Msk Dermatology · Year 2 · from Msk Dermatology

Case 3: Melanoma with Breslow Depth Assessment

Patient Presentation

Demographics: 45-year-old female

Chief Complaint: Changing mole on her back

History of Present Illness: The patient's husband noticed that a mole on her upper back has changed over the past 6 months. It has become darker, larger, and developed irregular borders. She reports it occasionally itches but has no pain or bleeding. She has a history of multiple sunburns as a child and teenager.

Past Medical History:

  • Fair skin with multiple nevi
  • History of blistering sunburns in childhood
  • Family history: Father had melanoma at age 52

Physical Examination:

  • Upper back:
  • 12 mm pigmented lesion
  • Asymmetric shape
  • Irregular, notched borders
  • Color variation: Brown, black, red, and blue-gray areas
  • The lesion looks different from her other moles ("ugly duckling")
  • No palpable lymphadenopathy

Workup and Results

ABCDE Assessment:

  • Asymmetry: Present
  • Border irregularity: Present
  • Color variation: Present (multiple colors)
  • Diameter: >6 mm (12 mm)
  • Evolving: Yes (changing over 6 months)

Excisional Biopsy:

  • Malignant melanoma, superficial spreading type
  • Breslow depth: 1.8 mm
  • Clark level IV
  • Ulceration: Absent
  • Mitotic rate: 3/mm2
  • Margins: Clear

Staging:

  • LDH: Normal
  • CT chest/abdomen/pelvis: No metastases
  • PET scan: Negative
  • BRAF V600E mutation: Positive

Clinical Image

Clinical photograph of melanoma demonstrating the ABCDE features: Asymmetry, Border irregularity, Color variation (brown, black, blue-gray), Diameter >6mm, and Evolution (history of change).

Diagnosis

Melanoma, Superficial Spreading Type, Stage IIA (T2a N0 M0)

Features:

  • ABCDE criteria positive
  • Superficial spreading (most common subtype)
  • Breslow depth 1.8 mm
  • BRAF V600E positive

Discussion

This case illustrates melanoma diagnosis and staging:

  • ABCDE Criteria: The lecture describes the ABCDE criteria: Asymmetry, Border irregularity, Color variation, Diameter >6mm, and Evolving. This patient meets all five criteria.
  • Superficial Spreading Most Common: The lecture identifies superficial spreading as the most common melanoma subtype (70% of cases).
  • Breslow Depth: The lecture emphasizes that Breslow depth (tumor thickness) is the most important prognostic factor for melanoma. This patient's 1.8 mm depth places her at intermediate risk.
  • BRAF Mutations: The lecture notes that BRAF mutations are present in approximately 50% of melanomas, making patients eligible for targeted therapy if advanced disease develops.
  • Sentinel Lymph Node Biopsy: The lecture recommends SLNB for melanomas with Breslow depth greater than 0.8-1.0 mm.

Treatment Plan

  1. Wide Local Excision:
  • 1-2 cm margins for 1.01-2.0 mm Breslow depth
  • 2 cm margin recommended for this 1.8 mm lesion
  1. Sentinel Lymph Node Biopsy:
  • Indicated (Breslow >0.8 mm)
  • Staged with wide excision
  1. Adjuvant Therapy (if SLNB positive):
  • Anti-PD-1 immunotherapy (pembrolizumab or nivolumab)
  • OR BRAF/MEK inhibitor (dabrafenib + trametinib)
  1. Surveillance:
  • Clinical exam every 3-6 months for 2 years, then every 6-12 months
  • Annual full-skin exam for life
  • Consider imaging based on stage
  1. Patient Education:
  • Sun protection
  • Monthly self-skin exams
  • Educate family members (increased risk)

Teaching Points

  1. ABCDE criteria: Asymmetry, Border, Color, Diameter >6mm, Evolving
  2. Superficial spreading is the most common melanoma subtype
  3. Breslow depth is the most important prognostic factor
  4. SLNB recommended for melanomas >0.8-1.0 mm thick
  5. BRAF mutations present in ~50%; targetable with BRAF/MEK inhibitors

All cases for this lecture as Markdown