Clinical clues to avoid missing melanoma when morphology is not sufficient

Question 1

Name 5 factors that are associated with increased death from melanoma

Answer 1

1. Aggressive melanoma
2. Delayed presentation
3. Patient not undressed
4. Melanoma mimics benign lesion
5. Incorrect pathological diagnosis

Question 2

How many patient do we need to examine on average to examine to detect one skin malignancy?

Answer 2

47

Question 3

How many patients do we need to examine on average to detect one melanoma?

Answer 3

400

Question 4

A physician seeing 20 patients a day who is not examining his or her patients, may need to work for how days to miss one melanoma

Answer 4

20

Question 5

Name 6 factors increasing the chance of detecting a skin cancer

Answer 5

1. Age: Elderly
2. Sex: Male
3. Previous nonmelanoma skin cancer
4. Skin type: Fair
5. Skin tumor as the reason for consultation
6. Presence of equivocal lesion on uncovered areas

Question 6

5 clinical clues to consider to reduce risk of missing melanoma when morphology does not provide the diagnosis.

Answer 6

1. Age of patient
2. Sex of patient
3. Lesion location
4. Lesion comparison
5. Palpable and or pink lesions

Question 7

Age as a clue when trying to reduce risk of missing melanoma

Answer 7

Melanoma uncommon in children

(Melanoma in children most likely in large congenital melanocytic nevi)

Question 8

Patient’s sex as a clue when trying to reduce risk of missing melanoma

Answer 8

High index of suspicion for melanocytic proliferation on the legs of middle-aged or elderly woman

Question 9

Lesion location as a clue when trying to reduce risk of missing melanoma

Answer 9

Consider special locations:
1. Flat facial lesions
2. Nail
3. Mucosal area

Question 10

Patient’s lesions comparison as a clue when trying to reduce risk of missing melanoma.

Name 3 principles to apply.

Answer 10

1. Examine all lesions
2. Use the comparative approach
3. Monitor the patient over time

Question 11

Approaching palpable and or pink lesions (when trying to reduce risk of missing melanoma)

Answer 11

• A palpable lesion should be excised immediately with a diagnosis of a benign lesion is not straightforward.
• Any pink tumor that cannot be clearly diagnosed as a benign lesion should be promptly excised.

Question 12

Approach to flat facial lesions (when trying to reduce risk of missing melanoma)

Answer 12

Use the inverse approach

(If none of the 6 benign features are clearly seen covering most of the lesion surface the lesion must be considered suspicious)

Question 13

Approach to pigmented lesions involving the nail : Describe 3 scenarios

Answer 13

1. Child: The most probable diagnosis is congenital melanocytic nevus of the nail matrix.
2. Adult patient with small Longitudinal melanonychia. Most likely nevus but 2-3 year follow-up should be carried out.
3. Adult patient with a large pigmented no pattern (>1/3 of the nail plate). This is likely a melanoma and should be excised.

Question 14

Approach to mucosal lesions (when trying to reduce risk of missing melanoma). Describe features distinguishing benign mucosal melanosis from melanoma.

Answer 14

1. Mucosal melanosis: Usually clinically flat lesion with dermoscopic parallel lines.
2. Melanoma: Most frequently palpable typified by structureless pigmentation varying from blue to white and red.

Question 15

Describe the dermoscopic inverse approach for diagnosis of LM in flat lesions on the face?

Answer 15

Presence of 1 or more of 6 structures as a predominant feature or the lesion.

(Thus classifying the lesion as either PAK or SK/SL)

Question 16

What are the 6 structures used in the dermoscopic inverse approach for diagnosis of LM?

Answer 16

1. Scale
2. White and wide follicular openings
3. Erythema
4. Reticular or parallel brown lines
5. Sharply demarcated border
6. Milia like cysts/ comedo like openings.

(Features must cover majority of the lesion)