The Farmer with the Skin LesionLogan Carr

History• CC: “Changing brown spot on hand”• HPI: PM is a 74 y/o Caucasian male with a fair

complexion. He has had a pigmented area on his left hand for 4-5 years, then he recently, within the last 2 years, noticed that a dark spot in the middle of the pigmented area was enlarging. He also reports a new white crust. He denies any bleeding, ulceration, itching or pain involved with the area. He has a history of sun exposure at an early age.

History Cont’d.• PMH: GERD, Hyperlipidemia• Meds: omeprazole, pravastatin• PSH: multiple BCC/SCC removed from back and

shoulders, bilateral cataract removal.• FMH: Sister has a hx of melanoma 20 years ago on

her inner thigh. • SH: Worked on a farm as a child and young adult

and then as a delivery man later in life. Had a great deal of sun exposure throughout his life.• ROS: No headache, fever, weight changes, SOB,

hemoptysis, CP, Palpitations, N/V/D/C, abd. pain, or swelling in his extremities.

Physical Exam• Vitals: BP: 132/88 P: 73 RR: 15 T: 98 F • HEENT: head normocephalic, EOMI, PERRL, nares

patent and nonerythematous, no neck LAD, no thyromegaly• Heart: normal S1/S1, no murmurs• Lungs: CTA b/l, no WRR• GI: NBS all quadrants, no bruits, tympanic, with no

pain on palpation, no masses• MS: normal strength • Neuro: CN 2-12 intact

Physical Exam Cont’d.• Skin: There is a roughly 3 cm x 1 cm patch on the

dorsal aspect of his left fifth metacarpophalangeal joint. It has irregular borders and color variation.• It also has a 1cm x 1cm papule that was slightly

darker. This area was previously biopsied.• Patient also has other nevi over chest, shoulders,

and arms. • No lymphadenopathy in epitrochlear or axillary area

on the left side. • Labs: CBC done preoperatively was completely

within normal range

The patient’s skin lesion

White Crust

1cm

3cm

Central area of darkening

Fifth digit

Fourth digit

Fifth MCP joint

Differential Diagnosis

• Malignant melanoma : Changing, darkening, large• Atypical Nevi: suspicious moles• Pigmented Basal Cell Carcinoma: pink, pearly,

rolled edges, crateriform • Seborrheic Keratosis: stuck on, verrucous or wart

like• Solar Lentigo (liver spots): light brown macules

Most likely diagnosis?

Clinical Diagnosis of MelanomaSpec Sens ABCDE mnemonic and description

72% 57%A- Asymmetry= a line through the middle will not create matching halves

71% 57% B- Border Irregularity= scalloped or notched edges

59% 65% C- Color Variation= varied shades of brown, tan or black and even red, white and blue at later stages

63% 90% D- Diameter >6mm

90% 84% E- Evolving= size, shape, surface (bleeding) and symptoms (itching, pain)

The patient’s skin lesion

Border irregularity

Asymmetry

Color variation

Diameter

Elevation

Evolving

Risk factors for Melanoma• A changing mole (most important risk factor) • Atypical/dysplastic nevi (particularly >5–10).• Large numbers of common nevi (>100).• A history of melanoma.• Sun sensitivity/history of excessive sun exposure or sunburn.• Melanoma in a first-degree relative.• Prior non-melanoma skin cancer (basal cell and squamous cell

carcinoma).• Male gender.• Age >50• A fair-skin phenotype (blue/green eyes, blond or red hair, light

complexion, sun sensitivity) and the occurrence of blistering sunburns in childhood and adolescence

Types of Melanoma

1. Superficial Spreading type: 70 % of all melanomas, occur in sun exposed areas. Arise from preexisting nevi, grow in radial growth pattern during early stages

2. Nodular: 15-25 % of all melanomas, occur in old men, resemble a blood blister, arise de novo and are usually deep at time of diagnosis

3. Lentigo maligna: 5-10% of all melanomas, occur only in sun exposed areas, have convoluted borders, and a prolonged radial growth phase

4. Acral lentiginous: 2-8% of all melanomas, more common in darker skin patients, occur in non sun exposed areas, on sole of foot, palm and beneath nail beds, very aggressive.

Epidemiology

In 2007 only in the US:• Approximately 110,000 people were

diagnosed with melanoma• 8110 people died of metastatic disease• Incidence has plateaued since the 90s•Most common cancer in women of 25-29 y/o•Median age of diagnosis is 53 y/o

Path report of punch biopsyHistological Type Malignant melanoma

Maximum thickness 0.95 mm (Breslow 3)

Anatomic level Invades reticular dermis (Clark 4)

Mitotic index <1 mitosis/mm2

Size 0.2mm in depth and diameter

Margins During Excision

Tumor Thickness

WHO

In situ 5mm

≤1mm 1cm

1-2mm 1cm

2-4mm 2cm

>4mm 2cm

Currently Recommended Excision Margins for Primary Melanoma

Clark Breslow Thickness

Historic Measurements of Invasion for staging and prognosis

Overview of Treatment Algorithm

Radiation and Chemotherapy

Technetium Lymphoscintogram • Purpose: To help localize the region of lymphatic

drainage and more specifically the sentinel node.• Solution: 454 uCi of Technetium Tc 99m Sulfur

Colloid • Procedure: The solution was divided into 4

aloquots and injected subdermally in 4 locations around the melanoma lesion. The area was massaged to help distribute the solution in the tissue. Do scintigraph to determine lymph node locations:• Adverse effects: small radiation exposure,

anaphylactic reactions, rash, and hypotension

Sentinel Lymph Node Biopsy

1. Inject lympho serum blue: ½ cc in all four quadrants

2. Initial background reading of axilla through skin: 200

3. Sentinel lymph node was located and dissected out with geiger counter assistance.

4. Ex vivo reading was 1300.5. New background noise was 130 (goal < 10% of

ex vivo).

Final Path Report

Histological Type Malignant melanoma

Thickness 1.02 mm

Mitotic index 5 mitosis/mm2

Clark level IV (invades reticular dermis)

Ulceration none

SLNB 2 nodes both negative for cancer

Staging

Histological Type Malignant melanoma

Thickness 1.02 mm

Ulceration none

SLNB 2 nodes both negative for cancer

Metastasis N/A

Staging

PATHOLOGIC STAGING T N0 Tis N0IA T1a N0IB T1b N0 T2a N0IIA T2b N0 T3a N0IIB T3b N0 T4a N0IIC T4b N0IIIA T1-4a N1a T1-4a N2aIIIB T1-4b N1a T1-4b N2a T1-4a N1b T1-4a N2b T1-4a N2cIIIC T1-4b N1b T1-4b N2b T1-4b N2c any T N3IV any T any N

Histological Type Malignant melanoma

Thickness 1.02 mm

Ulceration none

SLNB 2 nodes both negative for cancer

Metastasis N/A

T2a N0

Overview of Treatment Algorithm

See NCCN guidelines for complicated algorithm and follow-up recommendations (handout)

Sentinel node biopsy or nodal observation in melanoma.• Study design: Randomized controlled trial with 5 year

endpoint• Primary site: Dr. DL Morton at the John Wayne Cancer

Institute at Saint John’s Health Center Santa Monica, CA• Before SLNB: observation until clinically detectable

lymph nodes or CLND from the beginning. • Conclusions: Staging of primary melanomas according to

SLNB helps to prolong survival by identifying patients who had micro-metastasis and needed complete lymph node dissection immediately.

References1. Thomas L. Semiological value of ABCDE criteria in the diagnosis of

cutaneous pigmented tumors. Dermatology. 1998;197:11–17.2. Sabel MS. Chapter 44. Oncology. In: Doherty GM, ed. CURRENT

Diagnosis & Treatment: Surgery. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com.proxy.cc.uic.edu/ content.aspx?aID=5316764. Accessed November 14, 2011.

3. Usatine RP. Chapter 165. Melanoma. In: Usatine RP, Smith MA, Chumley H, Mayeaux, Jr. E, Tysinger J, eds. The Color Atlas of Family Medicine. New York: McGraw-Hill; 2011. http://www.accessmedicine.com.proxy.cc.uic.edu/content.aspx?aID=8207960. Accessed November 12, 2011.

4. Tsao H, Atkins MB, Sober AJ: Management of cutaneous melanoma. N Engl J Med 351:998, 2004

References

5. Lens MB, et al. Excision margins in the treatment of primary cutaneous melanoma: A systematic review of randomized controlled trials comparing narrow versus wide excision. Arch Surg. 2002;137:1101–1105.

6. Cole P, Heller L, Bullocks J, Hollier LH, Stal S. Chapter 16. The Skin and Subcutaneous Tissue. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, eds. Schwartz's Principles of Surgery. 9th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com.proxy.cc.uic.edu/content.aspx?aID=5019723. Accessed November 15, 2011.

7. Morton DL et al: Sentinel node biopsy or nodal observation in melanoma. N Engl J Med 2006;355:1307.