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Melanoma is a malignant tumour arising from melanocytes in the skin

Seven point checklist-Major features of the lesion → 2 points each

○ change in size
○ irregular shape or border
○ irregular contour
 Minor features of the lesion → 1 point each

○ Largest diametre 7 mm or more
○ inflammation
○ oozing or crusting of the lesion
○ change in sensation ( including itch )

3 point or more → lesion suspicious
However if strong concerns about cancer any one feature is adequate to promt a USC referral

ABCD lesion system –
ABCD Check list identifies early signs of melanoma that are useful for the diagnosis

 A → asymmetry B → border irregularity C → colour variegation or changes ( atleast 2 diff colours) D → diameter greater than 6 mm. E → elevated / evolutionary changes in
○ colour
○ size
○ symmetry
○ surface charecteristics and 
○ symptoms

 F → firm G → growing progressively for 1 month or longer

Risk factors-Family history of melanoma →1st degree family member Previous h/o melanoma Skin lesions such as :

○ high density of freckles or a tendency to freckle in sun
○ a large number of normal moles →risk rises with the number of common moles
○ five or more atypical moles
 ♦ Atypical moles →ill-defined or irregular border ; irregular pigmentation ;dia > 5 mm; erythema ; accentuated skin markings
○ actinic lentigines → flat brown , skin lesions associated with acute and chronic sun exposure
○ giant congenital melanocytic naevus
 Pale skin ( type 1 and 2 ) that does not tan easily and burns ; light coloured eyes Red or light- coloured hair Unusually high sun exposure Affluence Increasing age Female sex

Assessment –Examine in good light
 Use the 7 point checklist / ABCDE
 Thorough history ( taking into account risk factors )
 Complete skin examination
○ ugly duckling sign → lesion which stands out from crowd
 Lymph node palpation ( eg cervical , axillary and inguinal )
○ may disseminate through lymphatics and haematogenously can involve any node basin
 Dermatoscopy ( also called Dermoscopy )
○ if trained to do so
○ may more accurately distinguish betwenn benign and malignant lesions
○ device shines polarized light on the skin and magnified skin lesions with or without a fluid interface
 Consider baseline blood tests
○ LFT ( ↑ AlkPo4 – may indicate metastasis to bobe , liver)
 AST / ALT ↑ may suggest liver metastasis
○ ALbumin/ protein- indicate gen health
○ U/E- baseline ( chemotherapy can be nephrotoxic )
○ LDH – marked elevation may suggest distant metastasis and a poor prognosis

Superficial spreading melanoma –Most commonly seen subtype ( about 80 % of all melanomas ) Proliferation of atypical melanocytes singly and in nests at all levels within the epidermis Asymmetrical pigmented lesion with variable pigmentation and some time irregular outline Can be crusted and presents in different shades of brown , black , red , blue or white Pts may have noted growth , a change in sensation and / or colour , crusting , bleeding or inflammation of lesion Most frequently on calves of women and back of men Duration of the symptoms vary from a few months to several years Presents from 4th to 5th decade

Nodular melanoma –Second most common subtype First observed as a black or blue nodular growth Shape and pigmentation usually more uniform than that of superficial spreading melanoma Develops often over a period of few months into a dome shaped nodule- may ulcerate and bleed easily Commonly on legs and trunks 5th or 6th decade of life Grows faster than other melanomas →easily misdiagnosed

Lentigo maligna melanoma –Similar to normal lentigo but has colour variegation and irregular margins Grows slowly over yrs Sun damaged skin → head and neck of older patients Only type- has a clearly recognised and often lengthy pre-invasive ( in situ ) lesion called – Lentigo maligna before progressing

Acral lentignous melanoma –Commonly found on the palms of the hands and soles of the feet or around the big toe nail Flat pigmented area , slowly increasing in size becoming ↑ ingly irregular in colour May be covered with reactive callus ( corn ) if on sole →may develop a nodule with ulceration and bleeding Occurs in all ethnic groups

Amelanotic melanoma –Usually have no or very little colour→ flesh coloured pink or erythematous nodule Difficult to identify Any rapidly growing nodule → should be in the DD A small focus of pigments usually present

Lesions suggestive of melanoma –Lesion scoring 3 points or > on 7 pt checklist
( If strong suspicion cancer any one feature is adequate for referral ) New nodule which are pigmented or vascular in appearance Nail changes

Including nodular and amelanotic melanoma.Any doubt about the lesion Persistently slowly evolving unresponsive skin condition with an uncertain diagnosis and melanoma is a possibility Biopsy confirms melanoma

Giant congenital pigmented naevi – risk ↑↑ if 20 cm or more Family hx – 3 or more cases →refer clinical geneticist or specialised dermatology for counselline Family hx 2 cases- will also benefit More than 100 normal moles Multiple atypical moles 

Regularity of colour , surface and border → suggest benign nature Rapid growth over days rather than weeks → suggest pyogenic granuloma Stuck on appearance with keratotic plug on the surface → suggest seborrhoeic keratosis Dimpling if b/l pressure applied → suggest dermatofibroma Child presenting with a pigmented lesion

References Melanoma : summary of NICE guidance BMJ 2015;351:h3708 Melanoma and Cutaneous Malignant Neoplasms Sabiston Textbook of Surgery Charles W.Kimbrough et al Twentieth edition Problematic pigmented lesions: approach to diagnosis SL Edwards , K Blessing J Clin Pathol 2000;53:409-418 Treatment of Skin Disease : Comprehensive Therapeutic Strategies 4th Edition 2014 Malignant Melanoma Melanoma Types Cancer Research UK accessed via Suspected cancer : recognition and referral NICE guidelines NG 12 June 2015 Malignant melanoma BMJ 2009;339:b3078 Fast facts Skin Cancer Karen L agnew et al Health Press SIGN 146.Cutaneous melanoma A national clinical guideline January 2017 Melanoma and pigmented lesions CKS NHS Prevention , diagnosis , referral and management of melanoma of the skin Royal College of Physicians Concise guidelines 2007 Malignant Melanoma Clinical Presentation Medscape Winston W Tan et al Nov 2016 Cutaneous Malignant Melanoma : A Primary Care Perspetive Am Fam Physician.2012 Jan 15;85(2) 161-168

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