Melanoma evaluation and management: expanding the role of the general practitioner in skin examination

Meghan A. Rauchenstein

February 16, 2006

Pathophysiology

• Cancer of melanocytes

• Uncontrolled proliferation

• Spreading horizontal = in situ

• Vertical spread through the basement membrane

• Infiltration to regional lymph nodes

• Spread into organs, bones and new skin sites

http://www.patient.co.uk/showdoc/27000650/

Pigmented Nevus

Dysplasia of MIS

http://catalog.nucleusinc.com/enlargeexhibit.php?ID=855

Epidemiology

• Risk factors: – fair, freckled, blue eyes, burns without tanning– elderly (age) – 50+ nevi, > 2 mm in diameter– 3+ blistering sunburns, 3+ summer jobs

• Statistics: – 57,000 metastatic cases this year – 9,000 deaths– 46,170 in situ diagnoses

Epidemology

• #1 CA women 25-29, #2 CA women 30-34 behind BrCA

• 43% of white children under 12 had at least one sunburn last year

• Blacks present with more advanced disease than whites

• Uninsured/Medicaid present with late-stage disease

http://www.wff.nasa.gov/~healthline/skinlesions.jpg

Dermoscopy

• Allows magnification of lesion• Oil makes epithelium transparent• Algorithms increase sensitivity and

specificity• Training sessions allow any practitioner to

learn the technique• Only used by 17-23% of US

dermatologists

Dermatoscopes

Why do I need one?

• Standard practice for European PCPs

• United States in top 5 with highest incidence rates

• Inexpensive

• Improves accuracy in diagnosing melanoma

• Fewer benign excisions sent to lab

 

 

ABCD rule of dermoscopy score weight

A In 0, 1, or 2 axes; assess contour, colors and structures

0-2 X 1.3

B Abrupt ending of pigment at periphery in 0-8 segments

0-8 X 0.1

C White, red, tan, brown, blue-gray, black 1-6 X 0.5

D Network, structureless areas, streaks, dots, and globules

1-5 X 0.5

Score Interpretation

<4.75 Benign melanocytic lesion

4.8-5.45 Suspicious lesion; close follow-up or excision recommended

>5.45 Lesion highly suspicious for melanoma

Menzies scoring method

Negative features (both must be absent)• Symmetry in color and shape • A single color is observedPositive features (2 out of 9)• Blue-white veil • Focal collections of multiple, dark brown dots• Peripheral black dots and globules • Radial streaming • Pseudopods• Scarlike depigmentation • 5-6 colors: black, gray, blue, red, dark brown, and tan • Multiple “pepperlike” small, blue or gray dots. • Localized, thickened, and irregular pigmented network

http://www.emedicine.com/derm/topic557.htm

Pigmented benign nevus

http://www.dermoscopy.org/atlas/base.htm

http://catalog.nucleusinc.com/enlargeexhibit.php?ID=10378

Lesion excision

Patient outcomes

• Benign

• Malignant– May need to re-excise to get wider margins– Follow up with periodic exams– Check local lymph nodes for metastases– Refer to specialist

Metastatic melanoma

• FDA approved– Interferon α 2b– Proleukin® (aldesleukin) –recombinant IL-2– BCG: Bacille Calmette-Guérin– Chemotherapy– Radiation therapy

• Clinical trials– Vaccine therapy– PI-88

http://db2.photoresearchers.com/search/C3039

Any questions?

References available upon request