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
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI 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/LFemale: 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/mLFemale: 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/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative 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/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 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/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 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/minFemale: 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 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 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 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Palisading nuclei 10% (2/20) 2 Keratin pearls 0% (0/20) 3 Vertical tumor growth 65% (13/20) 4 Cellular atypia 15% (3/20) 5 Increased production of melanosomes 10% (2/20) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Depth of invasion of the lesion 82% (121/147) 2 Number of dysplastic cells within the lesion 9% (13/147) 3 Patient's age 1% (1/147) 4 Pruritic lesion 0% (0/147) 5 Patient's family history 6% (9/147) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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 6% (8/130) 2 Breast 12% (15/130) 3 Bone 18% (23/130) 4 Skin 62% (81/130) 5 Brain 1% (1/130) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4