Family Medicine · Year 3 · from Family Medicine

Case 2: Suspicious Pigmented Lesion

Patient Demographics

  • Age: 58 years old
  • Sex: Female
  • Occupation: Golf instructor

Chief Complaint

"I have a mole on my back that my husband says has changed."

History of Present Illness

Mrs. Barbara Thompson is a 58-year-old woman presenting because her husband noticed a mole on her upper back that appears to have changed. She cannot see it herself but he reports it has become darker and larger over the past 6 months. She first noticed it about 5 years ago as a small brown spot. She has no symptoms - no itching, bleeding, or pain. She has numerous other moles on her body that have not changed.

She has extensive sun exposure history due to her occupation as a golf instructor for 30 years. She admits to several blistering sunburns as a teenager. She does not regularly use sunscreen.

Past Medical History

  • Hypertension
  • History of actinic keratoses (treated with cryotherapy)
  • Basal cell carcinoma removed from nose 3 years ago

Family History

  • Mother: Melanoma (age 62, survived)
  • Father: Non-melanoma skin cancer
  • Sister: Multiple atypical moles

Social History

  • Non-smoker
  • Social drinker
  • Married
  • Golf instructor, extensive outdoor sun exposure
  • Lives in Arizona

Physical Examination

  • Vital Signs: BP 132/80 mmHg, HR 70, BMI 25
  • Skin - Full Body Examination:
  • Lesion of concern (left upper back):
  • 12 mm pigmented lesion
  • Asymmetric shape
  • Irregular, notched borders
  • Color variation: Brown, dark brown, and black areas
  • Raised area on one side, flat on other
  • Fitzpatrick skin type II (fair skin, burns easily)
  • Numerous (>50) benign-appearing nevi
  • Several atypical nevi on trunk
  • Actinic keratoses on forearms (2)
  • Well-healed scar on nose from BCC excision
  • Lymph nodes: No palpable cervical, axillary, or inguinal lymphadenopathy

ABCDE Assessment of Concerning Lesion

  • A - Asymmetry: Present (one half does not match the other)
  • B - Border: Irregular, notched, poorly defined
  • C - Color: Variegated (multiple shades of brown/black)
  • D - Diameter: 12 mm (>6 mm)
  • E - Evolution: Changed/enlarged over 6 months per husband

Assessment and Diagnosis

  1. Suspicious pigmented lesion - Concerning for melanoma given ABCDE criteria; requires biopsy
  2. Multiple risk factors for melanoma:
  • Prior melanoma in first-degree relative (mother)
  • History of non-melanoma skin cancer (BCC)
  • Extensive sun exposure
  • Fair skin (Fitzpatrick II)
  • Multiple nevi (>50)
  • History of blistering sunburns
  1. Actinic keratoses - Precancerous lesions from chronic sun damage
  2. Atypical nevi - Require monitoring

Management Plan

For Suspicious Lesion:

  • Excisional biopsy - Gold standard for suspicious pigmented lesion
  • Full-thickness excision with narrow margins (1-2 mm)
  • Send for histopathology
  • Do NOT perform shave biopsy for lesions suspicious for melanoma (need full depth for staging)
  • If melanoma confirmed: Wide local excision margins based on Breslow depth, possible sentinel lymph node biopsy, oncology referral

For Actinic Keratoses:

  • Cryotherapy to two lesions on forearms today
  • Discuss field therapy (5-fluorouracil cream) if multiple lesions develop

Skin Cancer Prevention Counseling:

  • Sun protection: Daily sunscreen SPF 30+, reapply every 2 hours when outdoors
  • Protective clothing, wide-brimmed hat
  • Avoid peak sun hours (10 AM - 4 PM)
  • No tanning beds
  • Monthly self-skin exams with partner assistance for back

Referral:

  • Dermatology referral for full-body skin examination given high-risk features
  • Dermatoscopy evaluation of atypical nevi
  • Consider baseline total body photography for monitoring

Follow-Up

  • Results of biopsy in 7-10 days
  • If melanoma confirmed: Urgent surgical oncology/dermatology for definitive management
  • Regular skin surveillance (every 3-6 months given risk factors)

Teaching Points

  1. ABCDE criteria for melanoma:
  • Asymmetry
  • Border irregularity
  • Color variation
  • Diameter >6 mm
  • Evolution (change over time)
  • "Ugly duckling sign": Lesion that looks different from patient's other moles
  1. Melanoma risk factors:
  • Family history of melanoma (2-3x increased risk with first-degree relative)
  • Fair skin, light hair/eyes
  • History of blistering sunburns
  • Multiple nevi (>50)
  • Atypical nevi
  • Prior melanoma or non-melanoma skin cancer
  • Immunosuppression
  • Intense intermittent sun exposure
  1. Biopsy technique: Excisional biopsy is preferred for lesions suspicious for melanoma to obtain full thickness and assess Breslow depth. Shave or punch biopsies may transect the lesion and compromise staging.
  1. Primary care role:
  • Perform skin cancer screening in high-risk patients
  • Recognize concerning lesions
  • Perform or refer for biopsy
  • Counsel on sun protection
  • Know when to refer to dermatology

All cases for this lecture as Markdown