1. Test yourself with these suspicious lesions
Mole or Melanoma?
Test yourself with these suspicious lesions

2. Slide 1: Melanoma is a malignancy of pigment-producing cells (melanocytes), located predominantly on the skin. Melanoma accounts for less than 5% of skin cancer cases, but the majority of skin cancer-related deaths. It is estimated that 76,100 new cases of melanoma will be diagnosed in the U.S. in 2014, with 9,710 resulting in death.[1] Early detection of cutaneous melanoma (shown) is the best means of reducing mortality. Can you correctly diagnose the lesions in this slideshow?

3. Slide 2: 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?

4. Slide 3: Answer: Congenital melanocytic nevus A congenital melanocytic nevus (ie, mole) is a proliferation of benign melanocytes that is either 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 occur approximately once in every 500,000 births. How are congenital nevi classified?

5. Slide 4: Congenital nevi are usually classified by size: small (<1
Slide 4: Congenital nevi are usually classified by size: small (<1.5 cm in diameter), medium ( cm in diameter), or giant (>20 cm in diameter). This benign congenital nevus shows 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?

6. Slide 5: 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). This patient has a nevus spilus (ie, speckled lentiginous nevus), a common benign melanocytic nevus with a speckled appearance. A nevus spilus can be macular or papular, exhibiting multiple smaller pigmented macules surrounding the central pigmentation. This lesion may be congenital or acquired, and it carries a small risk of malignant changes. 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 can be surgically removed for cosmetic appearance, a melanoma-like appearance, or new concerning changes in size or color.

7. Slide 6: A 55-year-man presented to his dermatologist for evaluation of this skin lesion located on the patient’s back. It is neither itchy nor tender and never bleeds. What is the likely diagnosis?

8. Slide 7: Answer: Compound nevus The congenital nevus on the previous slide was biopsied and found to be a category 1 superficial compound nevus. Compound nevi (a histologic diagnosis) often have features in common with malignant melanoma, such as asymmetry and poor circumscription. This nevus also has scattered darkly pigmented areas rather than a central darker area more typical of congenital nevi. Compound nevi are classified as follows: category 1, mild atypia; category 2, moderate atypia; and category 3, severe atypia, melanoma in situ arising in a nevus.

9. Slide 8: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 epidermis?

10. Slide 9: 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 mid-sternal area, exhibits irregular borders and asymmetry.

11. Slide 10:A 52-year-old woman presented to her primary care provider for evaluation of a new pigmented lesion with irregular borders to her left cheek. The patient states that her two sisters have multiple similar skin lesions. What dermatologic lesion(s) may be on your diagnosis given the patient’s family history?

12. Slide 11: Answer: Familial atypical mole and melanoma (FAMM) syndrome Atypical nevi that run in families may be part of the familial atypical mole and melanoma (FAMM syndrome; previously dysplastic nevus syndrome). People with FAMM syndrome must have the following: one or more first-degree or second-degree relatives with malignant melanoma; a large number of nevi (often more than 50), some of which are atypical nevi; nevi that are dysplastic on histopathology.[2]

13. Slide 12:This large compound nevus has mild to moderate atypia
Slide 12: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, 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,” shown). Atypical moles tend to be familial and have a higher rate of malignant transformation, so they must be closely monitored. This patient underwent a skin punch biopsy that revealed melanocytic atypia.

14. Slide 13: A 73-year-old man presented to his primary care provider for his yearly examination. On routine exam, the provider found this lesion on the posterior aspect of his right ear. What is this focal area of darker pigmentation?

15. Slide 14: Answer: Solar lentigo Solar lentigo is one of several benign conditions easily mistaken for melanoma. These small, 1-3 cm macules are usually round, light yellow to brown in color, and appear on chronically sun-exposed skin, such as the ear shown here. These macules can enlarge and eventually coalesce into patches. Solar lentigo (“liver spot”) is the most common benign sun-induced lesion of the skin.

16. Slide 15: This patient has a seborrheic keratosis on the nose, involving the skin and adipose tissue. It was diffusely pigmented, and no atypical melanocyte proliferation was identified after excisional biopsy. Seborrheic keratoses are the most common benign skin lesion in older individuals. Developing from a proliferation of epidermal cells, these growths occur more often in sun-exposed areas of the skin and have variable pigmentation (pinks to browns, occasionally dark brown or black). A reticulated type of seborrheic keratosis may develop from a solar lentigo. These lesions (“barnacles”) can grow larger; become irritated, crusty, and itch or bleed; and may appear waxy, soft, and greasy.

17. Slide 16: 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 with folds of skin. A shave biopsy can provide a histological diagnosis.

18. Slide 17: This benign seborrheic keratosis is located on the patient’s neck, an area that receives sun exposure. Because of its black color, this seborrheic keratosis can clinically resemble melanoma. Distinguishing superficial seborrheic keratoses from lentigo maligna and pigmented actinic keratoses can be difficult. The surface of this lesion is not as lustrous as that of a melanocytic nevus. Seborrheic keratosis does not develop into malignant melanoma.

19. Slide 18: This growth, measuring approximately 8 mm, is located on the patient’s shoulder and is well-defined with focal pigmentation. It is the most common variant of basal cell carcinoma. What is the diagnosis?

20. Slide 19: Answer: Nodular basal cell carcinoma This translucent pink papule has telangiectases and a crusted erosion, which are characteristic 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, although 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.

21. Slide 20: 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?

22. Slide 21: Answer: Features of melanoma, as evident in this image, include asymmetry, irregular borders, multiple shades of pigmentation, a blotchy appearance, an area of depigmentation, and an irregular surface texture. Melanoma is a malignancy of the pigment-producing melanocytes, a disease that has tripled among white individuals during the last 20 years. Malignant melanoma in situ was found on this patient’s shoulder.

23. Slide 22: A shave biopsy revealed this 7-8 mm asymmetrical growth to be melanoma in situ. “Melanoma in situ” implies that the melanoma is purely intraepidermal, and 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 greater suggests melanoma, although smaller melanomas are possible. The risk factors for melanoma include fair skin, having multiple sunburns as a child, having many moles (especially atypical nevi), use of tanning beds, and family history of melanoma in a first-degree relative.

24. Slide 23: 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 dermis, known as level I in the Clark system, as described on the next slide.

25. Slide 24: Clark levels are based on the layer of skin or tissue that is involved in the malignancy. However, 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, however (less than 1-mm thick), the Clark level can indicate that a melanoma is more advanced than indicated by the Breslow measurement. Therefore, both systems are used to help stage a melanoma. In either system, the melanoma has a worse prognosis if the pathologist determines it is ulcerated (covering layer of epidermis is absent).[3]

26. Slide 25: This table shows the Breslow depth of invasion as it relates to the approximate 5-year survival rate. The following melanomas include examples of Clark levels and Breslow depths of invasion.

27. Slide 26: Lentigo maligna melanoma is a subtype of invasive melanoma
Slide 26: 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 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. Usually found on sun-exposed skin, lentigo maligna melanoma is a slow-growing tumor that occurs most often in older adults. Legions are typically tan to brown, with varying colors; sometimes they appear to be a stain on the skin.

28. Slide 27: This 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 asymmetric 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.

29. Slide 28: This melanoma, located on the patient’s back, has a slightly irregular border and is also slightly asymmetrical. A brown macular and 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 be easy to bypass this melanoma as a melanocytic nevus if it was not examined closely, it was not compared to other moles on the patient’s body, and there was no inquiry about the evolution of the lesion.

30. Slide 29: This invasive malignant melanoma on a patient’s thigh is Clark level III, with a 0.6 mm Breslow level of invasion. Clinical findings include size greater than 7 mm, several different shades of brown including a dark center, and an irregular border. No ulceration was present.

31. Slide 30: This nodular pigmented malignant melanoma measures 3
Slide 30: 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.

32. Slide 31: 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 histological 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.