Updated: 8/16/2019

Melanoma

Topic
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Questions
4
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Evidence
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https://upload.medbullets.com/topic/120390/images/melanoma.jpg
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
 

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Questions (4)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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
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(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
1

Different pigmentation throughout the lesion

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Flat lesion with symmetric hyperpigmentation

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Hyperpigmented lesion with smooth borders

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4

Symmetrical ovoid lesion

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5

Tenderness to palpation

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(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:
1

Observation with serial photographs

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Shave biopsy

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Complete excision

60%

(9/15)

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Loop electrosurgical excision procedure (LEEP)

7%

(1/15)

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Punch biopsy

27%

(4/15)

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(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
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)

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