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Malignant Melanoma
Introduction: Incidence of malignant melanoma is rising faster than all other cancers in the United States.
The lifetime risk for developing melanoma in U.S citizens is currently 1 in 75 and rising, up from about 1in 250
twenty years ago. About 70,000 people in the U.S. develop melanoma each year, and about 7,000 die. The
5-year survival rate is about 83% (double what it was 50 years ago), but since melanoma is becoming more
common, the death rate is still rising (3 per 100,000/year). Melanoma is a killer, but is 100% curable with early
detection and surgery. Severe sun damage is worrisome, and should lower your threshold for recognizing
these lesions. Acral locations (hands and feet) are at risk for acral lentiginous melanoma. The nail beds and
nail matrix (which is just proximal to the cuticle and between the skin and the bone of the distal phalanx)
are also at risk, so have a high index of suspicion for pigmentation changes in these areas. Amelanotic
melanomas are difficult to diagnose because they do not have much pigment and can look nothing like the
above description. Amelanotic melanomas can be flesh-colored or hypopigmented papules or plaques and are
often thought to be some other entity when they are biopsied.
Subjective: Symptoms
High-risk history: family history of melanoma, childhood history of sunburns, personal history of many atypical
nevi. Focused History: Have you had melanoma in your family/childhood sunburns/ unusual moles or
freckles? (typical risk factors)
Objective: Signs
Using Basic Tools: Use the mnemonic ABCD for lesion: “A”–asymmetry, “B”– border irregularity, “C”–
color variegation or change, and “D”– diameter greater than 6mm. The earliest of these is probably color
variegation, and the colors red, white or blue are most worrisome. Irregular areas which are very dark, or
which become very light in color are also bad signs. Asymmetry and border irregularity come from uncontrolled
growth of abnormal melanocytes at the edges of the lesion. Notched, grooved or scalloped borders are
suspicious, and are usually apparent in a lesion of 6mm diameter or more. Early melanomas tend to be
at with nodular components indicating that the cancer is progressing, and a higher risk for metastasis.
Lymphadenopathy may suggest metastasis.
Assessment:
Differential Diagnosis: Seborrheic keratosis, pigmented basal cell carcinoma, atypical nevus, solar
lentigo. Differentiating these conditions in the eld is nearly impossible, since it requires expert microscopic
evaluation of a biopsy.
Plan:
Treatment: Evacuate immediately (aggressive tumor) for evaluation and biopsy, preferably by a dermatolo-
gist. If emergent evacuation is not possible, perform initial excisional biopsy with wide margins (5-10 mm)
around the entire tumor. Freeze or store tumor in formaldehyde if possible. Evacuate patient with biopsy
specimen as soon as possible.
Prevention: Perform self-exam of the entire skin at least monthly. Avoid ultraviolet exposure.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate immediately. Consult dermatology immediately.
Skin: Seborrheic Keratosis
Lt Col Gerald Peters, USAF, MCIntroduction: Seborrheic keratosis is a very common pigmented, benign tumor that typically presents on
the torso after the age of 30.
Subjective: Symptoms
Strong hereditary predisposition; slightly more common in males; rarely pruritic or painful unless irritated or
secondarily infected after trauma.