June 2008 quiz

Quiz to analyse ACSCM education activity performance

From June 15 to June 25, 2008 ACSCM asked all doctors who have attended ACSCM events or were associated with the College in any way to complete this short quiz on skin cancer management.

The following was the information provided at that that time:

This is a hypothetical case study. There are often no definite right and wrong answers. It is not based on a true clinical case study. Your personal preferences are being sought. Sometimes your preferred choice may not be exactly offered. In these circumstances we ask you to still choose your response from those provided.

We ask your name in this quiz. This is merely to verify that the response is genuine given this quiz is open access on the internet. Your name will be disrgeraded and NOT be associated with the data once this verification is complete.

The data analysis will be undertaken by a research assistant assigned by ACSCM for this specific purpose.

A 50 year old lady presents with a growing dark lesion on her mid left forearm. She says she does not normally have any moles on her skin. You observe a suspicious deeply pigmented 8 mm diameter lesion. She is otherwise well and has no other symptoms. She makes it clear to you that where possible she wants her treatment to take place in the town where she lives and you practice.

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Please complete all questions and then click "submit"

What is your level of ACSCM certification? - (select one only)

Full name

Town

Country / State / Territory

Email address

I have attended the following events - (select one or more)
2 day ACSCM certificate workshop
A 5 day skin cancer surgery workshop
2 day advanced weekend
Healthcert workshop
2007 ACSCM College conference
Other workshops
None of the above

Question 1. Regarding our hypothetical lady and her forearm lesion, would you (select one or more)
examine this lesion with an oil / fluid based dermoscope
examine this lesion with a polarizing light dermoscope
record a digital dermoscopic photograph of this lesion
record a conventional digital photograph of this lesion
examine the lesion with a loupe
do none of the above

Question 2. You consider that melanoma must be excluded. So you (select one only)
shave biopsy the lesion
2 mm punch biopsy the lesion
4 mm punch biopsy the lesion
curette the lesion
locally excise the lesion with a narrow margin
excise the lesion with a very wide margin

Question 3. She returns for the pathology report and you discuss further treatment. What further surgery to the site would you recommend if the diagnosis was junctional naevus? (Margins in these questions refers to a minimum margin of apparently normal skin around the tumour) (Select one only)
No further surgery
Excise with a minimum 3 mm margin of apparent normal skin
Excise with minimum 5 mm margin
Excise with minimum 10 mm margin
Excise with minimum 20 mm margin
Excise with > 20 mm further margin

What if histology reported it was a lentigo maligna (melanoma in situ)

What if pathology said Breslow 0.4mm, Clark 2 superficial spreading malignant melanoma?

What if pathology said pigmented morphoeic and micronodular basal cell carcinoma?

What if pathology said Breslow 4.5 mm, Clark 4 nodular malignant melanoma

What if pathology said Breslow 1.2 mm Clark 3 lentigo maligna melanoma

Question 4. Her lesion turned out to be a Breslow 0.4 mm, Clark 2 superficial spreading malignant melanoma. Having made your margin recommendation above, who would you organise to effect any wider surgery?

Had this malignancy been on her cheek, would you recommend

Who would you organise to undertake any cheek surgery

Who would you organise to do any surgery if the tumour was on the nasal dorsum?

Question 5. She feels well but is concerned that the lesion may already have metastatic disease and wants to know her chances of surviving this cancer. You advise her that her five year survival from this Breslow 0.4mm, Clark2 melanoma is?

Question 6. Other than excision, you consider that it is essential for her to have the following investigations. (Select one or more responses)
No investigations
Full blood examination
Liver function test
CT scan of chest and abdomen
CT scan of brain
Sentinel node biopsy of left axilla
PET scan
Chest X Ray
Ultrasound of left axilla

Question 7. She returns to you for a routine check up regarding her melanoma 2 years later. She has had no symptoms and has nothing to report. Which do you regard as your highest priority to include in your examination of her? (Select one only)
Percuss and auscultate her chest
Observe and feel her melanoma scar and the immediate surrounding skin
Tap firmly on her bones on the limbs and back to elicit any tenderness
Palpate lymph nodes in the axillae and elsewhere
Abdominal examination including liver and spleen palpation
Examine the rest of her skin on the trunk, limbs, head and neck
Sensory, motor and cognitive nervous system examination

What would be your second greatest priority in your examination of her? (Select one only)

What would be your third greatest priority in your clinical examination? (Select one only)

What would be your fourth greatest priority with your clinical examination today? (select one)

Question 8. Examination proves unremarkable. She has had no investigations since around the time of the initial treatment. So you order? (Select one or more responses).
No investigations
Full blood examination
Liver function test
CT scan of chest
CT scan of brain
Ultrasound of left axilla
PET scan
Chest X Ray

Question 9. Regarding melanoma follow up, you advise her that given she has survived two years without a set back she should? (Select one)
Return only if symptoms develops as no scheduled review is needed from this point onwards
Return in three years time for a melanoma check up
Have regular reviews for the next three years but then after that no more reviews will be required
Have reviews each six months for the next three years but then yearly reviews after that time
Have yearly reviews here in after

Question 10. At the reception desk after she leaves this appointment she lifts her hair and points out a red skin lesion on the upper back of her neck. She says it has been slowly growing for 12 months. You advise her (Select one)
That it needs careful examination as soon as possible and suggest she rebook next week to have this formally evaluated
To remind you about it on her next routine appointment
That patients who develop dark melanomas don't ever develop red melanomas. As such, it is of no immediate concern
That this is a nervous condition because of her fright regarding a past potentially life threatening melanoma

Question 11. She unexpectedly returns 3 days later saying she is very worried about her neck lesion and wants it sorted out today. You examine it. The lesion is on the posterior midline neck just below the hairline. It appears to be a thick lesion extending deep into the skin. It is about 2 cm in diameter. You feel unsure about the diagnosis. As such you decide to? (select one only)
Reassure her that it does not need to be biopsied or excised
Punch biopsy the lesion
Widely excise the lesion with a 4 mm margin of apparently normal skin
Widely excise the lesion with a 10 mm margin of apparently normal skin
Treat the lesion with cryotherapy and ask her to return if the lesion does not resolve
Treat the lesion with photodynamic therapy
Treat the lesion by laser ablation

Question 12. She tells you that she is not fully accepting of your advice and says she will seek another opinion. A week later you get a pathology report of a shave biopsy of her neck lesion. It says the lesion is a well differentiated SCC. Then she returns and asks you to now treat it. What do you do? (Select one)
Ask her to return to the doctor who did the biopsy for definitive treatment.
Treat the lesion with photodynamic therapy
Treat it with topical imiquimod
Excise it with a 5 mm margin of apparently normal skin
Excise it with a 10 mm margin of apparently normal skin
Treat it with cryotherapy
Treat it by curettage and electrodessication
Treat it by curettage and cryotherapy
Treat it with topical 5 fluoro uracil
Treat it with topical 3% diclofenac

Question 13. What if the shave biopsy showed superficial basal cell carcinoma. You explained that several treatment options were available. She asked what would you choose if it was on your neck? After being pressed on this, you respond

Question 14. What if the neck lesion biopsy showed Bowens Disease. Again you offered her several options and again she insisted on your favourite. you respond

Question 15. She listens to the options including surgery. She now tells you that since her melanoma she has developed hypertension and atrial fibrillation. She says she is now on daily warfarin and aspirin therapy. She asks you if this medication would need to be altered if she chose to have surgery for her neck lesion. Your advice is? (Select one)
Continue both warfarin & aspirin but check INR beforehand
Cease warfarin prior to surgery but continue aspirin
Cease aspirin but continue warfarin and check INR
Cease both warfarin and aspirin for the surgery
Cease warfarin and aspirin but commence low dose heparin

Question 16. She says a friend of hers also has a heart condition and must have antibiotics for skin surgery. Does she need antibiotics? Your advice is? (Select one)
Single dose antibiotic prior to surgery
Antibiotic course commencing prior to surgery and continuing for several days
Antibiotic course commencing after surgery
Antibiotic course commencing several days prior to surgery
Antibiotic ointment on the wound after closure
No antibiotics

Question 17. What if our patient had a 2 cm diameter well differemtiated SCC but it was on the mid calf rather than the neck, your preferred management would be? (Select one)

Question 18. She listens to you and then insists on a surgical option. You excised her leg SCC. How would you now manage the defect? (Select one)

Question 19. Before effecting this leg SCC excision, you would recommend the following antibiotics? (Select one)

This concludes the case study. We request a short piece of information about your professional background. Are you first and foremost a?

Estimate to the nearest percentage how much of your professional career is associated with diagnosing and managing patients with skin cancer?

Thank you for your time. You will have noticed that there is often no single correct answer. However, this survey will provide valuable insight into how doctors associated with ACSCM manage melanoma and non melanoma skin cancer. One final question if we may. Your plans regarding College conference in late August 2008 are? (Select one)
I will be attending BOTH conference and pre conference workshops
I will be attending conference only
I will be attending pre conference workshops only
I am unsure but will probably be attending
I am unsure but will probably NOT be attending
I will not be attending because I will be at another educational event
I will not be attending for work, family or other reasons

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June 2008 quiz

Quiz to analyse ACSCM education activity performance

Form Master