2.09 Nevi and Malignant Melanoma Flashcards
Examination of Nevi (ABCDEs)?
§Asymmetry
§Border irregularity
§Color variation
§Diameter (size/enlargement)
§Evolving (change in size, shape, color or a new lesion)
Patient presents with:
Sharply circumscribed, Uniform colored papules or macules, Irregular surface with or w/out hair, Single or multiple, Size varies greatly
Melanocytic Nevus
What are the 3 types of Acquired (Common Nevi)?
3 Types – Junctional, Compound, Dermal
Patient presents with:
Nest in the epidermis and epidermis-dermal junction, Flat or slightly elevated. Light brown to brown-black w/ uniform pigmentation. Size
What kind of Melanocytic Nevus is it?
Junctional
Patient presents with:
Nevus with nest into the upper dermis, Slightly elevated to dome shaped, smooth or warty surface, with or without hair. Uniformly round, oval, and symmetric.
What type of Melanocytic Nevus is it?
Compound
Patient presents with:
All nevus cells in dermis, sometimes in fat cells, Dome-shaped (MC), verrucous, pedunculated, sessile (broad based), Skin colored to brown/black with hair, become lighter with age, Common in adults.
What type of Melanocytic Nevus is it?
Dermal
How is congenital nevi categorized?
Small =
Medium=1.5-20cm
Large=>20cm
Patient presents with:
Subtype of congenital melanocytic nevus??? Hairless, oval or irregularly shaped brown lesion, Dotted w/ darker brown to black spots (usually papular 1-3mm). MC in adolescence.
What is it?
Nevus Spilus
Aka… “speckled lentiginous nevus”
Patient presents with:
Developmental Anomaly of adolescents – either a brown macule, a patch of hair or both (no nevus cells). Concurrent proliferation of hair, melanin, and smooth muscle. Upper back, shoulder, upper arm, submammary (MC areas); Unilateral. More common in men-? Hereditary, may start as café au lait
Becker’s Nevus
How do you treat Becker’s Nevus?
Usually too large to remove with excision
Hair may be shaved or permanently removed
Laser tx for removal of hair and pigmentation
Patient presents with:
One or more hypopigmented to white lesions that contain a central red, brown or black nevus (No melanocytes in halo). Nevus regresses and pigment returns. MC in adolescence and MC on truck. May herald onset of vitiligo
Halo Nevus
Halo Nevus may be seen more frequently in what syndrome?
Seen more frequently in Turner’s Syndrome (45X) pt’s (short stature, gonadal dysgenesis, webbed neck, cubitus valgus, lymphedema at birth)
Patient presents with:
A benign proliferation of epidermal cells, Hyperpigmented due to thickened epidermis, Verrucous or papillomatous eruption, In dermatomal, unilateral linear arrangement. Mostly on head and neck.
Linear Epidermal Nevus
How and why do you treat a Linear Epidermal Nevus?
To decrease discomfort & improve cosmetic appearance
▪Cryosurgery
▪Partial thickness excision
▪Topical agents (5-FU, retiniods)
▪Laser
Patient presents with:
Proliferation of sebaceous glands. Sharply demarcated, verrucous, yellow-orange plaque. MC location - scalp, neck -hairless. Hormonally responsive.
Birth - raised yellow-orange plaque without hair
Flattens within a few months as maternal hormones taper off. Remains as yellow or skin colored area of alopecia
At puberty area begins to rise and becomes verrucous
Nevus sebaceous
(organoid nevus)
What % of Nevus sebaceous (organoid nevus) progress to cancer?
20%
How do you treat Nevus sebaceous (organoid nevus)
Surgical excision during childhood
Plastic surgical excision is most effective tx
Clinical f/up
Patient presents with:
Blue-black lesions dermal melanocytes (more flattened)
MC in scalp & persacral area, Backs of hands, Face/trunk in dermatomal pattern.
MC in Asians and Africans
Visible at birth to childhood, Appear blue-black due to “Tyndall effect” of melanin deeper in skin.
Mongolian Spot
What is the Tyndall Effect?
Tyndall Effect – brown pigment absorbs the longer wavelengths of light and scatters blue light
Patient presents with:
Blue-black pigmentation in distro of 1st - 2nd branch of trigeminal nerve. Affects the sclera, conjunctiva and skin around eye. No visual changes. Occur at birth or later, darkening with age. Common in Asians, esp. females
Nevus of Ota
How do you treat nevus of Ota?
Laser to lighten lesions
Monitor patient for glaucoma
Patient presents with:
Slightly elevated, round, regular nevus. Typically < 5mm. Large amounts of pigment in dermis, all races. MC on extremities & dorsum of hands. Often confused with malignant melanoma. Develop in childhood, Remain unchanged.
Blue Nevus
Patient presents with:
Discrete lack of pigment due to reduction in or non-functioning of melanocytes. Dermatomal pattern, Bizarre, irreg. borders. Anywhere and is permanent
Nevus Depigmentosus
Patient present with:
Usually >5mm, either flat or flat w/ raised center – “Fried Egg”. Darkly or irregularly pigmented. Shades of brown and pink. Irregular or indistinct borders. Begin to appear near puberty & continue to develop past the 4th decade.
Dysplastic (Atypical) Nevus
How do you treat/manage Dysplastic Nevus?
§Excisional Bx with margins
§Pt education on self-exam and sun avoidance
§Consider baseline pictures
§F/up at least annually
▪Dysplastic nevi are a “marker” for pts at risk for MM
§Suggest screening for family members
What is the Most deadly form of skin cancer?
Malignant Melanoma
Malignant Melanoma is responsible for what % of skin cancer deaths?
Responsible for 75% of skin cancer deaths in US
What are some risk factors for malignant melanoma?
§Personal H/O atypical moles, Fam H/O MM, & >75-100 moles
§Previous Non MM skin Ca
§Congenital Nevus (Giant >20cm)
§H/O MM
§FamHx of MM in 1’ relative
§Immunosuppression
§Clinically atypical Nevi (2-9)
§Large # of Nevi
§Chronic Tanning w/ UVA
What is the MC distribution of malignant melanoma?
▪Back – MC for men
▪Arms & Legs – MC for women
▪Noncutaneous MM (mucosal) – more common in non-white populations
How do you treat malignant melanoma?
§Biopsy
▪Excision for Dx purposes with narrow margins (2-3mm)
▪Punch Bx – suspicion for MM is low, lesion is large, or impractical to perform excision
▪NO shave Bx – partial removal = inadequate Breslow depth measurement
§Interferon – later stages (Oncology)
§Close f/up – teach self exam, Derm F/U q 3-4 months…
What is the Breslow Microstage?
▪Breslow depth – most important histologic determinant of prognosis
▪Microscopic depth reported in mm’s
What is the Clark Level?
▪Depth is reported by anatomic site
▪1. Epidermis, 2. Papillary Dermis, 3. Fills Papillary Dermis, 4. Reticular Dermis, 5. Enters SubQ Fat
What are the 4 types of malignant melanoma and their prevalice?
§Spreading Superficial (70%)
§Nodular (15-20%)
§Lentigo maligna (10-15%)
§Acrolentiginous (
What is the most common type of melanoma?
What is the hallmark?
Superficial Spreading Melanoma
Hallmark is haphazard combo of many colors (more so with time)
What melanoma presents with Completely vertical growth phase (no radial growth)?
Nodular
Patient presents with:
Lesion. May not be pigmented, but MC dark brown, red-brown, or red-black, Rapid growth, Ulcerates and bleeds. Most commonly misdiagnosed b/c it could resemble blood blister, hemangioma, dermal nevus, SK, or dermatofibroma
Nodular malignant melanoma
What type of melanoma is a Lateral growth phase lesion?
Lentigo maligna (4-15%)
Patient presents with:
Palms, soles, terminal phalanges, and mucous membranes. Same colors and tendency to remain flat as Lentigo Maligna. Hutchinson’s sign. Very poor prognosis. Most common form in DPP (30-75%)
Acrolentiginous malignant melanoma
Pigment spreads to proximal and lateral nail folds is called what? (Kind of sign)
Hutchinson’s sign (under nail plate) – pigment spreads to proximal and lateral nail folds
What is the ABCDEF for DPP?
¡A-Age (5th-6th decades)
¡B-Brown or black band
¡C-Change - recent, sudden, or rapid development
¡D-Digit most commonly involved
¡E-Extension of brown pigment onto cuticle or where a hangnail may develop
¡F-Family hx or personal hx of unusual moles or MM
Depth of invasion based on the Clark Level - important indicator of survival (5-year); what are the levels?
§Level I - restricted to epidermis – 98%
§Level II - papillary dermis
§Level III - fill papillary dermis
§Level IV - reticular dermis
§Level V - invade subcutis – 44%
What is the Most important histologic determinant of prognosis?
¡Breslow microstage
§Most important histologic determinant of prognosis
§Determined by depth in mm at thickest point
§Reported as “Breslow Level #mm”
