Applied Evidence

Melanoma: An FP’s guide to diagnosis and management

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This review details the latest recommendations on dermoscopy and excision techniques, indications for sentinel lymph node biopsy, and Tx options.

PRACTICE RECOMMENDATIONS

› Consider adding dermoscopy to the physical exam to increase sensitivity and specificity in diagnosing melanoma. A

› Perform wide local excision for invasive cutaneous melanoma: 1-cm margin for tumors up to 1 mm thick; 1 to 2 cm for tumors > 1 mm to 2 mm thick; and 2 cm for tumors > 2 mm thick. A

› Do not hesitate to consider, as needed, hormone replacement therapy or hormonal contraception for women with a prior diagnosis of melanoma, as this form of contraception does not confer an increased risk of melanoma. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

References

CASE

A 48-year-old man comes to your clinic with a dark nevus on his right upper arm that appeared 2 months earlier. He says that the lesion has continued to grow and has bled (he thought because he initially picked at it). On exam, there is a 7-mm brown papule with 2 black dots and slightly asymmetric borders.

How would you proceed with this patient?

Melanoma is the fifth leading cause of new cancer cases annually, with > 96,000 new cases in 2019.1 Overall, melanoma is more common in men and in Whites, with 48% diagnosed in people ages 55 to 74.1 The past 2 decades have seen numerous developments in the diagnosis, treatment, and surveillance of melanoma. This article covers recommendations, controversies, and issues that require future study. It does not cover uveal or mucosal melanoma.

Evaluating a patient with a new or changing nevus

Known risk factors for melanoma include a changing nevus, indoor tanning, older age, many melanocytic nevi, history of a dysplastic nevus or of blistering sunburns during teen years, red or blonde hair, large congenital nevus, Fitzpatrick skin type I or II, high socioeconomic status, personal or family history of melanoma, and intermittent high-intensity sun exposure.2-3 Presence of 1 or more of these risk factors should lower the threshold for biopsy.

Worrisome physical exam features (FIGURE) are nevus asymmetry, irregular borders, variegated color, and a diameter > 6 mm (the size of a pencil eraser). Inquire as to whether the nevus’ appearance has evolved and if it has bled without trauma. In a patient with multiple nevi, 1 nevus that looks different than the rest (the so-called “ugly duckling”) is concerning. Accuracy of diagnosis is enhanced with dermoscopy. A Cochrane review showed that skilled use of dermoscopy, in addition to inspection with the naked eye, considerably increases the sensitivity and specificity of diagnosing melanoma.4 Yet a 2017 study of 705 US primary care practitioners showed that only 8.3% of them used dermoscopy to evaluate pigmented lesions.5

Asymmetric nodular melanoma

Several published algorithms and checklists can aid clinicians in identifying lesions suggestive of melanoma—eg, ABCDE, CASH, Menzies method, “chaos and clues,” and 2-step and 3- and 7-point checklists.6-10 A simple 3-step algorithm, the TADA (triage amalgamated dermoscopic algorithm) method is available to novice dermoscopy users.11 Experts in pigmented lesions prefer to use pattern analysis, which requires simultaneously assessing multiple lesion patterns that vary according to body site.12,13

Dermoscopic features suggesting melanoma are atypical pigment networks, pseudopods, radial streaking, irregular dots or globules, blue-whitish veil, and granularity or peppering.14 Appropriate and effective use of dermoscopy requires training.15,16 Available methods for learning dermoscopy include online and in-person courses, mentoring by experienced dermoscopists, books and articles, and free apps and online resources.17

Continue to: Perform a skin biopsy, but do this first

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