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Updated: Dec 26 2021


  • 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
  • Presentation
    • Physical exam
      • pigmented skin lesion
          • 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
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