Skin Lesion

James Warneke, MD University of Arizona

Mr. Smith
 Patient is a 64 year-old man with a history of a mole on his chest that has been present for years, but has recently grown is size. The mole has not bleed.

History
What other points of the history do you want to know?

MEDS. Smith Consider the Following  Characterization of symptoms  Temporal sequence  Alleviating / Exacerbating factors:  Pertinent PMH. ROS.History.  Relevant family hx.  Associated signs and symptoms . Mr.

History. Mr Smith  Characteristics of mole • Change in color • Nodular areas  Family History of melanoma  History of sun exposure and sunburns  History of previous atypical moles .

What is your Differential Diagnosis? .

Differential Diagnosis Based on History       Dysplastic Nevus Malignant Melanoma Basal Cell Carcinoma Squamous Cell Carcinoma Junctional Nevus Actinic Keratosis .

Physical Examination What would you look for? .

border irregularity. neck or groin . Mr. color variation and diameter greater than 6mm • Lymph nodes – none palpable in axilla. Smith  General: fair skin and blue eyes  Skin: Multiple moles and evidence or solar skin damage on face and arms • Large mole on anterior chest with • Asymmetry.Physical Examination.

Physical Examination .

Interventions at this point? .

Biopsy of Lesion     Biopsy thickest area Biopsy should be down to subcutaneous fat Biopsy entire lesion if small Large lesions should have punch biopsy or wedge  Orient extremity incisions in axial direction so re-excisions can be axial .

Would you like to revise your Differential Diagnosis? .

Results of Biopsy  Melanoma What is important to check on the pathology report? .

palms and sole of foot.Biopsy Results  Pattern of Melanoma • Superficial spreading – most common • Nodular – vertical growth • Acral lentiginous – nails. usually have in-situ precursor • Lentigo Maligna – in-situ melanoma in sun exposed area of the face and back of hand .

Biopsy Results  Breslow’s Thickness – measured with an optic micrometer  Clark’s Level • • • • • I II III IV V In-situ Papillary dermis Superficial reticular dermis Deep reticular dermis Subcutaneous fat .

regression.Biopsy Results  Ulceration of Epithelium  Other Factors – deep margin involved with melanoma. . lymphocytic infiltration.

Biopsy Results of Mr. Smith y Superficial spreading melanoma with areas of nodular invasion y Breslow’s thickness 2.5mm y Clark’s level IV y Non-ulcerated y Deep margin free of melanoma .

Laboratory and X-ray yWhat blood test should be ordered? yWhat X-ray studies are indicated? .

0mm .Laboratory and X-ray y Serum LDH is indicated for lesions deeper than 1.0mm y PA and Lateral Chest X-ray for lesions deeper than 1.

Smith y LDH is within normal limits y CXR shows no evidence of metastatic disease .Laboratory and X-ray of Mr.

Further Management What should be done next? .

Management Surgical Excision  How wide of an excision should be done?  When should a lymph node biopsy be planned? .

0 mm 2. Smith  Margin of excision should be 2.0 mm 1.0-2.0 cm margins Lesions >2.0mm 1.0 cm margins The depth of the excision is to the underlying fascia .0 cm margins Lesions 1.0-2.0 cm from all borders of the pigmented lesion • • • • Lesions <1.Management of Mr.

In this patient the lesion is wide.5-3.Management of Mr. the lateral edges are undermined for 2-3cm to allow the skin to stretch . Smith  For an acceptable cosmetic result. an ellipse of skin is usually excised with length 2.5 times the width. and the ellipse would be 6cm X 15cm  To close this defect primarily.

0mm do not need lymph nodes biopsied  Lesions >1. should have that lymph node biopsied .0mm thickness should have sentinel lymph node biopsy  All lesions which have an enlarged palpable lymph node in an adjacent lymph node basin.Evaluation of Lymph Nodes  Lesions <1.

Sentinel Lymph Node Biopsy  Lymphscintigraphy with Tc99 radiolabeled to colloid is done day of procedure to detect lymph drainage and to use intraoperatively with the gamma probe  Lymphazurin blue dye is injected into the dermis next to the melanoma to visually detect the sentinel lymph node .

Smith .Marking of Lymph Basin With Lymphscintigraphy in Mr.

Smith .Injection of Lymphazurin Blue Dye in Mr.

Smith’s Lymph Nodes .Evaluation of Mr.

Smith  Sentinel lymph node biopsy found two lymph nodes which where blue  Both blue lymph nodes were hot with the handheld gamma probe  Pathology by routine histology and immunohistochemistry did not detect any melanoma in the lymph nodes .Sentinel Lymph Nodes in Mr.

Smith’s Melanoma? .What Stage is Mr.

Smith’s Melanoma  Primary Tumor (T) 2.Staging of Mr.5mm with no  ulceration is T3a  Regional Lymph Nodes (N) no regional node metastasis is NO  Metastasis (M)  Stage is IIA none is MO T3a NO MO .

Prognosis  What is the estimated 10 year survival of Mr. Smith? .

and the negative sentinel nodes will have a increased survival to 80-90 % . Smith  Melanoma T3a with NO has a 10 year survival of 65%  With the inclusion of sentinel lymph node biopsy.10 Year Survival of Mr. the micrometastatic nodes with melanoma will have a worse prognosis of 50%.

Questions? .

200 new melanomas per year in US 7600 deaths from melanoma per year in US 1 in 57 white males 1 in 81 white females 89% 5-year survival for 1992-1998 .Summary of Melanoma      54.

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