Skin Lesion

James Warneke, MD

University of Arizona

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

What other points of the history do you want to know?

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

What is your Differential Diagnosis?

Differential Diagnosis Based on History

Dysplastic Nevus Malignant Melanoma Basal Cell Carcinoma Squamous Cell Carcinoma Junctional Nevus Actinic Keratosis

Physical Examination

What would you look for?

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

Physical Examination

Interventions at this point?

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

Would you like to revise your Differential Diagnosis?

Results of Biopsy

Melanoma

What is important to check on the pathology report?

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

What blood test should be ordered?What X-ray studies are indicated?

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

Further ManagementFurther Management

What should be done next?What should be done next?

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

Marking of Lymph Basin With Lymphscintigraphy in Mr. Smith

Injection of Lymphazurin Blue Dye in Mr. Smith

Evaluation of Mr. Smith’s Lymph Nodes

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

What Stage is Mr. Smith’s Melanoma?

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

Prognosis

What is the estimated 10 year survival of Mr. Smith?

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 %

Questions?

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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