Melanoma and Dermoscopy Richard P. Usatine, MD, FAAFP Professor, Family and Community Medicine Professor, Dermatology and Cutaneous Surgery Medical Director, University Skin Clinic University of Texas HSC, San Antonio Disclosure Statement: Co-President, Usatine Media medical app development company Author, medical books Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, Inc., Philadelphia. 2012. The Color Atlas of Family Medicine, 2 nd Edition. McGraw-Hill, New York, 2013 ABCDE's of melanoma. A - asymmetry. B - Border irregular. C - Color variation. D - Diameter > 6mm (pencil eraser). E Evolving, elevated, enlarging
Melanoma types Superficial spreading melanoma most common type, representing 70% Nodular melanoma - 15-30% Lentigo maligna melanoma 4-15% Acral lentiginous melanoma 2-8% Amelanotic melanoma rare Melanoma in-situ
Saucerization was done The National Comprehensive Cancer Network (NCCN) Melanoma Guidelines on the principles of biopsy Excisional biopsy (elliptical, punch [when whole lesion is small], or saucerization) with 1-3 mm margins is preferred. Avoid wider margins to permit accurate subsequent lymphatic mapping. Full-thickness incisional or punch biopsy of clinically thickest portion of the lesion is acceptable in certain anatomic areas (e.g., palm/sole, digit, face and ear) or for very large lesions. Shave biopsy [not saucerization or deep shave] may compromise pathologic diagnosis and complete assessment of Breslow thickness, but is acceptable when the index of suspicion is low. Coit DG, et al. NCCN Melanoma Panel. Melanoma. J Natl Compr Canc Netw. 2009 Mar;7(3):250-75. Saucerization of whole suspected melanoma is a recommended technique.
Punch biopsy The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma has been studied extensively by Ng, et al. in Australia. They found increased odds of histopathologic misdiagnosis were associated with punch biopsy of part of the melanoma (Odds Ratio, 16.6) and shallow shave biopsy (OR, 2.6) compared with excisional biopsy (including saucerization). Punch biopsy of part of the melanoma was also associated with increased odds of misdiagnosis with an adverse outcome (OR, 20). Arch Dermatol. 2010 Mar;146(3):234-9. Melanoma in-situ Melanoma in-situ
Superficial spreading melanoma
Nodular melanoma
Breslow depth is 8.5 mm with Clark s level V.
Clark s Level V 22 mm Lentigo maligna melanoma
Q: The best biopsy method for this suspected lentigo maligna melanoma is: 1. An elliptical excision with 3 mm margins 2. A 4 mm punch biopsy of the darkest portion 3. Three 2 mm punch biopsies 4. A broad shave biopsy The National Comprehensive Cancer Network (NCCN) Melanoma Guidelines on the principles of biopsy state: For lentigo maligna melanoma in situ, broad shave biopsy may help to optimize diagnosis. Coit DG, et al. NCCN Melanoma Panel. Melanoma. J Natl Compr Canc Netw. 2009 Mar;7(3):250-75. Lentigo maligna melanoma scalp 0.9 mm diagnosed with saucerization
Acral lentiginous melanoma ALM in situ parallel ridge
Acrolentiginous melanoma courtesy of Bob Gilson, MD and Usatine R, Pfenninger J, Stulberg D, Small R. Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, Inc., Philadelphia. 2012. Acrolentiginous melanoma of the thumb. Hyperpigmentation of the proximal nail fold (Hutchinson s sign) (Courtesy of Dr. Dubin at /www.skinatlas.com) Amelanotic melanoma Courtesy of EJ Mayeaux, MD
Melanoma - 1.5 mm depth on back of young Hispanic woman Dermoscopy FIGURE 32-1 ( A) Nonpolarized contact dermoscopes from Heine and Welch Allyn. (B) An assortment of polarized and hybrid dermoscopes from 3Gen. Usatine R, Pfenninger J, Stulberg D, Small R. Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, 2012. How can dermoscopy help? Helps differentiate benign from malignant lesions Miss less melanomas Biopsy less benign lesions Improves malignant to benign biopsy ratio
SK BCC melanoma Amelanotic melanoma Dermoscopy - Courtesy of Ash Marghoob, MD network streaks Blue-white veil Structureless areas Regression structures (peppering) Pathology diagnosis: Melanoma 0.55mm
Ugly Duckling or Outlier Lesion Courtesy of Ash Marghoob, MD This process is hardwired in all of us
Identify the ugly duckling A B C D Identify the ugly duckling A B D C Identify the ugly duckling C A B D
Identify the ugly duckling B A C D Surgery Literature Dogma about needing to do a whole elliptical excision for suspected melanoma is gone. There is evidence that a saucerization (scoop or deep shave biopsy) leads to an accurate diagnosis and staging 97% of the time Zager JS, et al. Shave biopsy is a safe and accurate method for the initial evaluation of melanoma. J. Am. Coll. Surg. 2011; 212(4):454 60 Biopsy to Diagnose Melanoma Excise full lesion if it is small using a punch biopsy or saucerization If lesion is large, perform a punch biopsy or saucerization of the darkest and thickest portion (or directed by dermoscopy) If partial biopsy is negative and lesion is still suspicious, excise the whole lesion to avoid a false negative Tumor depth will then determine the width of the margins needed
Margins for Tx Melanoma WHO recommendations: 5 mm for in situ lesions 1 cm for malignant lesions less than 1.5 mm in depth 2 cm margins for melanomas greater than 1.5 mm in thickness Some groups use 1 mm cut-off for change in margin from 1 to 2 cm Sentinel lymph node biopsies For tumors of greater than or equal to 1 mm in depth. (SOR= A) Melanomas with ulceration or areas of regression Metastatic workup if lymph node is positive Regular sunscreen use by white adults decreases the occurrence of: invasive cutaneous melanoma SCC Not proven for BCC
SLIP, SLOP, SLAP!!! SLIP on a shirt SLOP on sunscreen SLAP on a hat and POP some Vitamin D Conclusion Prevent skin cancers by risk factor reduction Early detection of pre-cancers and skin cancers can prevent morbidity and mortality Biopsy suspicious lesions and don t be afraid to do a deep shave (saucerization) It is fast and easy and will keep you from missing melanomas because you didn t have the time or equipment to do a full elliptical excision. Consider learning dermoscopy to increase your accuracy in diagnosis Online resources INFORMED: Melanoma and Skin Cancer Early Detection education series: http://www.skinsight.com/info/for_professional s/skin-cancer-detection-informed/skin-cancereducation National Cancer Institute http://www.cancer.gov/cancertopics/types/mel anoma The Skin Cancer Foundation - http://www.skincancer.org American Cancer Society - http://www.cancer.org/cancer/skincancermelanoma/index
Additional References Usatine R, Pfenninger J, Stulberg D, Small R. Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, Inc., Philadelphia. 2012. American Academy of Dermatology. Guidelines of care for the management of primary cutaneous melanoma. JAAD. 2011 Nov;65(5):1032-47. Evidence-based treatment of early-stage melanoma. J Surg Oncol. 2011 Sep;104(4):341-53. Skin cancer education for primary care physicians: a systematic review of published evaluated interventions. J Gen Intern Med. 2011 Sep;26(9):1027-35. Topical imiquimod or fluorouracil therapy for basal and squamous cell carcinoma: a systematic review. Arch Dermatol. 2009 Dec;145(12):1431-8. Ng JC, Swain S, Dowling JP, Wolfe R, Simpson P, Kelly JW. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol. 2010 Mar;146(3):234-9. Coit DG, Andtbacka R, Bichakjian CK, et al. NCCN Melanoma Panel. Melanoma. J Natl Compr Canc Netw. 2009 Mar;7(3):250-75.