1. Medical Student Core Curriculum In Dermatology
Melanoma
Medical Student Core Curriculum
In Dermatology
Updated August 22, 2011

2. Module Instructions
The following module contains a number of underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.
We encourage the learner to read all the hyperlinked information.

3. Goals and Objectives
The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients with lesions suspicious for melanoma.
By completing this module, the learner will be able to:
Identify and describe the morphology of melanoma
Recall prognostic factors in melanoma survival
Practice providing patient education on the ABCDEs of melanoma and skin self-examinations
Determine when to refer patients with suspicious skin lesions to dermatology

4. Clinical Case: History
Ms. Cary is a 40-year-old woman who presents to the dermatology clinic with a dark mole on her back.
She has had this new mole for several months. She is not sure if it has changed in any way. It is not painful or itchy and it has never bled.

5. History Continued Past Medical History Medications Family History
Usually burns, rarely tans (Fitzpatrick skin type II)
Sun bathed and used tanning booths as a teen
No history of skin cancer
Medications
None
Family History
Mother had some kind of skin cancer removed from her cheek; diagnosis unknown
Social History
Married with 2 children. 10 pack-year smoking history.
Health-related Behavior
Uses alcohol occasionally; no drug use

6. How would you describe her pigmented lesion?
Skin Exam
How would you describe her pigmented lesion?
© 2009 A. Garg, MD
© 2009 A. Garg, MD

7. Skin Exam
1.8 x 0.9 cm dark blue to black plaque demonstrating asymmetry, irregularly notched borders and a pink erythematous rim
© 2009 A. Garg, MD

8. Differential Diagnosis
What is your differential diagnosis?

9. Differential Diagnosis
What is your differential diagnosis?
Basal cell carcinoma
Dermatofibroma
Melanoma
Melanocytic Nevus
Seborrheic keratosis

10. Management What is your next step in management? Excisional biopsy
Liquid nitrogen cryotherapy
Photograph the lesion and have the patient return in two months
Topical Imiquimod

11. Management Answer: a What is your next step in management?
Excisional biopsy (Excisional biopsy is the best way of making a diagnosis of suspicious pigmented lesions)
Liquid nitrogen cryotherapy (You should not treat a pigmented skin lesion without knowing what it is. First, you must rule out skin cancers that can be black including melanoma and pigmented basal cell carcinoma)
Photograph the lesion and have the patient return in two months (This lesion is highly suspicious and must be removed or referred to a dermatologist for evaluation)
Topical Imiquimod (You should not treat a pigmented skin lesion without knowing what it is)

12. Biopsy Videos
Click here to watch a video on obtaining informed consent
Click here to watch a video on local anesthesia
Click here to watch a video on how to perform an excisional biopsy
Click here to watch a video on pathology requests

13. Biopsy reveals…
Lesion is asymmetric (the left side does not match the right side) as indicated by the circles
Melanocytes are grouped in nests in the dermis
Insert path image for melanoma

14. On high-power view…
Melanocytes (arrows) present in the upper portions of the epidermis. This is abnormal as melanocytes normally reside in the basal layer.
Their nuclei are large and of different shapes; this is abnormal and is known as “cytologic atypia”

15. Diagnosis What is your diagnosis? Click on the correct answer.
Basal Cell Carcinoma
Dermatofibroma
Melanoma
Melanocytic nevus, acquired
Seborrheic keratosis

16. Diagnosis That was incorrect. Try Again. Basal Cell Carcinoma
Dermatofibroma
Melanoma
Melanocytic nevus, acquired
Seborrheic keratosis

17. Melanoma Your diagnosis is correct! Basal Cell Carcinoma
Dermatofibroma
Melanoma
Melanocytic nevus, acquired
Seborrheic keratosis

18. Melanoma: Epidemiology
In 2008, there were approximately 62,480 new cases of melanoma and 8,420 deaths from melanoma in the US
The lifetime risk of melanoma has increased over time
1 in 1500 of persons born in the early 1900s
1 in 65 of persons born in 2005
Melanoma affects all ages
It is the most common cancer among young women between the ages of 25 and 29

19. Melanoma: Pathogenesis
Cell of origin: melanocyte
Etiology:
Cumulative and prolonged UVB and/or UVA exposure
UVA exposure from tanning beds increases risk for melanoma

20. Melanoma: Risk Factors
Individual risk factors for development of melanoma
Increasing age
Fair skin; blue eyes, red or blond hair; freckling
Greater than 100 acquired nevi
Atypical nevi
Immunosuppression
Personal or family history of melanoma (two or more 1st degree relatives)
Ultraviolet exposure: Risk directly related to # of severe blistering sunburns before puberty; tanning booth use
Genetic syndromes

21. Heredity of Melanoma
10 % of melanomas are familial and have a genetic basis
The genes CDKN2A and CDK4 together make up 50% of all inherited familial cases
Other identified genes include p53, BRCA2
50% of familial melanoma patients have no identified mutation – i.e., their genes have not been identified yet

22. Melanoma: Clinical Manifestations
May cause symptoms, but usually asymptomatic
May develop de novo or arise within a pre-existing nevus
Majority located in sun-exposed areas, but also occur in non- sun-exposed areas, such as the buttock
Also occur on mucous membranes (mouth, genitalia)
Typically appears as a pigmented papule, plaque or nodule.
Demonstrates any of the ABCDEs
It may bleed, be eroded or crusted
Patients may give history of change

23. Melanoma: Clinical & Histologic Subtypes
See the following slides to learn about each subtype

24. Melanoma: Superficial Spreading
Superficial spreading type
Most common type
Involves back in men; back and legs in women
Growth of tumor is primarily horizontal rather than down into the dermis

25. Melanoma: Nodular Nodular type Rapid growth
Growth is vertical, giving tumor an increased Breslow’s depth
Breslow’s depth = thickness of the primary melanoma measured from the granular layer of the epidermis to the deepest part of the tumor

26. Melanoma: Lentigo Maligna
Lentigo maligna type
Occurs on chronically sun-damaged skin, more common in elderly patients
Slow progression
Growth of tumor is primarily horizontal, and not vertical

27. Melanoma: Acral Lentiginous
Acral lentiginous type
More common in people with darker skin color (Asians and persons of African ancestry)
Diagnosis is often delayed, so lesions tend to be many centimeters in diameter

28. Melanoma: Amelanotic Amelanotic type
Morphologic appearance is variable, and the clinical appearance of pigment is subtle or often absent
As such, the lesion may be confused with a variety of benign lesions, such as psoriasis or dermatitis
This lesion may also be confused with a variety of malignant lesions, such as squamous cell carcinoma in situ or basal cell carcinoma
This is a difficult diagnosis to make, which is why it is important to biopsy when unsure of the diagnosis

29. Back to Our Case
The diagnosis of melanoma should prompt referral to a dermatologist or a multi-specialty melanoma clinic
Ms. Cary is doing well after wide local excision with sentinel lymph node evaluation, which was negative.

30. Management & Follow-up
For melanomas, a multidisciplinary approach is often taken.
At follow-up visits you perform total body skin exams, which include inspection of the scalp, genitalia, palms and soles, nails and mucous membranes.
You also counsel Ms. Cary on the importance of continued sun protection, skin self-exams, and regular follow-ups with the dermatologist

31. The Skin Exam
A history of skin cancer or suspected skin cancer is an indication to perform a Total Body Skin Exam (TBSE)
Click here to view a video on the TBSE
The TBSE is often performed in the dermatology clinic, however, a full skin exam can and should be done in other clinical settings
A “head to toe” approach of the skin exam easily incorporates into the full physical exam

32. What to look for on the skin exam
The ABCDE mnemonic is a useful tool for remembering what features to pay attention to in evaluating pigmented lesions

33. The ABCDEs of Melanoma Suspicious moles may have any of the following features:
ASYMMETRY
With regard to shape or color
BORDER
Irregular or notched
COLOR
Very dark or variegated colors
Blue, Black, Brown, Red, Pink, White
DIAMETER
>6 mm, or “larger than a pencil eraser”
Diameter that is rapidly changing
EVOLVING
Evolution or change in any of the ABCD features

34. Practice the ABCDEs with this Evolving Lesion

35. Melanoma: Patient Education
There are multiple resources to help educate patients about sun safety and skin cancer prevention, including:
American Academy of Dermatology: SPOT Skin Cancer™ initiative
American Cancer Society: Skin Cancer Prevention and Early Detection
The following slides are adapted from the AAD SPOT Skin Cancer™ program and reflect recent, Board-approved changes to public messages about sun safety:

36. Patient Education: SPOT Skin Cancer™
Seek shade when appropriate. Remember that the sun’s rays are strongest between 10 a.m. and 2 p.m. If your shadow appears to be shorter than you are, seek shade.
Wear protective clothing, such as a long-sleeved shirt, pants, a wide-brimmed hat, and sunglasses, where possible.
Generously apply a broad-spectrum, water-resistant sunscreen with a sun protection factor (SPF) of 30 or more to all exposed skin. “Broad-spectrum” provides protection from both ultraviolet A (UVA) and ultraviolet B (UVB) rays. Reapply approximately every two hours, even on cloudy days, and after swimming or sweating.

37. Patient Education: SPOT Skin Cancer™
Use extra caution near water, snow, and sand because they reflect and intensify the damaging rays of the sun, which can increase your chances of sunburn.
Avoid tanning beds. Ultraviolet light from the sun and tanning beds can cause skin cancer and wrinkling. If you want to look tan, consider using a self-tanning product or spray, but continue to use sunscreen with it.

38. How to perform a skin self-examination
Examine your body front and back in the mirror, then look at the right and left sides with your arms raised.
Look at the backs of your legs and feet, the spaces between your toes, and the soles of your feet.
Examine the back of your neck and scalp with a hand mirror. Part hair for a closer look.
Bend elbows and look carefully at forearms, upper underarms, and palms.

39. Melanoma: Course & Prognosis
Melanoma has high cure rates if diagnosed and treated early
Key prognostic factors for primary tumor
Thickness or depth of tumor invasion is the single most important prognostic factor for survival and clinical management
Survival decreases with increasing Breslow’s depth
Ulceration – confers a higher risk for developing advanced disease
Mitotic rate – considered an independent prognostic risk factor in melanoma survival
Lymphatic involvement – presence of regional lymph node metastasis portends a worse prognosis
Metastases – presence of distant metastases portends the worst prognosis

40. Take Home Points Melanoma is a common and deadly cancer
Physicians should integrate a skin exam into the routine visit
Patient education is a crucial component to skin cancer prevention
Suspect pigmented lesions may be identified through the ABCDEs of melanoma
Suspicion or diagnosis of melanoma should prompt immediate referral to a dermatologist

41. Acknowledgements
This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from
Primary authors: Amit Garg, MD, FAAD; Lisa Nguyen, MD; Meera Mahalingam, MD
Contributor: Sarah D. Cipriano, MD, MPH
Peer reviewers: Patrick McCleskey, MD, FAAD; Carlos Garcia, MD; Timothy G. Berger, MD, FAAD
Revisions and editing: Sarah D. Cipriano, MD, MPH; Alina Markova. Last revised in August 2011.

42. References
American Academy of Dermatology. ‘Be Sun Smart.’ care-and-safety/skin-cancer-prevention/be-sun-smart; 2011.
Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL
National Institutes of Health. ‘Melanoma.’ Comprehensive Cancer Information - National Cancer Institute
Ragel EL, et al. Cutaneous melanoma: Update on prevention, screening, diagnosis, and treatment. Am Fam Physician. 2005; 15:
Wolff K, Johnson RA, Suurmond D editor. Fitzpatrick's color atlas and synopsis of clinical dermatology. 5th ed.. New York: McGraw-Hill; 2005.
Wolff K et al., Fitzpatrick's Dermatology in General Medicine, 7th ed., New York: McGraw-Hill; 2008.

43. Additional Resources
Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 70-Year-Old Man with a Red Crusty Bump on his Right Arm. MedEdPORTAL; ?subid=8055.
Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 62-Year-Old Man With a Facial Growth. MedEdPORTAL; ?subid=7751.
Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 40-year-old Woman with a Dark Mole. MedEdPORTAL; ?subid=8067.