2.09 Nevi and Malignant Melanoma

Question 1

Examination of Nevi (ABCDEs)?

Answer 1

§Asymmetry
§Border irregularity
§Color variation
§Diameter (size/enlargement)
§Evolving (change in size, shape, color or a new lesion)

Question 2

Patient presents with:

Sharply circumscribed, Uniform colored papules or macules, Irregular surface with or w/out hair, Single or multiple, Size varies greatly

Answer 2

Melanocytic Nevus

Question 3

What are the 3 types of Acquired (Common Nevi)?

Answer 3

3 Types – Junctional, Compound, Dermal

Question 4

Patient presents with:
Nest in the epidermis and epidermis-dermal junction, Flat or slightly elevated. Light brown to brown-black w/ uniform pigmentation. Size

What kind of Melanocytic Nevus is it?

Answer 4

Junctional

Question 5

Patient presents with:
Nevus with nest into the upper dermis, Slightly elevated to dome shaped, smooth or warty surface, with or without hair. Uniformly round, oval, and symmetric.

What type of Melanocytic Nevus is it?

Answer 5

Compound

Question 6

Patient presents with:

All nevus cells in dermis, sometimes in fat cells, Dome-shaped (MC), verrucous, pedunculated, sessile (broad based), Skin colored to brown/black with hair, become lighter with age, Common in adults.

What type of Melanocytic Nevus is it?

Answer 6

Dermal

Question 7

How is congenital nevi categorized?

Answer 7

Small =

Medium=1.5-20cm

Large=>20cm

Question 8

Patient presents with:

Subtype of congenital melanocytic nevus??? Hairless, oval or irregularly shaped brown lesion, Dotted w/ darker brown to black spots (usually papular 1-3mm). MC in adolescence.

What is it?

Answer 8

Nevus Spilus

Aka… “speckled lentiginous nevus”

Question 9

Patient presents with:
Developmental Anomaly of adolescents – either a brown macule, a patch of hair or both (no nevus cells). Concurrent proliferation of hair, melanin, and smooth muscle. Upper back, shoulder, upper arm, submammary (MC areas); Unilateral. More common in men-? Hereditary, may start as café au lait

Answer 9

Becker’s Nevus

Question 10

How do you treat Becker’s Nevus?

Answer 10

Usually too large to remove with excision
Hair may be shaved or permanently removed
Laser tx for removal of hair and pigmentation

Question 11

Patient presents with:

One or more hypopigmented to white lesions that contain a central red, brown or black nevus (No melanocytes in halo). Nevus regresses and pigment returns. MC in adolescence and MC on truck. May herald onset of vitiligo

Answer 11

Halo Nevus

Question 12

Halo Nevus may be seen more frequently in what syndrome?

Answer 12

Seen more frequently in Turner’s Syndrome (45X) pt’s (short stature, gonadal dysgenesis, webbed neck, cubitus valgus, lymphedema at birth)

Question 13

Patient presents with:

A benign proliferation of epidermal cells, Hyperpigmented due to thickened epidermis, Verrucous or papillomatous eruption, In dermatomal, unilateral linear arrangement. Mostly on head and neck.

Answer 13

Linear Epidermal Nevus

Question 14

How and why do you treat a Linear Epidermal Nevus?

Answer 14

To decrease discomfort & improve cosmetic appearance
▪Cryosurgery
▪Partial thickness excision
▪Topical agents (5-FU, retiniods)
▪Laser

Question 15

Patient presents with:
Proliferation of sebaceous glands. Sharply demarcated, verrucous, yellow-orange plaque. MC location - scalp, neck -hairless. Hormonally responsive.

Birth - raised yellow-orange plaque without hair
Flattens within a few months as maternal hormones taper off. Remains as yellow or skin colored area of alopecia
At puberty area begins to rise and becomes verrucous

Answer 15

Nevus sebaceous

(organoid nevus)

Question 16

What % of Nevus sebaceous (organoid nevus) progress to cancer?

Answer 16

20%

Question 17

How do you treat Nevus sebaceous (organoid nevus)

Answer 17

Surgical excision during childhood
Plastic surgical excision is most effective tx
Clinical f/up

Question 18

Patient presents with:

Blue-black lesions dermal melanocytes (more flattened)
MC in scalp & persacral area, Backs of hands, Face/trunk in dermatomal pattern.
MC in Asians and Africans
Visible at birth to childhood, Appear blue-black due to “Tyndall effect” of melanin deeper in skin.

Answer 18

Mongolian Spot

Question 19

What is the Tyndall Effect?

Answer 19

Tyndall Effect – brown pigment absorbs the longer wavelengths of light and scatters blue light

Question 20

Patient presents with:

Blue-black pigmentation in distro of 1st - 2nd branch of trigeminal nerve. Affects the sclera, conjunctiva and skin around eye. No visual changes. Occur at birth or later, darkening with age. Common in Asians, esp. females

Answer 20

Nevus of Ota

Question 21

How do you treat nevus of Ota?

Answer 21

Laser to lighten lesions

Monitor patient for glaucoma

Question 22

Patient presents with:
Slightly elevated, round, regular nevus. Typically < 5mm. Large amounts of pigment in dermis, all races. MC on extremities & dorsum of hands. Often confused with malignant melanoma. Develop in childhood, Remain unchanged.

Answer 22

Blue Nevus

Question 23

Patient presents with:

Discrete lack of pigment due to reduction in or non-functioning of melanocytes. Dermatomal pattern, Bizarre, irreg. borders. Anywhere and is permanent

Answer 23

Nevus Depigmentosus

Question 24

Patient present with:

Usually >5mm, either flat or flat w/ raised center – “Fried Egg”. Darkly or irregularly pigmented. Shades of brown and pink. Irregular or indistinct borders. Begin to appear near puberty & continue to develop past the 4th decade.

Answer 24

Dysplastic (Atypical) Nevus

Question 25

How do you treat/manage Dysplastic Nevus?

Answer 25

§Excisional Bx with margins §Pt education on self-exam and sun avoidance §Consider baseline pictures §F/up at least annually ▪Dysplastic nevi are a “marker” for pts at risk for MM §Suggest screening for family members

Question 26

What is the Most deadly form of skin cancer?

Answer 26

Malignant Melanoma

Question 27

Malignant Melanoma is responsible for what % of skin cancer deaths?

Answer 27

Responsible for 75% of skin cancer deaths in US

Question 28

What are some risk factors for malignant melanoma?

Answer 28

§Personal H/O atypical moles, Fam H/O MM, & \>75-100 moles §Previous Non MM skin Ca §Congenital Nevus (Giant \>20cm) §H/O MM §FamHx of MM in 1’ relative §Immunosuppression §Clinically atypical Nevi (2-9) §Large # of Nevi §Chronic Tanning w/ UVA

Question 29

What is the MC distribution of malignant melanoma?

Answer 29

▪Back – MC for men ▪Arms & Legs – MC for women ▪Noncutaneous MM (mucosal) – more common in non-white populations

Question 30

How do you treat malignant melanoma?

Answer 30

§Biopsy ▪Excision for Dx purposes with narrow margins (2-3mm) ▪Punch Bx – suspicion for MM is low, lesion is large, or impractical to perform excision ▪NO shave Bx – partial removal = inadequate Breslow depth measurement §Interferon – later stages (Oncology) §Close f/up – teach self exam, Derm F/U q 3-4 months…

Question 31

What is the Breslow Microstage?

Answer 31

▪Breslow depth – most important histologic determinant of prognosis ▪Microscopic depth reported in mm’s

Question 32

What is the Clark Level?

Answer 32

▪Depth is reported by anatomic site ▪1. Epidermis, 2. Papillary Dermis, 3. Fills Papillary Dermis, 4. Reticular Dermis, 5. Enters SubQ Fat

Question 33

What are the 4 types of malignant melanoma and their prevalice?

Answer 33

§Spreading Superficial (70%) §Nodular (15-20%) §Lentigo maligna (10-15%) §Acrolentiginous (

Question 34

What is the most common type of melanoma? What is the hallmark?

Answer 34

Superficial Spreading Melanoma Hallmark is haphazard combo of many colors (more so with time)

Question 35

What melanoma presents with Completely vertical growth phase (no radial growth)?

Answer 35

Nodular

Question 36

Patient presents with: Lesion. May not be pigmented, but MC dark brown, red-brown, or red-black, Rapid growth, Ulcerates and bleeds. Most commonly misdiagnosed b/c it could resemble blood blister, hemangioma, dermal nevus, SK, or dermatofibroma

Answer 36

Nodular malignant melanoma

Question 37

What type of melanoma is a Lateral growth phase lesion?

Answer 37

Lentigo maligna (4-15%)

Question 38

Patient presents with: Palms, soles, terminal phalanges, and mucous membranes. Same colors and tendency to remain flat as Lentigo Maligna. Hutchinson’s sign. Very poor prognosis. Most common form in DPP (30-75%)

Answer 38

Acrolentiginous malignant melanoma

Question 39

Pigment spreads to proximal and lateral nail folds is called what? (Kind of sign)

Answer 39

Hutchinson’s sign (under nail plate) – pigment spreads to proximal and lateral nail folds

Question 40

What is the ABCDEF for DPP?

Answer 40

¡A-Age (5th-6th decades) ¡B-Brown or black band ¡C-Change - recent, sudden, or rapid development ¡D-Digit most commonly involved ¡E-Extension of brown pigment onto cuticle or where a hangnail may develop ¡F-Family hx or personal hx of unusual moles or MM

Question 41

Depth of invasion based on the Clark Level - important indicator of survival (5-year); what are the levels?

Answer 41

§Level I - restricted to epidermis – 98% §Level II - papillary dermis §Level III - fill papillary dermis §Level IV - reticular dermis §Level V - invade subcutis – 44%

Question 42

What is the Most important histologic determinant of prognosis?

Answer 42

¡Breslow microstage §Most important histologic determinant of prognosis §Determined by depth in mm at thickest point §Reported as “Breslow Level #mm”