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Image courtesy of the Centers for Disease Control and Prevention (CDC) Carl Washington, MD, Emory Univ. School of Medicine; Mona Saraiya, MD, MPH.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Melanoma is a malignancy of pigment-producing cells (melanocytes) located predominantly on the skin. Melanoma accounts for fewer than 5% of skin cancer cases but the majority of skin cancer–related deaths. Rates have tripled among white individuals over the past two decades; it is estimated that 96,480 new cases of melanoma will be diagnosed in the US in 2019, with 7230 people dying of the disease.[1] Early detection of cutaneous melanoma (shown) is the best means of reducing mortality.

Can you distinguish melanomas from the other skin lesions in this slideshow?

Image courtesy of Wikimedia Commons | M Sand, D Sand, C Thrandorf, V Paech, P Altmeyer, FG Bechara.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

A 9-year-old boy who recently emigrated from the Middle East with his family is seeing his new pediatrician for the first time. The pediatrician notes a prominent pigmented lesion on the child's nose, which the parents state has been there since the boy was an infant.

What is your diagnosis of this skin lesion?

Image courtesy of Wikimedia Commons/ S Sharma , NL Sharma, V Sharma.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Congenital melanocytic nevus.

A congenital melanocytic nevus (ie, mole) is a proliferation of benign melanocytes that either is present at birth or develops shortly afterwards. Small melanocytic nevi are very common. Approximately 1-2% of babies are born with a small melanocytic nevus. Large congenital nevi are rare and occur approximately once in every 20,000 births. Giant congenital nevi (shown) occur approximately once in every 500,000 births.[2]

How are congenital nevi classified?

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Congenital nevi are usually classified by size: small (< 1.5 cm in diameter), medium (1.5-20 cm in diameter), or giant (>20 cm in diameter). The benign congenital nevus shown has a normal variation in color. Other colors often displayed by congenital nevi include tan to dark brown, skin-colored to pink, and even blue-black; colors can change with maturity. Some nevi can even grow hair.

What is the frequency of malignant degeneration in congenital nevi?

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

The frequency of malignant degeneration in small congenital nevi, such as on the previous slide, is about 1%. Melanoma is more likely for giant nevi (~5% over a lifetime). Nevus spilus (ie, speckled lentiginous nevus), a common benign melanocytic nevus with a speckled appearance (shown), carries a small risk of malignant changes. A nevus spilus can be macular or papular, exhibiting multiple smaller pigmented macules surrounding the central pigmentation. This lesion may be congenital or acquired. Most congenital nevi do not need treatment. However, taking a close-up, detailed photograph of the lesion with a ruler beside it can make it easier to follow future changes in size and color. Congenital nevi may be surgically removed to improve cosmetic appearance or—if concerning changes occur—to rule out melanoma.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

A 55-year-old man presented to his dermatologist for evaluation of this skin lesion on his back. It is neither itchy nor tender and never bleeds.

What is the likely diagnosis?

Image courtesy of DermNetNZ.org.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Compound nevus.

The pigmented macule on the previous slide was biopsied and found to be a compound nevus. Histologically, compound nevi often have features in common with malignant melanoma, such as asymmetry and poor circumscription. This nevus also has scattered, darkly pigmented areas rather than the central darker area more typical of congenital nevi.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This congenital nevus, measuring approximately 5 mm, was located on the patient's upper chest. This is a junctional nevus, meaning that it is at the junction of the dermis and the epidermis. Junctional nevi have pigment regularity and are flat or slightly raised.

In a compound nevus, are melanocytes found in the dermis or the epidermis?

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Both the dermis and the epidermis.

In a compound nevus, melanocytes are found in both the dermis and the epidermis. In addition, the compound nevus can have both raised and flat areas. This compound nevus, located on the midsternal area, exhibits irregular borders and asymmetry.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

A 52-year-old woman presented to her primary care provider for evaluation of a new pigmented lesion with irregular borders on her left cheek. The patient states that her two sisters have multiple skin lesions that are similar.

What diagnosis would you suspect for this dermatologic lesion, given the patient's family history?

Image courtesy of DermNetNZ.org.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Atypical nevus.

Atypical nevi that run in families may represent familial atypical mole and melanoma syndrome (FAMM syndrome, previously referred to as dysplastic nevus syndrome). People are considered to have FAMM syndrome if the following applies: they have one or more first- or second-degree relatives with malignant melanoma; a large number of nevi (often > 50) are present, including some atypical nevi; histopathology reveals the nevi to be dysplastic.[3]

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This large compound nevus has mild-to-moderate atypia. These moles usually begin to appear during adolescence, most often on the back, chest, abdomen, buttocks, and scalp. Atypical nevi are often larger than 0.6 cm and have variegated coloration ranging from pink to brown, indistinct borders, and a textured surface. They may have a central raised papule that is darker and a surrounding macule of lighter pigmentation ("fried-egg" appearance, shown). Atypical moles tend to be familial and have a higher rate of malignant transformation; accordingly, they must be closely monitored. This patient underwent a skin punch biopsy that revealed melanocytic atypia.[4]

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

A 73-year-old man presented to his primary care provider for his yearly examination. On routine examination, the provider found this lesion on the posterior aspect of the patient's right ear.

What is this focal area of darker pigmentation?

Image courtesy of DermNetNZ.org.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Solar lentigo.

Solar lentigo is one of several benign conditions easily mistaken for melanoma. These small 1- to 3-cm macules are usually round and light yellow to brown in color and appear on chronically sun-exposed skin, such as the ear. These macules can enlarge and eventually coalesce into patches. Solar lentigo ("liver spot") is the most common benign sun-induced lesion of the skin.

Image courtesy of Brett Sloan, MD, FAAD.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This seborrheic keratosis, on a patient's back, is diffusely pigmented. No melanocyte proliferation was identified on biopsy. Seborrheic keratoses are the most common benign skin lesions in older individuals. Developing from a proliferation of epidermal cells, these growths often have variable pigmentation (pink to brown, occasionally dark brown or black). These lesions ("barnacles") can grow larger, can become irritated and crusty and itch or bleed, and may appear waxy, soft, and greasy.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This is another example of a pigmented seborrheic keratosis, illustrating the variety in coloration that these lesions may produce. The surface of a mature lesion can display multiple plugged follicles and have a dull or nonlustrous appearance (not reflecting light). More than 50% of seborrheic keratoses are located on the trunk, as shown here. In some patients, multiple seborrheic keratoses will align along the folds of the skin. A shave biopsy can provide a histologic diagnosis.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This benign seborrheic keratosis is located on the patient's neck on an area that receives sun exposure. When black in color, like this lesion, seborrheic keratoses can clinically resemble melanomas. Distinguishing seborrheic keratoses from lentigo maligna and pigmented actinic keratoses can be difficult. Seborrheic keratoses have an appearance of being stuck on the skin surface. A seborrheic keratosis does not develop into malignant melanoma.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This growth, measuring approximately 8 mm, is located on the patient's shoulder and is well defined with focal pigmentation.

What is the diagnosis?

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Nodular basal cell carcinoma.

This translucent pink papule has telangiectases and a crusted erosion, which are characteristics of nodular basal cell carcinoma, the most common variant of basal cell carcinoma. Basal cell carcinomas are slow-growing, rarely metastasize, and have an excellent prognosis, though untreated tumors can be disfiguring. These lesions arise from pluripotential cells in the basal layer of the epidermis or outer root sheaths of follicular structure. They are far more common in light-skinned individuals and appear in adulthood, usually on the face, ears, scalp, neck, or upper trunk. These growths are easily irritated and may bleed when traumatized. The patient often has a history of chronic sun exposure.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This large malignancy, measuring more than 1 cm, is asymmetrical with variegated coloring (and focal black areas) and irregular borders. Note that this tumor is located just above the area that would be covered by a bikini. The patient admitted to multiple sunburns as a child. This location illustrates the importance of examining the entire body to identify melanomas.

What are the common features of melanoma?

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Features of melanoma, as evident in this image of a melanoma in situ on a patient's shoulder, include asymmetry, irregular borders, multiple shades of pigmentation, a blotchy appearance, an area of depigmentation, and an irregular surface texture.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

A shave biopsy revealed this 7- to 8-mm asymmetrical growth to be melanoma in situ. The term melanoma in situ implies that the melanoma is purely intraepidermal and that no neoplastic cells have penetrated the dermoepidermal junction. This melanoma displays different colors with focal areas of darker pigmentation. Generally, a lesion that grows to a size of 6 mm or larger suggests melanoma, though smaller melanomas are possible. The risk factors for melanoma include fair skin, the experience of multiple sunburns as a child, the presence of many moles (especially atypical nevi), the use of tanning beds, and a family history of melanoma in a first-degree relative.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This example of melanoma in situ occurred on the patient's shoulder. Features include markedly asymmetrical appearance, irregular borders, hypopigmentation, and a bumpy surface. The pinkish area indicates regression (an immune phenomenon whereby a portion of the cancer cells are destroyed and replaced by fibrosis). This lesion measured approximately 1.5 cm in diameter. Melanoma in situ is confined to the epidermis, known as level I in the Clark system (see slide 24).

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Two classification schemes, those of Breslow and Clark, are used for melanoma. Clark levels are based on the layer of skin or tissue that is involved in the malignancy. The Breslow measurement has become more important as the first prognostic factor because thickness is a more accurate measure of outcome than penetration and depends less on the pathologist's judgment. In thin melanomas (< 1 mm thick), however, the Clark level can indicate that a melanoma is more advanced than is indicated by the Breslow measurement. Therefore, both systems are used to help stage melanoma. In either system, the melanoma has a worse prognosis if the pathologist determines that it is ulcerated (ie, the covering layer of epidermis is absent).[5,6]

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

The most important prognostic factors in melanoma are thickness and/or depth of invasion, presence of ulceration or bleeding, regional lymph node involvement, and systemic metastasis.[7] This table shows the Breslow depth of invasion and the corresponding 5-year survival rate. The following slides include examples of Clark levels and Breslow depths of invasion in different melanomas.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Lentigo maligna melanoma is a subtype of invasive melanoma. This lentigo maligna melanoma, on the patient's shoulder, has a subtle appearance; the only abnormal signs apparent to the naked eye are irregular borders, asymmetry, and variations in color. The melanoma is Clark level II, with a Breslow depth of 0.4 mm. Lentigo maligna melanoma is a slow-growing tumor that occurs most often in older adults and is usually found on sun-exposed skin. Lesions are typically tan to brown, with varying colors; sometimes they appear to be a stain on the skin.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

The image shown is an invasive malignant melanoma that penetrates to a Breslow depth of 0.45 mm. A close look at this tumor reveals that it is asymmetrical with irregular borders, multiple small dots, and a faint rim of erythema. Fairly rapid development was also a factor in this case. In invasive melanoma, cancer cells have descended through the basement membrane into the dermis.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This melanoma, located on the patient's back, has a slightly irregular border and is also slightly asymmetrical. A brown macule and a central black nodule are present, but there is no ulceration. This lesion is Clark level III, with a Breslow depth of invasion of 0.6 mm. It would have been easy to bypass this melanoma as a melanocytic nevus if it had not been examined closely, if it had not been compared with other moles on the patient's body, and if there had been no inquiry about the evolution of the lesion.

Image courtesy of Brett Sloan, MD, FAAD.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This invasive malignant melanoma on a patient's right upper back is Clark level IV, with a 1.5 mm Breslow level of invasion. Clinical findings include size greater than 3 cm, several different shades of brown and pink, and an irregular border. Ulceration is present, and histopathology showed focal regression and 1-2 mitotic figures/mm2. Sentinel lymph node biopsy yielded negative results.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This nodular pigmented malignant melanoma measures 3.5 mm in thickness. The tumor is bluish black in color with a wide, faint rim of erythema. Many melanomas grow radially first and then vertically, but nodular melanoma has an early vertical growth phase. Nodules are more uniform in color and can ulcerate and bleed. Nodular melanoma is an aggressive tumor, is twice as common in men as in women, and often occurs at younger ages.

Image courtesy of Theodore Scott, RN, MSN, FNP-C.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This growth has all of the features suggestive of classic malignant melanoma: irregular borders, asymmetry, several different colors with black areas, a rim of erythema, chronic inflammation, and ulceration with bleeding and crusting. Biopsy revealed the histologic diagnosis to be invasive malignant melanoma. Patients are often oblivious to changes in their own moles that might indicate malignancy, and as a result, many malignancies are discovered incidentally. The only way to halt the rapidly growing number of deaths from malignant melanoma is through early diagnosis and intervention.

Image courtesy of Brett Sloan, MD, FAAD.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

This macule has been present on a 56-year-old man's frontal scalp for as long as he can remember and has not changed over that time.

What is the most likely diagnosis?

Image courtesy of Medscape.

Mole or Melanoma? Test Yourself With These Suspicious Lesions

Theodore D Scott, RN, MSN, FNP-C, DCNP; Laura A Stokowski, RN, MS | September 30, 2019 | Contributor Information

Answer: Common blue nevus.

Blue nevi are gray-blue to bluish black; smooth-surfaced; flat, slightly elevated, or dome-shaped papules that slowly develop from a macule into a papule. Lesions are usually solitary and are found on the head and the neck, the sacral region, and the dorsal aspects of the hands and feet.[8]

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Hidden Heart Disease: 19 Dermatologic Clues You Should Know

Cardiac diseases often have cutaneous manifestations. Are you able to correctly diagnose these patients based on their dermatologic presentations?Slideshows, August 2019
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Malignant Melanoma

Malignant melanoma is a neoplasm of melanocytes or a neoplasm of the cells that develop from melanocytes. Although it was once considered uncommon, the annual incidence has increased dramatically over the past few decades. Surgery is the definitive treatment for early-stage melanoma, with medical management generally reserved for adjuvant treatment of advanced melanoma.Diseases/Conditions, February 2019
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