Tuesday, July 31, 2012

Malignant Melanoma

What do you see when you see a lesion such as this?  Do you see merely a melanoma, or do you see more?  By examining this picture, I hope you will start to look at lesions such as this more critically, because your perception dictates your actions, which in turn dictates your outcomes.  So, let us take a "Zen" look at this lesion, and decide what to do.

This lesion is on the trunk of a Caucasian gentleman, and could not more clearly violate all of the ABCDs.  It is asymmetric, irregularly bordered, wildly variegated in coloring, and if one compares the lesion to the hair, is well north of 6 mm in diameter.  

What about the ddx?  My ddx would be a Pigmented SBCC, Pigmented Bowens, and SK.  All three are dismissed easily, though, because of the appearance.  Pigmented Bowen's is more uniform in color, and is usually on darker skin individuals.  Pigmented BCCs would not have the elevation, irregular pigmentation, and would have an accentuated border.  SKs have a different texture, different coloration and, even when traumatized, would not have the same notched border and color variegation of this one.

So, having settled on MM being the likely dx, we choose to do an excisional biopsy.  Why excisional?  Because one never knows which day a melanoma will decide to metastasize.  If you are sure it is MM, cut the damn thing out. Seeing it is large, my preference is as follows:  Excise with narrow, but complete margins because if it is large or shows signs of regression (more on this in a minute) then one can reasonably demand a sentinel node biopsy down the road.  

If the lesion is on an extremity, close the incision, if possible, in the direction of nodal drainage, i.e. longitudinally.  On the trunk, close it via the long axis, to make the overall incision as short as possible. Do not extensively reduce the standing cones (dog ears).  It will theoretically confuse the determination of which is the best nodal basin to sample on SLNB.

Now, looking at the lesion, it is elevated in spots, but not too significantly so.  My estimation was at first 1.5 mm Breslow's but I changed it after a little reflection to 1.1 mm.  It turned out to be .95.  Next, I looked for signs of inflammation.  I saw not only the pink spot, but also a faint pink area extending away from the lesion at 9 o'clock.  Also, I saw two unequivocal signs of regression:  the notching at 12 o'clock and the linear scarring within the lesion.  What this tells me is this:  regardless of whether or not he has palpable lymphadenopathy, his immune system has "presented" the tumor cells to the draining node or nodes, and as a result has at least micrometastasis.  As the late dermatopathologist Bernie Ackerman said, signs of regression are uniformly bad news for the patient.  

Finally, the size of the superficial spreading melanoma tells the tragic part of the story:  It has been there for a very long time.  It was on a visible part of the trunk, on a well-educated man, and he watched it grow for years.  Even when I raised the possibility that it might be melanoma, he seemed surprised, but relatively unconcerned.  He didn't really grasp the gravity of the diagnosis.  How this can be is a mystery to me, but he was blissfully ignorant of the concept of how a lesion such as this could change his world.

This is the thing that all of you live, eat and breathe to fight against.  There is no more worthy goal than for all of you to educate, both in your clinic and in your community, those who, like this man, those who don't know how horrible this disease is.  And maybe, one day, someone will come up to you at the end of a lecture at a church or garden club or civic center, and they will ask you about a small brown spot with irregular borders, and you will tell them to get it biopsied, and they will live long, happy lives because you educated them, and saved their life.  Isn't that a goal worth having?

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