Snapshot A 43-year-old man presents to his primary care physican for a pigmented lesion on his right forearm. He has had multiple sunburns in the past and works as a farmer, spending most of the day outside. Physical examination is notable for a 7-mm hyperpigmented lesion that is asymmetric with irregular borders and color variation. He undergoes an excisional biopsy, which demonstrates larger than normal melanocytes of various sizes with large hyperchromatic nuclei in the lower epidermis and dermis. Introduction Overview malignant tumor of melanocytes most commonly affects the skin other sites of involvement brain uvea intestines mucosa 4 types of cutaneous invasive melanoma superficial spreading (most common) usually seen in sunexposed areas nodular usually seen in men and often associated with ulceration acral most commonly seen in Asians, Hispanics, and patients from African descent lentigo maligna (invasive melanoma) invasive melaoma Epidemiology Incidence most commonly seen between the ages of 40-60 Risk factors dysplastic nevi multiple nevi ultraviolet radiation exposure fair-skin color immunsuppresion ETIOLOGY Pathophysiology Clark model of pathogenesis melanocytes proliferate to form a benign nevus genetic mutations (e.g., BRAF) lead to the nevus becoming dysplastic (pre-malignant) radial growth → vertical growth can eventually metastasize Presentation Physical exam pigmented skin lesion ABCDEs Asymmetric Border irregularity Color variation Diameter ≥ 6 mm Evolution over time Studies Serum labs S-100 tumor marker Invasive studies excisional biopsy indication preferred biopsy method to confirm the diagnosis findings atypical melanocytes and architectural disorder atypical larger than normal melanocytes large hyperchromatic nuclei irregular nuclear shape abnormal chromatin pattern architectural disorder asymmetry nests of melanocytes of varying sizes and shapes Differential Actinic keratosis differentiating factors secondary to proliferation of atypical epiderminal keratinocytes lesions are small, rough papules that are erythematous or brownish Basal cell carcinoma differentiating factors lesions are waxy, pink, and pearly can have central crusting or ulceration histology demonstrates palisading nuclei Treatment Medical vemurafenib indication BRAF kinase inhibitor that can be considered in patients with metastatic or unresectable melanoma with BRAF V600E mutations typically given with cobimetinib Surgical local wide excision indication mainstay of treatment for primary cutaneous melanoma Complications Metastatic melanoma lung brain liver bone intestines Prognosis Prognostic favorable favorable localized disease with the tumor being ≤ 1 mm deep negative metastatic disease
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next (M2.OMB.18.4729) A 53-year-old farmer presents to the clinic for evaluation of a pigmented lesion on his arm. He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size. He otherwise does not have any complaints and is generally healthy. Which of the following findings on physical exam would suggest a malignant diagnosis? QID: 210809 Type & Select Correct Answer 1 Different pigmentation throughout the lesion 100% (2/2) 2 Flat lesion with symmetric hyperpigmentation 0% (0/2) 3 Hyperpigmented lesion with smooth borders 0% (0/2) 4 Symmetrical ovoid lesion 0% (0/2) 5 Tenderness to palpation 0% (0/2) M 6 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.ON.14.19) A 40-year-old Caucasian female presents to a dermatologist for evaluation of a mole. While the skin lesion has been present since she was young, she has noticed a change in its size and color. She has a significant sun exposure history from working as a lifeguard in high school and college, and a family history of skin cancer - although she is unsure of what kind. As seen in Figure A, the physician notes a 1cm skin lesion on her calf with irregular borders and varied pigmentation. What is the next appropriate course of action? QID: 104230 FIGURES: A Type & Select Correct Answer 1 Observation with serial photographs 0% (0/19) 2 Shave biopsy 0% (0/19) 3 Complete excision 68% (13/19) 4 Loop electrosurgical excision procedure (LEEP) 5% (1/19) 5 Punch biopsy 21% (4/19) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.ON.13.18) A 47-year-old woman comes to her primary care doctor because of a new, pruritic rash. She was gardening in her yard two days ago and now has an eczematous papulovesicular rash on both ankles. You also note a single, 5 mm brown lesion with a slightly raised border on her left thigh. You prescribe a topical corticosteroid for contact dermatitis. Which of the following is the appropriate next step for the thigh lesion? QID: 104229 Type & Select Correct Answer 1 Further questioning 31% (5/16) 2 Topical corticosteroid 0% (0/16) 3 Reassurance 25% (4/16) 4 Simple shave biopsy 6% (1/16) 5 Full thickness biopsy 31% (5/16) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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