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 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 Prognosis prognostic favorable favorable localized disease with the tumor being ≤ 1 mm deep negative metastatic disease 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
QUESTIONS 1 of 4 1 2 3 4 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + You have 100% on this question. Just skip this one for now. Take This Question Anyway (OMB11.4729) 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? Review Topic QID: 210809 Type & Select Correct Answer 1 Different pigmentation throughout the lesion 0% (0/0) 2 Flat lesion with symmetric hyperpigmentation 0% (0/0) 3 Hyperpigmented lesion with smooth borders 0% (0/0) 4 Symmetrical ovoid lesion 0% (0/0) 5 Tenderness to palpation 0% (0/0) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ON.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? Review Topic QID: 104230 FIGURES: A Type & Select Correct Answer 1 Observation with serial photographs 0% (0/15) 2 Shave biopsy 0% (0/15) 3 Complete excision 60% (9/15) 4 Loop electrosurgical excision procedure (LEEP) 7% (1/15) 5 Punch biopsy 27% (4/15) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ON.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? Review Topic QID: 104229 Type & Select Correct Answer 1 Further questioning 33% (5/15) 2 Topical corticosteroid 0% (0/15) 3 Reassurance 27% (4/15) 4 Simple shave biopsy 7% (1/15) 5 Full thickness biopsy 27% (4/15) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 1