Atypical Nevi/ Melanoma

Question 1

A nevus that appears on the back, upper or lower limbs, on SUN protected areas, with a diameter greater than 5 mm, with ill defined borders and margins

Answer 1

Dysplasic Nevus

Tx with Excisional Bx with margins if suspicious

• TBSE every 6-12 months
• Consider baseline pictures

Pt education on self-exam and sun avoidance

Suggest screening for family members

Consider referral for ophthalmologic exams if located around the eyes

Question 2

Dx criteria for Dysplasitc Nevus

Answer 2

Diagnosis
At least 3 of the following:
-Diameter > 5mm
-Ill-defined borders
-Irregular margin
-Varying pigmentation within the lesion
-Presence of papular + macular components

Question 3

What is the relative risk for malignant melanoma

Answer 3

Personal Hx of Atypical moles or greater than 75-100 moles (35%)

Previous non melanoma cancer (17%)

Congenital nevus larger than 20cm
(15%)

Question 4

Where is the mc location for melanoma in men and women

Answer 4

Back – MC for men
Arms & Legs – MC for women

Mucosal in non white people

Question 5

Approach to assessing malignant melanoma

Answer 5

ABCDE

Annotate skin type

TBSE

CBC, CMP, UA
-leukocytosis or s/s of metz

Question 6

MGMT approach to Melanoma

Answer 6

Refer to Derm

Excision, NOT SHAVE!

Teach pt self examination (ABCDE)

F/u q3-4 months with derm for a full year then q 6 months for life

Question 7

How do you stage Melanoma

Answer 7

Breslow Microstage (Depth)

• Breslow depth – most important histologic determinant of prognosis
• Microscopic depth reported in mm’s

Question 8

What is the 5 yr survival of a Breslow in Situ

Answer 8

95-100%

Question 9

What is the 5 yr survival for a breslow depth <1mm

Answer 9

95-100%

Question 10

What is the 5yr of a breslow depth of 1-2 mm

Answer 10

80-96%

Question 11

5yr survival of a breslow depth 2.1-4mm

Answer 11

60-75%

Question 12

5yr survival of a breslow depth greater than 4mm

Answer 12

50%

Question 13

What are the 4 types of malignant melanoma

Answer 13

Superficial Spreading (70%)
Nodular (15-20%)
Lentigo maligna (10-15%)
Acral-lentiginous (<10%)

Question 14

What is the hallmark of malignant melanoma subtype superficial spreading

Answer 14

Hallmark is haphazard combo of many colors (more so with time)

Question 15

ABCDE for nodular melanoma

Answer 15

A – dome shaped, polypoid or pedunculated
B – irregular, surrounding primary lesion
C – brown to black papule or nodule
Up to 8% may not be pigmented
D – rapid size growth
E – ulcerates and bleeds

Question 16

ABCDE for superficial spread Melnoma

Answer 16

A – asymmetric
B – irregular
C – brown to black macule initially
D – typically > 5mm (undergoes radial growth first)
E – evolves into black, blue, white, red, and undergoes vertical growth (elevated)

Question 17

What type of growth is specific to lentigo malignant melanoma

Answer 17

Slow growth

Question 18

What is hutchinsons sign

Answer 18

Sudden appearance of melanoma in the nail bed

Dx for Acral Lentiginous melanoma

Question 19

ABDDE”F” for mal. Melanoma in DPP

Answer 19

Age in the 5th to 6th decade

Brown/ Black Band

Recent Change

Digit (MC)

Extension onto cuticle

Family Fx

Question 20

What is the single most important prognostic variable for Malignant melanoma?

Answer 20

Breslow Thickness

Sentinel lymph node status most important prognostic factor in lesions >1mm thick

Question 21

How do you DDx nodular melanoma for hemangioma

Answer 21

Press on the suspected nodule for 30 seconds, near total involution is Dx for hemangioma, not melanoma