Pigmented Skin Lesion in a 58-Year-Old Female (Case 12)

Chapter 23 Pigmented Skin Lesion in a 58-Year-Old Female (Case 12)

James G. Bittner, IV, MD, D. Scott Lind, MD

Differential Diagnosis

Basal cell carcinoma Malignant melanoma Actinic keratosis
Squamous cell carcinoma Atypical nevus Benign nevus

Speaking Intelligently

When I’m asked to see a 48-year-old female who presents with an abnormal screening mammogram, I ask if the mammogram was truly a screening mammogram or was it prompted because the patient or her physician discovered an abnormality in her breast. I inquire about associated symptoms (e.g., nipple discharge, lumpiness, skin changes, or tenderness) and I determine menstrual hx. I probe for risk factors (e.g., family hx of breast cancer or previous biopsies). Most nonpalpable abnormalities found on mammography that are suspicious for malignancy will require an image-guided biopsy (stereotactic, ultrasound-guided, or needle-guided excisional biopsy) for dx so I try to prepare the patient for this at first consultation.

PATIENT CARE

Clinical Thinking

• Most patients think cancer first (perhaps rightfully so) and they want an answer … yesterday.
• Different pigmented skin lesions present differently and often atypically. Melanoma must be excluded.
• The tx of melanoma is dependent on its depth (Breslow’s thickness), Clark’s level (level of skin involved), and whether or not ulceration is present. Therefore, all biopsy samples of skin lesions should be full thickness to include the dermis. Shave biopsies are to be avoided.

History

Of particular interest in patients presenting with a skin lesion are the following:

• Occupation: Risk increases with prolonged ultraviolet exposure
• Geographic location: Patients who spend a significant amount of time in sunbelts around the world are at increased risk.
• Chemical carcinogens: Exposure to tar, arsenic, nitrogen mustard, soot, etc.
• Radiation: Hx of industrial, therapeutic, and occupational exposure constitutes high risk.
• Medications: Topical acne medications may predispose to skin sloughing and anticoagulants may affect surgical planning.
• Immune status: Patients with HIV, AIDS, those on immunosuppression, or individuals with repeated skin sloughing from bullous disease, decubitus ulcers, or Marjolin’s ulcers all have an increased risk for developing malignant lesions.
• Previous hx of the removal of a skin lesion.
• Family hx of melanoma, atypical nevi, or pancreatic cancer.
• Hx of blistering sunburns.

Physical Examination

• The age and gender of a patient contributes to the likelihood of malignancy. Men most often have melanoma on the trunk while women have it on the lower extremities.
• Notice the skin color. Fair-skinned freckled individuals are at highest risk for skin malignancy.
• A complete skin examination in a well-lighted room includes inspection from the scalp to the toes, paying careful attention to those areas most notable for harboring cutaneous malignancies, such as the face, neck, upper back, upper and lower extremities, plus both dorsal and ventral aspects of the hands and feet.
• Document the anatomic location, size, shape, color (pigmentation), presence or absence of ulceration, blanching, bleeding, or evidence of inflammation (ABCDE of melanoma) for all skin lesions of concern.
• The findings of Asymmetry, Border irregularity, variegated Colors, larger Diameter (>5 mm), or Erythema raise the suspicion for malignancy.
• Careful examination of the lymph node basins is crucial (cervical, supraclavicular, axillary, inguinal). Pay close attention to the path of lymphatic drainage of the skin involved and palpate for subcutaneous nodules.

Tests for Consideration

The following tests should be considered when planning biopsy of a skin lesion:

• Punch biopsy: A 6-mm punch biopsy is appropriate for small (< 5 mm), benign-appearing lesions that will be entirely removed or for larger lesions (2 cm or more) that will require wide local excision. This test will provide a full-thickness specimen and the single most important prognostic feature—depth of invasion.
 $100
• Excisional biopsy: This procedure is preferred for all malignant-appearing lesions at least 5 mm in diameter where complete excision is possible. A full-thickness biopsy specimen determines depth of invasion; orient the incision in a fashion compatible with future wide local excision.
 $250

The following tests should be considered when planning a lymph node biopsy:

• Sentinel lymph node biopsy: An accurate, minimally invasive method of assessing the status of a lymph node basin in patients with malignant melanoma.
 $1,000
• Lymphoscintigraphy: A test using technetium colloid to determine lymphatic drainage of an area where drainage is ambiguous.
 $650

IMAGING CONSIDERATIONS

The following tests should be considered when working up a biopsy-proven melanoma:  
→ Chest radiography: Evaluate for pulmonary nodules.
 $75
→ CT: When melanoma depth of invasion is 4 mm or greater and/or palpable lymph nodes are present, CT of the chest, abdomen, and pelvis with contrast is indicated; the scans stage for metastases.
 $1,500
→ Positron emission tomography (PET): The positron-emitting isotope of glucose is highly sensitive to melanoma. Hour-long scanning of the entire body should be purposely modified to evaluate skin and deep tissues.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Pigmented Skin Lesion in a 58-Year-Old Female (Case 12)

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