08 Skin/Derm Flashcards
I. A 65-year-old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2-cm skin mass over the bridge of the nose that has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck.
II. A 71-year-old West Texas farmer of Irish ancestry has a non-healing, indolent, punched out, clean-looking 2-cm ulcer over the left temple that has been slowly becoming larger over the past 3 years. There are no enlarged lymph nodes in the head and neck.
What is it? Basal cell carcinoma has 2 potential configurations: waxy raised lesion or punched out ulcer, but both have a preference for the upper part of the face.
Diagnosis. Full-thickness biopsy at the edge of the lesion (punch or knife) or complete excision with narrow margin of uninvolved skin.
Management. Surgical excision with clear margins, but conservative width. Alternatives include electrodessication with curettage or ablation.
A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent 1.5-cm ulcer on the lower lip that has been slowly enlarging, for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings.
What is it? Squamous cell carcinoma. The location is classic.
Diagnosis. Biopsy, as described before.
Management. He will need surgical resection with wider (about 1 cm) clear margins. Local radiation therapy is another option.
A red-headed 23-year-old lady who worships the sun, and who happens to be full of freckles, consults you for a concerning skin lesion on her shoulder. She has a pigmented lesion that is asymmetrical, with irregular borders of different colors within the lesion, and measuring 1.8 cm.
What is it? The classic ABCD that alerts you to melanoma or a forerunner (dysplastic nevus).
Management. Excisional biopsy with narrow margin preferred. Once diagnosis is confirmed, definitive treatment is wide local excision with margins based on depth of invasion (Breslow). Sentinel lymph node biopsy is indicated for lesions 1–4 mm Breslow thickness.
A 35-year-old blond, blue-eyed man left his native Minnesota at age 18 and has been living an idyllic life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi all over his body, but one of them has changed recently.
What is it? Change in a pigmented lesion is the other tip off to melanoma. It may be growth, or bleeding, or ulceration, or change in color—whatever. Manage as above.
A 44-year-old man has unequivocal signs of multiple liver metastases, but no primary tumor has been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical examination is a missing toe, which he says was removed at the age of 18 for a black tumor under the toenail.
What is it? A classic vignette for malignant melanoma (the alternate version has a glass eye, and history of enucleation for a tumor). No self-respecting malignant tumor would have this time interval, but melanoma will.
A 32-year-old gentleman had a 3.4-mm deep melanoma removed from the middle of his back 3 years ago. He now has… (a tumor in a weird place, like his left ventricle, his duodenum, his ischiorectal area—anywhere!).
The point of this vignette is that invasive melanoma (it has to be deep) metastasizes to all the usual places (lymph nodes plus liver-lung-brain-bone) but it is also the all-time-champion in going to weird places where few other tumors dare to go. Because tumor behavior is unpredictable in any given patient, we tend to be aggressive in resecting these metastasis.
