An 82-year-old man comes to the office for evaluation of a spot on his back. He thinks the skin lesion has been present for many months to a few years but is unsure. The lesion was asymptomatic until it recently started itching; it is large and dark, but the patient is not sure whether it is evolving. The spot is shown in the image below: Which of the following is the most appropriate next step in management of this patient's skin lesion?

Question

An 82-year-old man comes to the office for evaluation of a spot on his back.  He thinks the skin lesion has been present for many months to a few years but is unsure.  The lesion was asymptomatic until it recently started itching; it is large and dark, but the patient is not sure whether it is evolving.  The spot is shown in the image below:  Which of the following is the most appropriate next step in management of this patient's skin lesion?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8b5_4d5f_bc81_935da4b8524f_MD0003_00 The initial clinical assessment of pigmented skin lesions should emphasize identifying those that could be melanoma and therefore warrant biopsy. Biopsy is appropriate in any of the following situations: The lesion has features that suggest melanoma using a validated predictive rule (eg, lesions displaying ≥1-2 of the ABCDE criteria). The lesion has inflammatory changes; itching, crusting, or bleeding; or sensory changes (eg, paresthesia). The lesion is significantly different in appearance from other lesions on the same patient (ugly duckling sign). The lesion develops thickening or nodularity, which may indicate vertical growth and increase metastatic risk. This patient's lesion is asymmetrical with a somewhat irregular border and notable color variegation (dark brown, light brown, and pink). The associated itching further raises the risk, as does the apparent nodularity. To rule out melanoma, full-thickness excisional biopsy with 1- to 3-mm margins of normal tissue is recommended. Partial excision (eg, deep shave biopsy, central or peripheral punch biopsy) is generally only considered for very large lesions or lesions in locations where complete excision may be problematic (eg, ear, face); partial excision may not allow adequate sampling for diagnosis or accurate measurement of the lesion's depth (the most important prognostic indicator in melanoma) (Choices D and E). (Choice A) In-situ destruction via cryotherapy or topical fluorouracil is indicated for treatment of actinic keratosis. Actinic keratosis presents as small, roughened papules in sun-exposed areas (eg, scalp, face, hands) and typically is not pigmented. Actinic keratosis (Choice C) Periodic surveillance is recommended for patients with numerous or atypical nevi that do not have suspicious features. Suspected melanomas warrant tissue confirmation without delay. Educational objective: The assessment of pigmented skin lesions should include a predictive rule to estimate the risk of melanoma, such as the ABCDE (Asymmetry, Border irregularities, Color variegation, Diameter, Evolving) rule; lesions with ≥1-2 of the ABCDE criteria warrant excisional biopsy. Biopsy is also recommended for lesions with inflammation; itching, crusting, or bleeding; or sensory changes and for lesions that are significantly different in appearance from other pigmented spots on the same patient (ugly duckling sign).

An 82-Year-Old Man Comes to the Office for Evaluation of a Spot