Malignant Melanoma Clinical Presentation

Updated: Jan 31, 2020
  • Author: Winston W Tan, MD, FACP; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

Family history

Carefully obtain any family history of melanoma or skin cancer. Also, a family history of irregular, prominent moles is important. Approximately 10% of all patients with melanoma have a family history of melanoma. These patients typically develop melanoma at an earlier age and tend to have multiple dysplastic nevi. These patients also are more likely to have multiple primaries.

Presence of a familial melanoma syndrome should be considered in patients with a family history of pancreatic cancer or astrocytoma. Mutations in the CDKN2A tumor suppressor gene (also known as p16) are the most common genetic abnormalities found in these families.

Patient history

Any previous history of melanoma must be elicited from patients, because those patients are at increased risk of developing a second melanoma. Patients have reported as many as 8 or more primary melanomas. Multiple primaries especially are prevalent in patients with multiple dysplastic nevi. The term familial atypical mole or melanoma (FAMM) syndrome is used to describe this hereditary tendency to develop multiple dysplastic nevi and melanomas.

Sun exposure

Question the patient extensively about previous sun exposure, including severe sunburns in childhood. The capacity to tan is also important, because individuals who tan easily are less likely to develop a melanoma than those who burn easily.

Moles

Question the patient about any changes noted in moles. Any history of change in size, color, or symmetry, as well as knowledge of bleeding or ulceration of the lesion must be obtained. Also elicit any history or family history of multiple nevus syndrome.

Next:

Physical Examination

Total body examination

A total-body skin examination is crucial when evaluating a patient with an atypical nevus or a melanoma. The skin examination should be performed on initial evaluation of the patient and during all subsequent visits. A study from a general dermatology practice found that most melanomas diagnosed during a 3-year period were not the presenting complaint but were discovered only because a dermatologist performed a total-body skin examination; moreover, these incidentally discovered melanomas were more likely to be thinner or in-situ lesions. [16]

Crucial to a good skin examination is a well-lit examining room and a completely disrobed patient.

Serial photography and new techniques, such as epiluminescence microscopy and computerized image analysis, are useful adjuncts. Epiluminescence microscopy uses a magnifying lens to examine a lesion that has had oil applied. Computerized image analysis stores images of the lesions and makes them available for comparison over time.

Skin examination

During a skin examination, assess the total number of nevi present on the patient's skin. Attempt to differentiate between typical and atypical lesions. (The images below depict examples of melanomas.) The ABCDs for differentiating early melanomas from benign nevi include the following:

  • A - Asymmetry (melanoma lesion more likely to be asymmetrical)

  • B - Border irregularity (melanoma more likely to have irregular borders)

  • C - Color (melanoma more likely to be very dark black or blue and to have variation in color than would a benign mole, which more often is uniform in color and light tan or brown)

  • D - Diameter (mole < 6 mm in diameter usually benign)

    A 1.5-cm melanoma with characteristic asymmetry, i A 1.5-cm melanoma with characteristic asymmetry, irregular borders, and color variation.
    Malignant melanoma. Image courtesy of Hon Pak, MD. Malignant melanoma. Image courtesy of Hon Pak, MD.
    Lentigo maligna melanoma, right lower cheek. The c Lentigo maligna melanoma, right lower cheek. The centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ). Image courtesy of Susan M. Swetter, MD.

Lymph node examination

If a patient is diagnosed with a melanoma, examine all lymph node groups. Melanoma may disseminate through the lymphatics, leading to the involvement of regional lymph nodes, and hematogenously, leading to the involvement of any node basin in the body.

Mucosal melanoma

CKIT mutations have been described in 39% of mucosal melanoma, 36% of acral lentiginous melanoma, 28% of cutaneous melanomas arising in areas of chronic sun-damaged skin, and none in melanomas of skin without chronic sun damage. (98)

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