The Farmer with the Skin Lesion

Logan Carr Click to edit Master subtitle style

8/18/12

History

CC: Changing brown spot on hand HPI: PM is a 74 y/o Caucasian male with a fair complexion. He has had a pigmented area on his left hand for 4-5 years, then he recently, within the last 2 years, noticed that a dark spot in the middle of the pigmented area was enlarging. He also reports a new white crust. He denies any bleeding, ulceration, itching or pain involved with the area. He has a history of sun exposure at an early age.
8/18/12

History Contd.

PMH: GERD, Hyperlipidemia PSH: multiple BCC/SCC removed from back and shoulders, bilateral cataract removal. FMH: Sister has a hx of melanoma 20 years ago on her inner thigh. SH: Worked on a farm as a child and young adult and then as a delivery man later in life. Had a great deal of sun exposure throughout his life.
8/18/12

Meds: omeprazole, pravastatin

Physical Exam

Vitals: BP: 132/88 P: 73 RR: 15 T: 98 F HEENT: head normocephalic, EOMI, PERRL, nares patent and nonerythematous, no neck LAD, no thyromegaly Heart: normal S1/S1, no murmurs Lungs: CTA b/l, no WRR GI: NBS all quadrants, no bruits, tympanic, with no pain on palpation, no masses MS: normal strength Neuro: CN 2-12 intact
8/18/12

Physical Exam Contd.

It also has a 1cm x 1cm papule that was slightly darker. This area was previously biopsied. Patient also has other nevi over chest, shoulders, and arms. No lymphadenopathy in epitrochlear or axillary area on the left side. Labs: CBC done preoperatively was

8/18/12

Skin: There is a roughly 3 cm x 1 cm patch on the dorsal aspect of his left fifth metacarpophalangeal joint. It has irregular borders and color variation.

The patients skin lesion

CP Fifth M joint

3cm

Fifth digit 1cm

White Crust Central area of darkening

8/18/12

Fourth digit

Differential Diagnosis

Atypical Nevi: suspicious moles Pigmented Basal Cell Carcinoma: pink, pearly, rolled edges, crateriform Seborrheic Keratosis: stuck on, verrucous or wart like Solar Lentigo (liver spots): light brown macules

8/18/12

Malignant melanoma : Changing, darkening, large

Most likely diagnosis?

8/18/12

Spec Sens ABCDE mnemonic and description 72% 57%

Clinical Diagnosis of Melanoma

A- Asymmetry= a line through the middle will not create matching halves
8/18/12

71% 59%

57% 65%

B- Border Irregularity= scalloped or notched edges C- Color Variation= varied shades of brown, tan or black and even red, white and blue at later stages

63%

90% D- Diameter >6mm E- Evolving= size, shape, surface (bleeding) and symptoms (itching, pain)

90% 84%

The patients skin lesion

Diameter Border irregularit y Evolvin g 8/18/12

Elevation Color variation

Asymmet ry

Risk factors for Melanoma

A changing mole (most important risk factor) Large numbers of common nevi (>100). A history of melanoma. Sun sensitivity/history of excessive sun exposure or sunburn. Melanoma in a first-degree relative. Prior non-melanoma skin cancer (basal cell and squamous cell carcinoma). Male gender. Age >50 A fair-skin phenotype (blue/green eyes, blond or red
8/18/12

Atypical/dysplastic nevi (particularly >510).

Types of Melanoma
1.

Superficial Spreading type: 70 % of all melanomas, occur in sun exposed areas. Arise from preexisting nevi, grow in radial growth pattern during early stages Nodular: 15-25 % of all melanomas, occur in old men, resemble a blood blister, arise de novo and are usually deep at time of diagnosis Lentigo maligna: 5-10% of all melanomas, occur only in sun exposed areas, have convoluted borders, and a prolonged radial growth phase Acral lentiginous: 2-8% of all melanomas, more common in darker skin patients, occur in non sun exposed areas, on sole of foot, palm and beneath nail beds, very aggressive.

2.

3.

4.

8/18/12

Epidemiology

Approximately 110,000 people were diagnosed with melanoma 8110 people died of metastatic disease Incidence has plateaued since the 90s Most common cancer in women of 25-29 y/o

8/18/12

In 2007 only in the US:

Path report of punch biopsy

Histological Type Malignant melanoma 8/18/12 Maximum thickness Anatomic level Mitotic index Size 0.95 mm (Breslow 3) Invades reticular dermis (Clark 4) <1 mitosis/mm2 0.2mm in depth and diameter

Margins During Excision

Clark Tumor WHO Thickness In situ 1mm 1-2mm 2-4mm >4mm 5mm 1cm 1cm 2cm 2cm 8/18/12 Historic Measurements of Invasion for staging and prognosis Breslow Thickness Currently Recommended Excision Margins for Primary Melanoma

Overview of Treatment Algorithm

8/18/12 Radiation and Chemotherapy

Technetium Lymphoscintogram

Solution: 454 uCi of Technetium Tc 99m Sulfur Colloid Procedure: The solution was divided into 4 aloquots and injected subdermally in 4 locations around the melanoma lesion. The area was massaged to help distribute the solution in the tissue. Do scintigraph to determine lymph node locations:

8/18/12

Purpose: To help localize the region of lymphatic drainage and more specifically the sentinel node.

Sentinel Lymph
8/18/12

Node Biopsy
1.

Inject lympho serum blue: cc in all four quadrants Initial background reading of axilla through skin: 200 Sentinel lymph node was located and dissected out with geiger counter assistance. Ex vivo reading was 1300. New background noise was 130 (goal

2.

3.

4.

5.

Final Path Report

Thickness Mitotic index Clark level Ulceration SLNB 1.02 mm 5 mitosis/mm2 IV (invades reticular dermis) none 2 nodes both negative for cancer 8/18/12 Histological Type Malignant melanoma

Stagin g
8/18/12 Histological Type Malignant melanoma Thickness Ulceration SLNB Metastasis 1.02 mm none 2 nodes both negative for cancer N/A

8/18/12

Stagin g

0 IA IB IIA IIB IIC IIIA IIIB Histological Type Thickness Ulceration SLNB IIIC Metastasis IV

PATHOLOGIC STAGING T N Tis N0 T1a N0 T1b N0 T2a N0 T2b N0 T3a N0 T3b N0 T4a N0 T4b N0 T1-4a N1a T1-4a N2a T1-4b N1a Malignant melanoma T1-4b N2a 1.02 mm T1-4a N0 N1b T2a none T1-4a N2b 2 nodes both negative for N2c T1-4a cancer T1-4b N1b T1-4b N2b N/A T1-4b N2c any T N3 any T any N

Overview of Treatment Algorithm

8/18/12 See NCCN guidelines for complicated algorithm and follow-up recommendations

Sentinel node biopsy or nodal observation in melanoma. Study design: Randomized controlled trial

Primary site: Dr. DL Morton at the John Wayne Cancer Institute at Saint Johns Health Center Santa Monica, CA Before SLNB: observation until clinically detectable lymph nodes or CLND from the beginning. Conclusions: Staging of primary melanomas according to SLNB helps to prolong survival by identifying patients who had micrometastasis and needed complete lymph node dissection immediately.

8/18/12

with 5 year endpoint

References
1.

Thomas L. Semiological value of ABCDE criteria in the diagnosis of cutaneous pigmented tumors. Dermatology. 1998;197:1117. Sabel MS. Chapter 44. Oncology. In: Doherty GM, ed. CURRENT Diagnosis & Treatment: Surgery. 13th ed. New York: McGraw-Hill; 2011. http:// www.accessmedicine.com.proxy.cc.uic.edu/ content.aspx?aID=5316764. Accessed November 14, 2011. Usatine RP. Chapter 165. Melanoma. In: Usatine RP, Smith MA, Chumley H, Mayeaux, Jr. E, Tysinger J, eds. The Color Atlas of Family Medicine. New York: McGrawHill; 2011. http://www.accessmedicine.com.proxy.cc.uic.edu/content .aspx?aID=8207960. Accessed November 12, 2011. Tsao H, Atkins MB, Sober AJ: Management of cutaneous
8/18/12

2.

3.

4.

References
5.

Lens MB, et al. Excision margins in the treatment of primary cutaneous melanoma: A systematic review of randomized controlled trials comparing narrow versus wide excision. Arch Surg. 2002;137:11011105. Cole P, Heller L, Bullocks J, Hollier LH, Stal S. Chapter 16. The Skin and Subcutaneous Tissue. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, eds. Schwartz's Principles of Surgery. 9th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com.proxy.cc.uic.edu/conte nt.aspx?aID=5019723. Accessed November 15, 2011. Morton DL et al: Sentinel node biopsy or nodal observation in melanoma. N Engl J Med 2006;355:1307.

6.

7.

8/18/12

8/18/12