CCE-CBD-024

Examiner Only Information

Questions

Q1. What features of Peter’s lesion raise concern for malignancy?

• Prompt: What clinical signs differentiate melanoma from benign skin lesions?
• Prompt: What risk factors increase Peter’s likelihood of skin cancer?

Q2. What investigations are required to confirm the diagnosis?

• Prompt: What type of biopsy is recommended for suspected melanoma?
• Prompt: When is dermoscopy useful in assessing skin lesions?

Q3. What is the management plan for a confirmed malignant melanoma?

• Prompt: What surgical treatment is required?
• Prompt: When should referral to a dermatologist or surgeon be considered?

Q4. What advice would you provide Peter on skin cancer prevention and surveillance?

• Prompt: How can he reduce his future skin cancer risk?
• Prompt: What is the role of regular skin checks?

Q5. When would you consider referral for further assessment beyond standard surgical excision?

• Prompt: What features suggest high-risk or metastatic melanoma requiring multidisciplinary care?
• Prompt: When is sentinel lymph node biopsy indicated?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What features of Peter’s lesion raise concern for malignancy?

The competent candidate should:

• History red flags:
  • Lesion has been changing in size, colour, and border over 6 months.
  • Occasional bleeding, which is concerning for malignancy.
  • Long-term sun exposure due to outdoor work as a landscaper.
  • Personal history of multiple non-melanoma skin cancers (BCCs).
  • Family history of melanoma (father diagnosed at age 72).
• Clinical features suggesting melanoma (ABCDE rule):
  • A – Asymmetry: Uneven shape.
  • B – Border: Irregular, indistinct margins.
  • C – Colour: Mixed pigmentation (dark brown and black).
  • D – Diameter: >6 mm (1.5 cm in this case).
  • E – Evolution: Recent changes in colour and shape.

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Q2: What investigations are required to confirm the diagnosis?

The competent candidate should:

• Dermoscopy:
  • Useful for assessing pigmentation patterns and vascular structures.
  • Cannot replace a biopsy but can support clinical suspicion.
• Skin biopsy:
  • Excisional biopsy with 2 mm margins is the preferred method if the lesion is small enough.
  • Punch biopsy or incisional biopsy may be used if the lesion is large or located in a functionally sensitive area.
  • Shave biopsy should NOT be used for suspected melanoma due to the risk of incomplete assessment.
• Pathology assessment:
  • Histopathology will confirm melanoma and determine Breslow thickness, ulceration, and mitotic rate.
  • If melanoma is confirmed, further staging investigations may be required.

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Q3: What is the management plan for a confirmed malignant melanoma?

The competent candidate should:

• Surgical excision:
  • Wide local excision (WLE) with margin based on Breslow thickness:
    • <1 mm: 1 cm margin.
    • 1-2 mm: 1-2 cm margin.
    • >2 mm: 2 cm margin.
• Sentinel lymph node biopsy (SLNB):
  • Considered if Breslow thickness >1 mm or high-risk features (e.g., ulceration).
• Referral:
  • Urgent dermatology or surgical oncology referral for high-risk melanoma.
  • Multidisciplinary team (MDT) input if locally advanced or metastatic.
• Follow-up and surveillance:
  • Full skin check every 6 months for recurrence or new lesions.
  • Lymph node examination at follow-ups.

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Q4: What advice would you provide Peter on skin cancer prevention and surveillance?

The competent candidate should:

• Sun protection strategies:
  • Use broad-spectrum SPF 50+ sunscreen daily.
  • Wear protective clothing, wide-brimmed hats, and sunglasses.
  • Avoid peak UV exposure (10 am – 4 pm).
• Skin self-examination:
  • Regular self-checks using a mirror for any new or changing lesions.
  • Look for ABCDE features and report suspicious lesions.
• Regular skin checks:
  • Annual full-body skin checks by a GP or dermatologist.
  • More frequent checks if new lesions or high-risk features.

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Q5: When would you consider referral for further assessment beyond standard surgical excision?

The competent candidate should:

• Referral to a melanoma specialist or multidisciplinary team if:
  • Breslow thickness >1 mm (higher risk of spread).
  • Ulceration, high mitotic rate, or lymphovascular invasion.
  • Evidence of lymph node involvement or distant metastases.
• Consider imaging (CT/MRI) if:
  • Palpable lymph nodes or systemic symptoms (weight loss, fatigue).
  • Large or rapidly growing melanoma (>4 mm Breslow thickness).
• Oncology referral for immunotherapy or targeted therapy if metastatic disease is confirmed.

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SUMMARY OF A COMPETENT ANSWER

• Recognises key features of melanoma using the ABCDE rule and risk factors.
• Orders appropriate investigations, including excisional biopsy for histological confirmation.
• Manages confirmed melanoma with wide local excision, sentinel lymph node biopsy if indicated, and referral for advanced disease.
• Educates on sun protection and regular skin checks to prevent future melanomas.
• Refers appropriately to dermatology, oncology, or a multidisciplinary team if needed.

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PITFALLS

• Failing to biopsy a suspicious lesion and relying on clinical assessment alone.
• Using an inappropriate biopsy technique (e.g., shave biopsy for melanoma).
• Not recognising high-risk features requiring urgent referral.
• Overlooking sun protection advice and surveillance for secondary prevention.

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REFERENCES

• Cancer Council Australia on Melanoma Guidelines
• RACGP Guidelines on Skin Cancer Diagnosis and Management
• DermNet NZ on Melanoma Overview

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages the patient in a discussion about skin cancer risk and diagnosis.

2. Clinical Information Gathering and Interpretation

2.1 Identifies suspicious lesion features and orders appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates melanoma from benign lesions and follows diagnostic protocols.

4. Clinical Management and Therapeutic Reasoning

4.1 Plans appropriate surgical excision and referral for advanced disease.

5. Preventive and Population Health

5.2 Educates on sun safety and regular skin checks.

6. Professionalism

6.3 Provides empathetic, patient-centred care in discussing potential malignancy.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate biopsy technique and histological confirmation.

9. Managing Uncertainty

9.1 Determines when referral or additional investigations are required.

10. Identifying and Managing the Patient with Significant Illness

10.3 Recognises melanoma as a high-risk condition requiring urgent intervention.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD