The Journal of the Arkansas Medical Society Med Journal Dec 2019 | Page 6

Special Section: Short Dermatological Cases
Derm Dilemma: Melanoma
Kyle Sandiford
Candidate, UAMS Class 2021
Logan Rush, MD
Resident, UAMS Department of Dermatology
Kevin St. Clair, MD
A
40-year-old male with no history of D. Monitor with serial photographs
skin cancer presents with a dark E. 3 mm punch biopsy of the darkest part of the
lesion
“mole” on his left posterior shoulder. It
is asymptomatic and has never bled, but his spouse
has noticed enlargement over the past nine months.
Clinical and dermoscopic photographs are below:
Answer: C.
What is your next step?
A. Reassurance that this is a benign seborrheic
keratosis
Discussion:
B. Excisional biopsy with 3 cm margins at time of
presentation
C. Excisional biopsy of visible pigment, or if not
feasible because of lesion size, a shave biopsy
with the saucerization method
NOT JUST A LAW FIRM.
When it comes to helping
physicians we got you covered.
At Mitchell Blackstock we are not only a law
firm, we are lobbyists and consultants. Our
team has years of experience in law, politics,
management, public and private enterprise,
and for-profit and non-profit businesses. We
understand the real-world problems you face
and how to address them in a complex legal,
political, and regulatory environment.
PRACTICE AREAS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Health Law and Policy
Labor and Employment Law
Professional Licensure and Ethics
Education Law
Personal Injury
Whistleblower and Qui Tam Cases
Divorce and Family Law
Business Litigation
Creditor Rights
Child Maltreatment
Medical Malpractice Defense
Real Estate
Criminal Law
Wills, Estates, Asset Protection
1010 West Third St.
Little Rock, AR 72201
501.378.7870
501.375.1940 (fax)
www.mitchellblackstock.com
126 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The lesion in the photograph is a melanoma,
which is notorious for its risk of metastasis and at-
tendant morbidity and mortality. Fortunately, most
melanomas are characterized by an initial “horizon-
tal” growth phase, during which time local and distant
metastasis is unlikely. therefore, early recognition is
critical. Melanoma incidence has increased consider-
ably in the last several decades, due at least in part
to advances in detection and diagnosis. Hand-held
dermoscopes have led to improvement in distinction
from benign pigmented lesions and earlier recognition
of melanoma; however, dermatopathologic examina-
tion remains the gold standard in melanoma diagno-
sis. Vertical tumor thickness, or Breslow depth, is the
most important prognostic factor.
Clinically, melanoma is often characterized by
the ABCD’s:
A Asymmetry
B Border irregularity
C Color (dark, but not uniform)
D Diameter > 6mm; continuing enlargement
If possible, smaller suspected melanomas should
be excised completely at the time of presentation. For
larger lesions where complete excision is not feasible,
a deep shave biopsy (“saucerization”) method may
be employed. Care must be taken not to transect the
pigmented lesion at the deep margin, so that the der-
matopathologist may determine the Breslow depth.
Later, when melanoma is confirmed, wide local exci-
sion is performed with appropriate margins that are
determined by the Breslow depth and other histologic
features. Sentinel lymph node biopsy may be indicat-
ed, and immunotherapeutic agents are available for
metastatic disease.
VOLUME 116