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

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.

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

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.

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

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

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

Differential Diagnosis What is your differential diagnosis?

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

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

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)

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

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

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”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

Practice the ABCDEs with this Evolving Lesion

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:

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.

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.

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.

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

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

Acknowledgements This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012. 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.

References American Academy of Dermatology. ‘Be Sun Smart.’ http://www.aad.org/skin- 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. www.mededportal.org/publication/462; 2007. National Institutes of Health. ‘Melanoma.’ Comprehensive Cancer Information - National Cancer Institute. www.cancer.gov/cancertopics/types/melanoma; 2011. Ragel EL, et al. Cutaneous melanoma: Update on prevention, screening, diagnosis, and treatment. Am Fam Physician. 2005; 15:269-276. 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.

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; 2010. http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/ ?subid=8055. Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 62-Year-Old Man With a Facial Growth. MedEdPORTAL; 2010. http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/ ?subid=7751. Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 40-year-old Woman with a Dark Mole. MedEdPORTAL; 2010. http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/ ?subid=8067.