Mr. Smith
Patient is a 64 year-old man with a history of a mole on his chest that has been present for years, but has recently grown is size. The mole has not bleed.
History, Mr. Smith
Characterization of symptoms
Temporal sequence Alleviating /
Exacerbating factors:
Pertinent PMH, ROS, MEDS.
Relevant family hx. Associated signs and
symptoms
Consider the Following
History, Mr Smith
Characteristics of mole• Change in color• Nodular areas
Family History of melanoma History of sun exposure and sunburns History of previous atypical moles
Differential Diagnosis Based on History
Dysplastic Nevus Malignant Melanoma Basal Cell Carcinoma Squamous Cell Carcinoma Junctional Nevus Actinic Keratosis
Physical Examination, Mr. Smith
General: fair skin and blue eyes Skin: Multiple moles and evidence or solar skin
damage on face and arms• Large mole on anterior chest with• Asymmetry, border irregularity, color variation and
diameter greater than 6mm• Lymph nodes – none palpable in axilla, neck or
groin
Biopsy of Lesion
Biopsy thickest area Biopsy should be down to subcutaneous fat Biopsy entire lesion if small Large lesions should have punch biopsy or
wedge Orient extremity incisions in axial direction so
re-excisions can be axial
Biopsy Results
Pattern of Melanoma• Superficial spreading – most common• Nodular – vertical growth• Acral lentiginous – nails, palms and sole of foot,
usually have in-situ precursor• Lentigo Maligna – in-situ melanoma in sun exposed
area of the face and back of hand
Biopsy Results
Breslow’s Thickness – measured with an optic micrometer
Clark’s Level• I In-situ• II Papillary dermis• III Superficial reticular dermis• IV Deep reticular dermis• V Subcutaneous fat
Biopsy Results
Ulceration of Epithelium Other Factors – deep margin involved with
melanoma, regression, lymphocytic infiltration.
Biopsy Results of Mr. Smith
Superficial spreading melanoma with areas of nodular invasion
Breslow’s thickness 2.5mmClark’s level IVNon-ulceratedDeep margin free of melanoma
Laboratory and X-ray
Serum LDH is indicated for lesions deeper than 1.0mm
PA and Lateral Chest X-ray for lesions deeper than 1.0mm
Laboratory and X-ray of Mr. Smith
LDH is within normal limits
CXR shows no evidence of metastatic disease
Management
Surgical Excision How wide of an excision should be done? When should a lymph node biopsy be
planned?
Management of Mr. Smith
Margin of excision should be 2.0 cm from all borders of the pigmented lesion• Lesions <1.0mm 1.0 cm margins• Lesions 1.0-2.0 mm 1.0-2.0 cm margins• Lesions >2.0 mm 2.0 cm margins• The depth of the excision is to the underlying fascia
Management of Mr. Smith
For an acceptable cosmetic result, an ellipse of skin is usually excised with length 2.5-3.5 times the width. In this patient the lesion is wide, and the ellipse would be 6cm X 15cm
To close this defect primarily, the lateral edges are undermined for 2-3cm to allow the skin to stretch
Evaluation of Lymph Nodes
Lesions <1.0mm do not need lymph nodes biopsied
Lesions >1.0mm thickness should have sentinel lymph node biopsy
All lesions which have an enlarged palpable lymph node in an adjacent lymph node basin, should have that lymph node biopsied
Sentinel Lymph Node Biopsy
Lymphscintigraphy with Tc99 radiolabeled to colloid is done day of procedure to detect lymph drainage and to use intraoperatively with the gamma probe
Lymphazurin blue dye is injected into the dermis next to the melanoma to visually detect the sentinel lymph node
Sentinel Lymph Nodes in Mr. Smith
Sentinel lymph node biopsy found two lymph nodes which where blue
Both blue lymph nodes were hot with the hand-held gamma probe
Pathology by routine histology and immunohistochemistry did not detect any melanoma in the lymph nodes
Staging of Mr. Smith’s Melanoma
Primary Tumor (T) 2.5mm with no ulceration is T3a Regional Lymph Nodes (N) no regional node
metastasis is NO
Metastasis (M) none is MO
Stage is IIA T3a NO MO
10 Year Survival of Mr. Smith
Melanoma T3a with NO has a 10 year survival of 65%
With the inclusion of sentinel lymph node biopsy, the micrometastatic nodes with melanoma will have a worse prognosis of 50%, and the negative sentinel nodes will have a increased survival to 80-90 %
Summary of Melanoma
54,200 new melanomas per year in US 7600 deaths from melanoma per year in US 1 in 57 white males 1 in 81 white females 89% 5-year survival for 1992-1998
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