A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left forearm. She first noticed the lesion 4 months ago and says it occasionally itches but is otherwise asymptomatic. The patient also has numerous "freckles" that she attributes to playing golf during the summer. Medical history includes psoriasis, hypertension, and mild chronic obstructive pulmonary disease. She quit smoking 5 years ago and drinks 2 or 3 glasses of wine a week after golfing. On examination, there is a 5-mm, dark brown lesion at the dorsal surface of her distal left forearm; it has a smooth border and a small, eccentric nodule. In addition, multiple scattered, flat, light brown lesions are present on the nose, cheeks, and dorsal surface of the hands. Which of the following is the most appropriate next step in management of this patient's forearm lesion?

Question

A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left forearm.  She first noticed the lesion 4 months ago and says it occasionally itches but is otherwise asymptomatic.  The patient also has numerous "freckles" that she attributes to playing golf during the summer.  Medical history includes psoriasis, hypertension, and mild chronic obstructive pulmonary disease.  She quit smoking 5 years ago and drinks 2 or 3 glasses of wine a week after golfing.  On examination, there is a 5-mm, dark brown lesion at the dorsal surface of her distal left forearm; it has a smooth border and a small, eccentric nodule.  In addition, multiple scattered, flat, light brown lesions are present on the nose, cheeks, and dorsal surface of the hands.  Which of the following is the most appropriate next step in management of this patient's forearm lesion?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8b4_3bec_bc81_f931169fbb06_MD0003_00 The ABCDE criteria (Table) are useful in visual inspection of pigmented skin lesions to identify which may represent malignant melanoma. However, although the ABCDE criteria can assist in evaluation of superficial spreading melanoma, they are less effective in identifying nodular or atypical melanomas. Nodular melanomas account for up to 30% of all melanomas but may not meet any of the ABCDE criteria until they are relatively advanced. To address this shortcoming, additional visual criteria should be considered in assessing risk of melanoma: In a patient with multiple pigmented lesions, a lesion that is substantially different from the others (eg, shape, color) may represent melanoma ("ugly duckling sign"). The "ugly duckling sign" has a sensitivity of up to 90% for melanoma. Palpable nodularity often corresponds with vertical growth of a melanoma and increases metastatic risk. The Breslow depth (distance from the epidermal granular cell layer to the deepest visible melanoma cells) is the most important prognostic indicator in malignant melanoma. Benign pigmented lesions are usually asymptomatic; biopsy should be considered for moles that itch, bleed, or are associated with local sensory symptoms (eg, tingling). Although this patient's lesion does not have any of the ABCDE characteristics, she has a pruritic, nodular lesion that is significantly different from her other pigmented lesions. She should therefore undergo a full-thickness excisional biopsy with initial margins of 1-3 mm of normal tissue. (Choices A and E) Actinic keratoses are roughened papules that usually occur in sun-exposed areas (eg, face, hands). They can be treated by destruction in situ with cryotherapy or topical fluorouracil. Actinic keratoses are rarely pigmented, and nodularity is more consistent with melanoma. Actinic keratoses (Choice C) Periodic surveillance is recommended for patients with numerous or atypical nevi, but suspected melanomas warrant tissue confirmation without delay. atypical nevi (Choice D) Shave biopsy is not recommended for most cases of suspected melanoma because partial removal may not provide adequate tissue for diagnosis and does not allow for accurate depth measurement. Educational objective: A mole may represent melanoma if it appears substantially different from others ("ugly duckling sign"), itches or bleeds, or develops nodularity. If melanoma is suspected, an excisional biopsy should be obtained. References: Revised U.K. guidelines for the management of cutaneous melanoma 2010. (http://www.ncbi.nlm.nih.gov/pubmed/20608932) The ABCDEF rule: Combining the "ABCDE rule" and the "ugly duckling sign" in an effort to improve patient self-screening examinations. (http://www.ncbi.nlm.nih.gov/pubmed/25741397)

A 62-Year-Old Woman Comes to the Office for Evaluation of a Pigmented