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Melanoma
Basic Dermatology Curriculum
Updated August 22, 2011
1
Module Instructions
 The following module contains a number of
underlined terms which are hyperlinked to
the dermatology glossary, an illustrated
interactive guide to clinical dermatology and
dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
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Goals and Objectives
 The purpose of this module is to help medical
students develop a clinical approach to the evaluation
and initial management of patients with lesions
suspicious for melanoma.
 By completing this module, the learner will be able to:
• Identify and describe the morphology of melanoma
• Recall prognostic factors in melanoma survival
• Practice providing patient education on the ABCDEs of
melanoma and skin self-examinations
• Determine when to refer patients with suspicious skin
lesions to dermatology
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Clinical Case: History
 Ms. Cary is a 40-year-old
woman who presents to
the dermatology clinic with
a dark mole on her back.
 She has had this new
mole for several months.
She is not sure if it has
changed in any way. It is
not painful or itchy and it
has never bled.
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History Continued
 Past Medical History
• Usually burns, rarely tans (Fitzpatrick skin type II)
• Sun bathed and used tanning booths as a teen
• No history of skin cancer
 Medications
• None
 Family History
• Mother had some kind of skin cancer removed from her cheek;
diagnosis unknown
 Social History
• Married with 2 children. 10 pack-year smoking history. Uses alcohol
occasionally; no illicit drug use
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Skin Exam
© 2009 A. Garg, MD
© 2009 A. Garg, MD
How would you describe her pigmented lesion?
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1.8 x 0.9 cm dark blue
to black plaque
demonstrating
asymmetry, irregularly
notched borders and a
pink erythematous rim
© 2009 A. Garg, MD
Skin Exam
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Differential Diagnosis
What is your differential
diagnosis?
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Differential Diagnosis
 What is your differential diagnosis?
• Basal cell carcinoma
• Dermatofibroma
• Melanoma
• Melanocytic Nevus
• Seborrheic keratosis
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Management
 What is your next step in management?
a. Excisional biopsy
b. Liquid nitrogen cryotherapy
c. Photograph the lesion and have the
patient return in two months
d. Topical Imiquimod
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Management
Answer: a
 What is your next step in management?
a. Excisional biopsy (Excisional biopsy is the best way of making a
diagnosis of suspicious pigmented lesions)
b. Liquid nitrogen cryotherapy (You should not treat a pigmented
skin lesion without knowing what it is. First, you must rule out skin
cancers that can be black including melanoma and pigmented
basal cell carcinoma)
c. Photograph the lesion and have the patient return in two months
(This lesion is highly suspicious and must be removed or referred
to a dermatologist for evaluation)
d. Topical Imiquimod (You should not treat a pigmented skin lesion
without knowing what it is)
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Biopsy Videos
 Click here to watch a video on obtaining
informed consent
 Click here to watch a video on local
anesthesia
 Click here to watch a video on how to
perform an excisional biopsy
 Click here to watch a video on pathology
requests
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Biopsy reveals…
• Lesion is
asymmetric (the
left side does not
match the right
side) as indicated
by the circles
• Melanocytes are
grouped in nests
in the dermis
Insert path image for melanoma
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On high-power view…
• Melanocytes (arrows)
present in the upper
portions of the
epidermis. This is
abnormal as
melanocytes normally
reside in the basal layer.
• Their nuclei are large
and of different shapes;
this is abnormal and is
known as “cytologic
atypia”
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Diagnosis
 What is your diagnosis? Click on the
correct answer.
a. Basal Cell Carcinoma
b. Dermatofibroma
c. Melanoma
d. Melanocytic nevus, acquired
e. Seborrheic keratosis
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Diagnosis
That was incorrect. Try Again.
a. Basal Cell Carcinoma
b. Dermatofibroma
c. Melanoma
d. Melanocytic nevus, acquired
e. Seborrheic keratosis
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Melanoma
Your diagnosis is correct!
a. Basal Cell Carcinoma
b. Dermatofibroma
c. Melanoma
d. Melanocytic nevus, acquired
e. Seborrheic keratosis
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Melanoma: Epidemiology
 In 2008, there were approximately 62,480 new
cases of melanoma and 8,420 deaths from
melanoma in the US
 The lifetime risk of melanoma has increased over
time
• 1 in 1500 of persons born in the early 1900s
• 1 in 65 of persons born in 2005
 Melanoma affects all ages
• It is the most common cancer among young women
between the ages of 25 and 29
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Melanoma: Pathogenesis
 Cell of origin: melanocyte
 Etiology:
• Cumulative and prolonged UVB and/or UVA
exposure
• UVA exposure from tanning beds increases
risk for melanoma
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Melanoma: Risk Factors
 Individual risk factors for development of melanoma
•
•
•
•
•
•
Increasing age
Fair skin; blue eyes, red or blond hair; freckling
Greater than 100 acquired nevi
Atypical nevi
Immunosuppression
Personal or family history of melanoma (two or more 1st
degree relatives)
• Ultraviolet exposure: Risk directly related to # of severe
blistering sunburns before puberty; tanning booth use
• Genetic syndromes
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Heredity of Melanoma
 10 % of melanomas are familial and have a
genetic basis
 The genes CDKN2A and CDK4 together make up
50% of all inherited familial cases
 Other identified genes include p53, BRCA2
 50% of familial melanoma patients have no
identified mutation – i.e., their genes have not
been identified yet
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Melanoma:
Clinical Manifestations
 May cause symptoms, but usually asymptomatic
 May develop de novo or arise within a pre-existing nevus
 Majority located in sun-exposed areas, but also occur in nonsun-exposed areas, such as the buttock
• Also occur on mucous membranes (mouth, genitalia)
 Typically appears as a pigmented
papule, plaque or nodule.
 Demonstrates any of the ABCDEs
• It may bleed, be eroded or crusted
• Patients may give history of change
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Melanoma:
Clinical & Histologic Subtypes
See the following slides to learn about each subtype
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Melanoma: Superficial Spreading
 Superficial
spreading type
• Most common type
• Involves back in men;
back and legs in
women
• Growth of tumor is
primarily horizontal
rather than down into
the dermis
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Melanoma: Nodular
 Nodular type
• Rapid growth
• Growth is vertical, giving
tumor an increased
Breslow’s depth
• Breslow’s depth =
thickness of the primary
melanoma measured
from the granular layer of
the epidermis to the
deepest part of the tumor
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Melanoma: Lentigo Maligna
 Lentigo maligna type
• Occurs on chronically
sun-damaged skin, more
common in elderly
patients
• Slow progression
• Growth of tumor is
primarily horizontal, and
not vertical
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Melanoma: Acral Lentiginous
 Acral lentiginous type
• More common in people
with darker skin color
(Asians and persons of
African ancestry)
• Diagnosis is often delayed,
so lesions tend to be many
centimeters in diameter
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Melanoma: Amelanotic
 Amelanotic type
• Morphologic appearance is variable, and the
clinical appearance of pigment is subtle or
often absent
• As such, the lesion may be confused with a
variety of benign lesions, such as psoriasis
or dermatitis
• This lesion may also be confused with a
variety of malignant lesions, such as
squamous cell carcinoma in situ or basal
cell carcinoma
• This is a difficult diagnosis to make, which is
why it is important to biopsy when unsure of
the diagnosis
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Back to Our Case
 The diagnosis of melanoma should prompt
referral to a dermatologist or a multispecialty melanoma clinic
 Ms. Cary is doing well after wide local
excision with sentinel lymph node
evaluation, which was negative.
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Management & Follow-up
 For melanomas, a multidisciplinary approach is
often taken.
 At follow-up visits you perform total body skin
exams, which include inspection of the scalp,
genitalia, palms and soles, nails and mucous
membranes.
 You also counsel Ms. Cary on the importance of
continued sun protection, skin self-exams, and
regular follow-ups with the dermatologist
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The Skin Exam
 A history of skin cancer or suspected skin cancer is
an indication to perform a Total Body Skin Exam
(TBSE)
 Click here to view a video on the TBSE
 The TBSE is often performed in the dermatology
clinic, however, a full skin exam can and should be
done in other clinical settings
 A “head to toe” approach of the skin exam easily
incorporates into the full physical exam
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What to look for on the skin exam
The ABCDE mnemonic is a useful tool
for remembering what features to pay
attention to in evaluating pigmented
lesions
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The ABCDEs of Melanoma
Suspicious moles may have any of the following features:
ASYMMETRY
• With regard to shape or color
BORDER
• Irregular or notched
COLOR
• Very dark or variegated colors
• Blue, Black, Brown, Red, Pink, White
DIAMETER
• >6 mm, or “larger than a pencil eraser”
• Diameter that is rapidly changing
EVOLVING
• Evolution or change in any of the ABCD features
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Practice the ABCDEs with this
Evolving Lesion
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Melanoma: Patient Education
 There are multiple resources to help educate
patients about sun safety and skin cancer
prevention, including:
• American Academy of Dermatology: Skin
Cancer Prevention
• American Cancer Society: Skin Cancer
Prevention and Early Detection
 The following slides are adapted from the AAD Be
Sun Smart® program
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Patient Education:
Be Sun Smart®
 Generously apply a broad-spectrum, water-resistant
sunscreen with a Sun Protection Factor (SPF) of 30 or more
to all exposed skin.
• “Broad-spectrum” provides protection from both UVA and UVB rays.
• Reapply approximately every two hours, even on cloudy days, and
after swimming or sweating.
 Wear protective clothing, such as a long-sleeved shirt,
pants, a wide-brimmed hat, and sunglasses.
 Seek shade.
• Remember that the sun's rays are strongest between 10 AM – 4PM.
• If your shadow appears to be shorter than you are, seek shade.
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Patient Education:
Be Sun Smart®
 Use extra caution near water, snow, and sand because
they reflect and intensify the damaging rays of the sun, which
can increase your chances of a sunburn.
 Get vitamin D safely through a healthy diet that may include
vitamin supplements. Don't seek the sun.
 Avoid tanning beds. Ultraviolet light from the sun and
tanning beds can cause skin cancer and wrinkling. If you want
to look tan, consider using a self-tanning product, but
continue to use sunscreen with it.
 Check your birthday suit on your birthday. If you notice
anything changing, growing, or bleeding on your skin, see a
dermatologist.
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How to perform a skin selfexamination
Examine your body front
and back in the mirror,
then look at the right
and left sides with your
arms raised.
Look at the backs of
your legs and feet, the
spaces between your
toes, and the soles of
your feet.
Bend elbows and look
carefully at forearms,
upper underarms, and
palms.
Examine the back of
your neck and scalp
with a hand mirror.
Part hair for a closer
look.
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Melanoma: Course & Prognosis
 Melanoma has high cure rates if diagnosed and treated early
 Key prognostic factors for primary tumor
• Thickness or depth of tumor invasion is the single most
important prognostic factor for survival and clinical management
• Survival decreases with increasing Breslow’s depth
• Ulceration – confers a higher risk for developing advanced disease
• Mitotic rate – considered an independent prognostic risk factor in
melanoma survival
• Lymphatic involvement – presence of regional lymph node metastasis
portends a worse prognosis
• Metastases – presence of distant metastases portends the worst
prognosis
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Take Home Points
 Melanoma is a common and deadly cancer
 Physicians should integrate a skin exam into the
routine visit
 Patient education is a crucial component to skin
cancer prevention
 Suspect pigmented lesions may be identified
through the ABCDEs of melanoma
 Suspicion or diagnosis of melanoma should
prompt immediate referral to a dermatologist
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Acknowledgements
 This module was developed by the American Academy
of Dermatology Medical Student Core Curriculum
Workgroup from 2008-2012.
 Primary authors: Amit Garg, MD, FAAD; Lisa Nguyen,
MD; Meera Mahalingam, MD
 Contributor: Sarah D. Cipriano, MD, MPH
 Peer reviewers: Patrick McCleskey, MD, FAAD; Carlos
Garcia, MD; Timothy G. Berger, MD, FAAD
 Revisions and editing: Sarah D. Cipriano, MD, MPH;
Alina Markova. Last revised in August 2011.
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References

American Academy of Dermatology. ‘Be Sun Smart.’ http://www.aad.org/skincare-and-safety/skin-cancer-prevention/be-sun-smart; 2011.

Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based
Illustrated Clinical Dermatology Glossary. MedEdPORTAL.
www.mededportal.org/publication/462; 2007.

National Institutes of Health. ‘Melanoma.’ Comprehensive Cancer Information National Cancer Institute. www.cancer.gov/cancertopics/types/melanoma; 2011.

Ragel EL, et al. Cutaneous melanoma: Update on prevention, screening,
diagnosis, and treatment. Am Fam Physician. 2005; 15:269-276.

Wolff K, Johnson RA, Suurmond D editor. Fitzpatrick's color atlas and synopsis of
clinical dermatology. 5th ed.. New York: McGraw-Hill; 2005.

Wolff K et al., Fitzpatrick's Dermatology in General Medicine, 7th ed., New York:
McGraw-Hill; 2008.
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Additional Resources
 Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules:
70-Year-Old Man with a Red Crusty Bump on his Right Arm.
MedEdPORTAL; 2010.
http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/
?subid=8055.
 Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules:
62-Year-Old Man With a Facial Growth. MedEdPORTAL; 2010.
http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/
?subid=7751.
 Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules:
40-year-old Woman with a Dark Mole. MedEdPORTAL; 2010.
http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/
?subid=8067.
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