Presentation on theme: "Medical Student Core Curriculum In Dermatology"— Presentation transcript:
1 Medical Student Core Curriculum In Dermatology MelanomaMedical Student Core CurriculumIn DermatologyUpdated August 22, 2011
2 Module InstructionsThe 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 ObjectivesThe 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 melanomaRecall prognostic factors in melanoma survivalPractice providing patient education on the ABCDEs of melanoma and skin self-examinationsDetermine 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 teenNo history of skin cancerMedicationsNoneFamily HistoryMother had some kind of skin cancer removed from her cheek; diagnosis unknownSocial HistoryMarried with 2 children. 10 pack-year smoking history.Health-related BehaviorUses alcohol occasionally; no drug use
8 Differential Diagnosis What is your differential diagnosis?
9 Differential Diagnosis What is your differential diagnosis?Basal cell carcinomaDermatofibromaMelanomaMelanocytic NevusSeborrheic keratosis
10 Management What is your next step in management? Excisional biopsy Liquid nitrogen cryotherapyPhotograph the lesion and have the patient return in two monthsTopical 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 VideosClick here to watch a video on obtaining informed consentClick here to watch a video on local anesthesiaClick here to watch a video on how to perform an excisional biopsyClick 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 circlesMelanocytes are grouped in nests in the dermisInsert 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 CarcinomaDermatofibromaMelanomaMelanocytic nevus, acquiredSeborrheic keratosis
16 Diagnosis That was incorrect. Try Again. Basal Cell Carcinoma DermatofibromaMelanomaMelanocytic nevus, acquiredSeborrheic keratosis
17 Melanoma Your diagnosis is correct! Basal Cell Carcinoma DermatofibromaMelanomaMelanocytic nevus, acquiredSeborrheic keratosis
18 Melanoma: Epidemiology In 2008, there were approximately 62,480 new cases of melanoma and 8,420 deaths from melanoma in the USThe lifetime risk of melanoma has increased over time1 in 1500 of persons born in the early 1900s1 in 65 of persons born in 2005Melanoma affects all agesIt is the most common cancer among young women between the ages of 25 and 29
19 Melanoma: Pathogenesis Cell of origin: melanocyteEtiology:Cumulative and prolonged UVB and/or UVA exposureUVA exposure from tanning beds increases risk for melanoma
20 Melanoma: Risk Factors Individual risk factors for development of melanomaIncreasing ageFair skin; blue eyes, red or blond hair; frecklingGreater than 100 acquired neviAtypical neviImmunosuppressionPersonal 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 useGenetic syndromes
21 Heredity of Melanoma10 % of melanomas are familial and have a genetic basisThe genes CDKN2A and CDK4 together make up 50% of all inherited familial casesOther identified genes include p53, BRCA250% 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 asymptomaticMay develop de novo or arise within a pre-existing nevusMajority located in sun-exposed areas, but also occur in non- sun-exposed areas, such as the buttockAlso occur on mucous membranes (mouth, genitalia)Typically appears as a pigmented papule, plaque or nodule.Demonstrates any of the ABCDEsIt may bleed, be eroded or crustedPatients 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 typeMost common typeInvolves back in men; back and legs in womenGrowth 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 depthBreslow’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 typeOccurs on chronically sun-damaged skin, more common in elderly patientsSlow progressionGrowth of tumor is primarily horizontal, and not vertical
27 Melanoma: Acral Lentiginous Acral lentiginous typeMore 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 absentAs such, the lesion may be confused with a variety of benign lesions, such as psoriasis or dermatitisThis lesion may also be confused with a variety of malignant lesions, such as squamous cell carcinoma in situ or basal cell carcinomaThis is a difficult diagnosis to make, which is why it is important to biopsy when unsure of the diagnosis
29 Back to Our CaseThe diagnosis of melanoma should prompt referral to a dermatologist or a multi-specialty melanoma clinicMs. 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 ExamA 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 TBSEThe TBSE is often performed in the dermatology clinic, however, a full skin exam can and should be done in other clinical settingsA “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: ASYMMETRYWith regard to shape or colorBORDERIrregular or notchedCOLORVery dark or variegated colorsBlue, Black, Brown, Red, Pink, WhiteDIAMETER>6 mm, or “larger than a pencil eraser”Diameter that is rapidly changingEVOLVINGEvolution or change in any of the ABCD features
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™ initiativeAmerican Cancer Society: Skin Cancer Prevention and Early DetectionThe 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 earlyKey prognostic factors for primary tumorThickness or depth of tumor invasion is the single most important prognostic factor for survival and clinical managementSurvival decreases with increasing Breslow’s depthUlceration – confers a higher risk for developing advanced diseaseMitotic rate – considered an independent prognostic risk factor in melanoma survivalLymphatic involvement – presence of regional lymph node metastasis portends a worse prognosisMetastases – 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 visitPatient education is a crucial component to skin cancer preventionSuspect pigmented lesions may be identified through the ABCDEs of melanomaSuspicion or diagnosis of melanoma should prompt immediate referral to a dermatologist
41 AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary authors: Amit Garg, MD, FAAD; Lisa Nguyen, MD; Meera Mahalingam, MDContributor: Sarah D. Cipriano, MD, MPHPeer reviewers: Patrick McCleskey, MD, FAAD; Carlos Garcia, MD; Timothy G. Berger, MD, FAADRevisions and editing: Sarah D. Cipriano, MD, MPH; Alina Markova. Last revised in August 2011.
42 ReferencesAmerican 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. MedEdPORTALNational Institutes of Health. ‘Melanoma.’ Comprehensive Cancer Information - National Cancer InstituteRagel 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 ResourcesNguyen 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.