Updated: 6/14/2018

Melanoma

Topic
Review Topic
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Questions
5
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Evidence
5
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Snapshot
  • A 46-year old woman presents to office complaining of a dark spot on the back of her right hand. She states that the spot first appeared about 2 years ago and has slowly been growing. It doesn't burn, itch, or sting. She has a history of regular sun-tanning and minimal sunscreen use. On exam, you note a 2 cm asymmetric thin brownish-blue plaque with somewhat ill-defined borders and an irregular pattern of coloration.
Introduction
  • An aggressive skin malignancy of melanocytic origin 
  • Epidemiology
    • risk factors
      • previous melanoma
      • light skin
      • sun exposure
      • family history
      • xeroderma pigmentosum
      • large number of nevi
        • dysplastic nevi are a precursor
  • Genetics
    • majority of tumors have a mutation in the BRAF gene (protein kinase) 
    • specific mutation is the Val to Glu at position 600 
  • Pathophysiology
    • growth phases
      • radial
        • first phase
        • spreads laterally within the epidermis
        • non-metastatic
      • vertical
        • second phase
        • breaches the dermis and extends into deeper layers of skin
        • metastatic potential
  • Prognosis
    • depth (Breslow thickness)    
      •  most important prognostic factor 
Classification
  • Types
    • superficial spreading melanoma 
      • irregular brown-black to red plaque
      • found on limbs and back
      • most frequent type
    • lentigo maligna melanoma 
      • irregular, superficial brown-black to red-white plaque
      • found on face
      • seen in elderly patients
    • nodular melanoma 
      • blue-black, smooth or eroded nodule with deep vertical invasion
      • found on trunk
      • no radial phase leading to undetected metastasis
    • acral lentiginous melanoma 
      • irregular black to white plaque with erosion
      • found on palms and plantar surface of feet
      • not caused by sun exposure
      • seen in black and Asian populations
Presentation
  • Symptoms
    • a pigmented lesion that have recently changed shape or size
  • Physical exam (ABCDEs)  
    • Asymmetry
    • Border irregularity
    • Color variation
    • Diameter (<6mm benign)
    • Elevation
Evaluation
  • Biopsy
    • marked cellular atypia
    • invasion into the dermis
    • vacuolated cytoplasm
    • hyperchromatic nuclei with prominent nucleoli
  • S-100 tumor marker
Treatment
  • Surgical
    • primary excision with histologically negative margin
      • margins for invasive melanoma should be >1 cm and <2 cm around tumor
    • lymph node dissection
      • indications
        • metastases
  • Chemotherapy
    • vemurafenib
      • targeted BRAF inhibitor towards BRAF-mutation positive tumor
    • indications
      • metastases
  • Prevention
    • daily sunscreen use 
    • limit direct sun exposure to <30 minutes/day
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.ON.19) A 63-year-old male has been referred to the dermatologist for evaluation of a concerning skin lesion (pictured in Figure A). The man first noticed the lesion years ago, but believes it has changed in the last 2 months. He notes it is changing color and has become itchy. He is very concerned because his mother was diagnosed with basal cell carcinoma in her 60s. As the dermatologist, which of the following factors is most important for prognosis of this lesion? Review Topic

QID: 103812
FIGURES:
1

Depth of invasion of the lesion

83%

(129/156)

2

Number of dysplastic cells within the lesion

8%

(13/156)

3

Patient's age

1%

(1/156)

4

Pruritic lesion

0%

(0/156)

5

Patient's family history

6%

(10/156)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.ON.1) A 52-year-old Caucasian male presents to your office with an 8 mm dark lesion on his back. The lesion, as seen below, has irregular borders and marked internal color variation. Upon excisional biopsy, the presence of which of the following would best estimate the risk of metastasis in this patient’s lesion: Review Topic

QID: 101307
FIGURES:
1

Palisading nuclei

10%

(2/21)

2

Keratin pearls

0%

(0/21)

3

Vertical tumor growth

67%

(14/21)

4

Cellular atypia

14%

(3/21)

5

Increased production of melanosomes

10%

(2/21)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M1.ON.1) A 61-year-old Caucasian male presents to your office complaining of morning headaches of 6 weeks duration. A head MRI reveals a likely metastasis of unknown origin in the supratentorial region of the brain. On biopsy, the neoplastic mass is shown to have a mutation in BRAF, a protein kinase, in which a glutamic acid is substituted for valine at position 600 of the protein. Where did this metastasis most likely originate? Review Topic

QID: 101301
1

Stomach

7%

(9/135)

2

Breast

11%

(15/135)

3

Bone

17%

(23/135)

4

Skin

63%

(85/135)

5

Brain

1%

(1/135)

M1

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PREFERRED RESPONSE 4
ARTICLES (5)
Topic COMMENTS (9)
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