The Journal of the Arkansas Medical Society Med Journal Feb 2019 Final 2 | Page 18

Special section where the JAMS will feature short dermatology cases.
Derm Dilemma: Melanoma
Kyle Sandiford, MD 1 ; Logan Rush, MD 2
Kevin St. Clair, MD
1
Candidate UAMS, class 2021
Resident, UAMS Dept of Dermatology
2
A
40-year-old male with no history of skin cancer presents with a dark “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:
What is your next step?
A. Reassurance that this is a benign seborrheic keratosis
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
D. Monitor with serial photographs
E. 3 mm punch biopsy of the darkest part of the lesion
Answer: C.
Discussion:
The lesion in the photograph is a melanoma, which is notorious for its’
risk of metastasis and attendant morbidity and mortality, Fortunately, most
melanomas are characterized by an initial “horizontal” growth phase dur-
ing which time local and distant metastasis is unlikely. Early recognition is
therefore critical. Melanoma incidence has increased considerably in the last
several decades, due at least in part to advances in detection and diagnosis.
Hand-held dermoscopes have lead to an improvement in distinction from
benign pigmented lesions and earlier recognition of melanoma; however,
186 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
dermatopathologic examination remains the gold standard in melanoma di-
agnosis. 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 dermatopathologist may determine the Breslow depth.
Later, when melanoma is confirmed, wide local excision is performed with
appropriate margins that are determined by the Breslow depth and other
histologic features. Sentinel lymph-node biopsy may be indicated, and
immunotherapuetic agents are available for metastatic disease.
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