12/11/2019 Malignant Melanoma Clinical Presentation: History, Physical Examination

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Malignant Melanoma Clinical

Presentation
Updated: Feb 17, 2019
Author: Winston W Tan, MD, FACP; Chief Editor: Dirk M Elston, MD more...

PRESENTATION

History
Family history
Carefully obtain any family history of melanoma or skin cancer. Also, a family history of irregular,
prominent moles is important. Approximately 10% of all patients with melanoma have a family history
of melanoma. These patients typically develop melanoma at an earlier age and tend to have multiple
dysplastic nevi. These patients also are more likely to have multiple primaries.

Presence of a familial melanoma syndrome should be considered in patients with a family history of
pancreatic cancer or astrocytoma. Mutations in the CDKN2A tumor suppressor gene (also known as
p16) are the most common genetic abnormalities found in these families.

Patient history

Any previous history of melanoma must be elicited from patients, because those patients are at
increased risk of developing a second melanoma. Patients have reported as many as 8 or more
primary melanomas. Multiple primaries especially are prevalent in patients with multiple dysplastic
nevi. The term familial atypical mole or melanoma (FAMM) syndrome is used to describe this
hereditary tendency to develop multiple dysplastic nevi and melanomas.

Sun exposure
Question the patient extensively about previous sun exposure, including severe sunburns in
childhood. The capacity to tan is also important, because individuals who tan easily are less likely to
develop a melanoma than those who burn easily.

Moles

Question the patient about any changes noted in moles. Any history of change in size, color, or
symmetry, as well as knowledge of bleeding or ulceration of the lesion must be obtained. Also elicit
any history or family history of multiple nevus syndrome.

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12/11/2019 Malignant Melanoma Clinical Presentation: History, Physical Examination

Physical Examination
Total body examination

A total-body skin examination is crucial when evaluating a patient with an atypical nevus or a
melanoma. The skin examination should be performed on initial evaluation of the patient and during all
subsequent visits. A study from a general dermatology practice found that most melanomas
diagnosed during a 3-year period were not the presenting complaint but were discovered only
because a dermatologist performed a total-body skin examination; moreover, these incidentally
discovered melanomas were more likely to be thinner or in-situ lesions. [16]

Crucial to a good skin examination is a well-lit examining room and a completely disrobed patient.

Serial photography and new techniques, such as epiluminescence microscopy and computerized
image analysis, are useful adjuncts. Epiluminescence microscopy uses a magnifying lens to examine
a lesion that has had oil applied. Computerized image analysis stores images of the lesions and
makes them available for comparison over time.

Skin examination

During a skin examination, assess the total number of nevi present on the patient's skin. Attempt to
differentiate between typical and atypical lesions. (The images below depict examples of melanomas.)
The ABCDs for differentiating early melanomas from benign nevi include the following:

A - Asymmetry (melanoma lesion more likely to be asymmetrical)

B - Border irregularity (melanoma more likely to have irregular borders)

C - Color (melanoma more likely to be very dark black or blue and to have variation in color than
would a benign mole, which more often is uniform in color and light tan or brown)

D - Diameter (mole < 6 mm in diameter usually benign)

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12/11/2019 Malignant Melanoma Clinical Presentation: History, Physical Examination

A 1.5-cm melanoma with characteristic asymmetry, irregular borders, and color variation.

Malignant melanoma. Image courtesy of Hon Pak, MD.

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12/11/2019 Malignant Melanoma Clinical Presentation: History, Physical Examination

Lentigo maligna melanoma, right lower cheek. The centrally located erythematous papule represents invasive
melanoma with surrounding macular lentigo maligna (melanoma in situ). Image courtesy of Susan M. Swetter, MD.

Lymph node examination

If a patient is diagnosed with a melanoma, examine all lymph node groups. Melanoma may
disseminate through the lymphatics, leading to the involvement of regional lymph nodes, and
hematogenously, leading to the involvement of any node basin in the body.

Differential Diagnoses

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