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MalignantMelanomaClinicalPresentation
PRESENTATION

History
Familyhistory
Carefullyobtainanyfamilyhistoryofmelanomaorskincancer.Also,afamilyhistoryofirregular,
prominentmolesisimportant.Approximately10%ofallpatientswithmelanomahaveafamilyhistory
ofmelanoma.Thesepatientstypicallydevelopmelanomaatanearlierageandtendtohavemultiple
dysplasticnevi.Thesepatientsalsoaremorelikelytohavemultipleprimaries.
Presenceofafamilialmelanomasyndromeshouldbeconsideredinpatientswithafamilyhistoryof
pancreaticcancerorastrocytoma.MutationsintheCDKN2Atumorsuppressorgene(alsoknownas
p16)arethemostcommongeneticabnormalitiesfoundinthesefamilies.

Patienthistory
Anyprevioushistoryofmelanomamustbeelicitedfrompatients,becausethosepatientsareat
increasedriskofdevelopingasecondmelanoma.Patientshavereportedasmanyas8ormore
primarymelanomas.Multipleprimariesespeciallyareprevalentinpatientswithmultipledysplastic
nevi.Thetermfamilialatypicalmoleormelanoma(FAMM)syndromeisusedtodescribethis
hereditarytendencytodevelopmultipledysplasticneviandmelanomas.

Sunexposure
Questionthepatientextensivelyaboutprevioussunexposure,includingseveresunburnsin
childhood.Thecapacitytotanisalsoimportant,becauseindividualswhotaneasilyarelesslikelyto
developamelanomathanthosewhoburneasily.

Moles
Questionthepatientaboutanychangesnotedinmoles.Anyhistoryofchangeinsize,color,or
symmetry,aswellasknowledgeofbleedingorulcerationofthelesionmustbeobtained.Alsoelicit
anyhistoryorfamilyhistoryofmultiplenevussyndrome.

PhysicalExamination
Totalbodyexamination
Atotalbodyskinexaminationiscrucialwhenevaluatingapatientwithanatypicalnevusora
melanoma.Theskinexaminationshouldbeperformedoninitialevaluationofthepatientandduring
allsubsequentvisits.Astudyfromageneraldermatologypracticefoundthatmostmelanomas
diagnosedduringa3yearperiodwerenotthepresentingcomplaintbutwerediscoveredonly

becauseadermatologistperformedatotalbodyskinexaminationmoreover,theseincidentally
discoveredmelanomasweremorelikelytobethinnerorinsitulesions.[13]
Crucialtoagoodskinexaminationisawelllitexaminingroomandacompletelydisrobedpatient.
Serialphotographyandnewtechniques,suchasepiluminescencemicroscopyandcomputerized
imageanalysis,areusefuladjuncts.Epiluminescencemicroscopyusesamagnifyinglenstoexamine
alesionthathashadoilapplied.Computerizedimageanalysisstoresimagesofthelesionsand
makesthemavailableforcomparisonovertime.

Skinexamination
Duringaskinexamination,assessthetotalnumberofnevipresentonthepatient'sskin.Attemptto
differentiatebetweentypicalandatypicallesions.(Theimagesbelowdepictexamplesofmelanomas.)
TheABCDsfordifferentiatingearlymelanomasfrombenignneviincludethefollowing:
AAsymmetry(melanomalesionmorelikelytobeasymmetrical)
BBorderirregularity(melanomamorelikelytohaveirregularborders)
CColor(melanomamorelikelytobeverydarkblackorblueandtohavevariationincolorthan
wouldabenignmole,whichmoreoftenisuniformincolorandlighttanorbrown)
DDiameter(mole<6mmindiameterusuallybenign)

A1.5cmmelanomawithcharacteristicasymmetry,irregularborders,andcolorvariation.

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Malignantmelanoma.ImagecourtesyofHonPak,MD.

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Lentigomalignamelanoma,rightlowercheek.Thecentrallylocatederythematouspapulerepresents
invasivemelanomawithsurroundingmacularlentigomaligna(melanomainsitu).ImagecourtesyofSusan
M.Swetter,MD.

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Lymphnodeexamination
Ifapatientisdiagnosedwithamelanoma,examinealllymphnodegroups.Melanomamay
disseminatethroughthelymphatics,leadingtotheinvolvementofregionallymphnodes,and
hematogenously,leadingtotheinvolvementofanynodebasininthebody.
DifferentialDiagnoses
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Formulary
Slideshow

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