, and follow-up. The dermatologist is best trained to complete a full and thorough skin examination and is best able to recognize a melanoma at its earliest stages of radial growth. In large part because of advances in dermatology, the dysplastic nevus syndrome has been identified as an important marker and precursor lesion for melanoma; the dermatologist has the best knowledge base for the recognition and management of both sporadic and familial dysplastic nevi. Dermatologists also have the unique opportunity (by virtue of their patient population concerned with skin problems) to prevent melanoma through patient education concerning sun protection, self-examinations, and the ABCDs of melanoma recognition. The dermatologist is well trained to obtain an appropriate, full-thickness skin biopsy specimen and is also knowledgeable to interpret the pathologist's report, understanding the significance of the various histologic prognostic indices. Because of the changing trends in excisional margin size and fewer recommendations for ELND, the dermatologist is becoming more active in the surgical management of melanoma patients. In the MDMC, the dermatologist was clearly recognized as a capable surgeon to perform the wide local excisions for stage I patients. Almost one half of the patients seen (49%) were surgically treated in the department of dermatology. Of group I patients, 78% were treated by dermatologists. The dermatologist as surgeon should be capable of performing a wide local excision to the level of deep subcutaneous tissue or muscle fascia with an appropriate primary layered closure, local flap, or graft. Our experience confirms that the majority of patients present with local disease and a thin Breslow depth and thus can be skillfully treated in an outpatient setting under local anesthesia by a dermatologic surgeon. In follow-up, the dermatologist should provide continuity of care and should be knowledgeable in appropriate interval examinations and tests. The dermatologist is thoroughly skilled at the cutaneous examination and has the knowledge base to perform a careful and competent lymph node examination. As primary medical oncologist to these patients, the dermatologist needs to recognize stage II and stage III disease and be able to comprehensively discuss with the patient the options for treatment and how they affect their prognosis.(ABSTRACT TRUNCATED AT 400 WORDS)
随着黑色素瘤发病率持续上升，皮肤科医生作为这些患者的医学和外科肿瘤专家所发挥的作用也日益重要，尤其是对于那些处于I期疾病的患者。皮肤科医生在护理的各个阶段都起着关键作用，包括预防、诊断、治疗和随访。皮肤科医生接受过全面而彻底的皮肤检查培训，最有能力在黑色素瘤的早期径向生长阶段识别它。很大程度上由于皮肤科的进展，发育异常痣综合征已被确认为黑色素瘤的重要标志物和前驱病变；皮肤科医生在识别和管理散发性和家族性发育异常痣方面拥有最佳的知识基础。皮肤科医生还拥有独特的机会（凭借其关注皮肤问题的患者群体），通过对患者进行防晒、自我检查以及黑色素瘤识别的ABCD等方面的教育来预防黑色素瘤。皮肤科医生在获取合适的全层皮肤活检标本方面训练有素，并且也有能力解读病理学家的报告，理解各种组织学预后指标的意义。由于切除边缘大小的变化趋势以及对预防性区域淋巴结清扫（ELND）的推荐减少，皮肤科医生在黑色素瘤患者的手术管理中变得更加活跃。在MDMC，皮肤科医生被明确认可为有能力为I期患者进行广泛局部切除的外科医生。几乎一半（49%）的就诊患者在皮肤科接受了手术治疗。在I组患者中，78%由皮肤科医生治疗。作为外科医生的皮肤科医生应能够进行广泛局部切除，达到深皮下组织或肌肉筋膜层面，并进行适当的一期分层缝合、局部皮瓣或植皮。我们的经验证实，大多数患者表现为局部疾病且Breslow厚度较薄，因此可以由皮肤科外科医生在门诊局部麻醉下熟练治疗。在随访中，皮肤科医生应提供持续的护理，并应熟悉适当的定期检查和检测。皮肤科医生在皮肤检查方面技术娴熟，并且有知识基础进行仔细且胜任的淋巴结检查。作为这些患者的主要医学肿瘤专家，皮肤科医生需要识别II期和III期疾病，并能够与患者全面讨论治疗选择及其对预后的影响。（摘要截选至400字）
