Family Medicine · Year 3 · from Family Medicine

Case 1: Skin Lesion Evaluation and Excision

Patient Demographics

  • Age: 52 years old
  • Sex: Male
  • Occupation: Outdoor landscaper

Chief Complaint

"I have this spot on my arm that's been changing. My wife is worried it might be cancer."

History of Present Illness

Mr. David Reynolds is a 52-year-old landscaper presenting with a changing pigmented lesion on his left forearm. He first noticed the spot about 2 years ago and thought it was a "sun spot" or freckle. Over the past 6 months, he has noticed it has grown larger, developed an irregular border, and become darker with some variation in color. It does not itch or bleed. His wife has become increasingly concerned and urged him to come in.

Past Medical History

  • Hypertension, well-controlled
  • History of multiple sunburns, including blistering sunburns as a teenager
  • No prior skin cancers

Family History

  • Father: Basal cell carcinoma (multiple)
  • No family history of melanoma

Social History

  • Works outdoors 8-10 hours daily
  • Does not consistently use sunscreen
  • Light skin type, freckles easily, does not tan well (Fitzpatrick Type I-II)
  • Non-smoker

Physical Examination of the Lesion

Location: Left dorsal forearm

ABCDE Assessment:

  • A - Asymmetry: YES - one half does not match the other
  • B - Border: Irregular, notched edges
  • C - Color: Variegated - brown, tan, black, with areas of pink
  • D - Diameter: 8 mm (larger than 6 mm pencil eraser)
  • E - Evolution: YES - patient reports significant changes over 6 months

Additional findings:

  • Flat (macular) without palpable elevation
  • No ulceration or bleeding
  • No satellite lesions
  • No palpable regional lymphadenopathy (axillary)

Clinical Image

Image: Visual demonstration of the ABCDE criteria for melanoma detection showing asymmetry, border irregularity, color variation, diameter greater than 6mm, and evolution over time.

Image Source: Wikimedia Commons Attribution: National Cancer Institute, Public Domain URL: https://commons.wikimedia.org/wiki/File:Melanoma_ABCDE.jpg

Clinical Impression

High suspicion for melanoma - lesion meets multiple ABCDE criteria in a high-risk patient (Fitzpatrick I-II, extensive sun exposure, family history of skin cancer)

Management Decision: Excisional Biopsy

Given the high clinical suspicion for melanoma, an excisional biopsy is the appropriate approach (rather than shave or punch biopsy) to:

  1. Provide complete histopathologic assessment including Breslow depth
  2. Potentially serve as definitive treatment if margins are adequate and lesion is thin
  3. Avoid transecting the lesion which could compromise staging

Informed Consent Discussion

Procedure explained: Complete removal of the lesion with a small margin of normal-appearing skin

Risks discussed:

  • Bleeding
  • Infection
  • Scarring
  • Nerve damage (numbness around the wound)
  • Need for re-excision if margins inadequate or melanoma confirmed
  • Pathology may reveal malignancy requiring further treatment

Benefits discussed:

  • Definitive diagnosis
  • Potentially curative if lesion is benign or early melanoma with adequate margins

Alternatives discussed:

  • Referral to dermatology for biopsy (appropriate alternative)
  • Observation (not recommended given high clinical suspicion)

Patient consented to procedure.

Procedure: Elliptical Excision

Preparation:

  • Surgical site marking: ellipse oriented along relaxed skin tension lines (longitudinal on forearm)
  • 2 mm clinical margins marked around visible lesion
  • Ellipse designed with 3:1 length-to-width ratio to prevent dog ears
  • Site cleansed with chlorhexidine
  • Sterile field established

Anesthesia:

  • 1% lidocaine with epinephrine
  • Calculated maximum dose: 7 mg/kg = 560 mg for 80 kg patient
  • Used approximately 5 mL (50 mg) - well within safe limits
  • Field block around lesion (not through the lesion)
  • Waited 5 minutes for vasoconstriction

Excision:

  • Incision made along marked ellipse using #15 scalpel
  • Incision extended to subcutaneous fat
  • Specimen undermined and removed in one piece
  • Hemostasis achieved with electrocautery

Specimen handling:

  • Specimen oriented with marking suture at 12 o'clock (superior)
  • Placed in 10% formalin
  • Pathology requisition completed with clinical description, diagram, and differential diagnosis (melanoma vs. dysplastic nevus vs. other)

Closure:

  • Wound undermined to reduce tension
  • Deep layer: 4-0 Vicryl buried interrupted sutures
  • Skin: 4-0 nylon simple interrupted sutures

Post-procedure:

  • Wound cleaned and dressed with petrolatum and non-adherent dressing
  • Patient instructed on wound care: keep dry 24-48 hours, then gentle cleaning, apply petrolatum and bandage daily
  • Activity: avoid heavy lifting or strenuous arm use for 1 week
  • Suture removal: 10-14 days (forearm)
  • Signs of infection to watch for: increasing redness, warmth, swelling, purulent drainage, fever
  • Follow-up scheduled for pathology results

Pathology Result (returned 5 days later)

Diagnosis: Malignant melanoma, superficial spreading type

  • Breslow thickness: 0.6 mm
  • No ulceration
  • Mitotic rate: 0/mm2
  • Margins: Negative (closest margin 1.5 mm)
  • No lymphovascular invasion

Stage: T1a (thin melanoma, no ulceration, no mitoses)

Further Management

Referral to surgical oncology/dermatology for:

  • Discussion of wide local excision (standard is 1 cm margins for melanoma ≤1 mm)
  • Current margins may be adequate but specialist evaluation recommended
  • Sentinel lymph node biopsy: generally not indicated for T1a melanoma <0.8 mm
  • Surveillance plan

Patient counseled on:

  • Excellent prognosis for thin melanoma (5-year survival >95% for T1a)
  • Importance of full body skin examinations regularly
  • Sun protection going forward
  • Teaching family members about skin examination

Teaching Points

  1. ABCDE criteria for melanoma: Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution/change
  1. Excisional biopsy is preferred for lesions suspicious for melanoma - allows complete assessment including Breslow depth
  1. Breslow thickness is the most important prognostic factor for melanoma
  1. Proper specimen handling:
  • Orient the specimen
  • Place in formalin
  • Complete requisition with clinical information
  1. Elliptical excision principles:
  • Orient along relaxed skin tension lines
  • 3:1 length-to-width ratio
  • Extend to subcutaneous fat
  • Undermine to reduce tension

All cases for this lecture as Markdown