Saturday General Session Pigmented Lesions: When to Worry

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Saturday General Session

Pigmented Lesions: When to Worry

Ted Rosen, MD Professor of Dermatology Baylor College of Medicine Chief of Dermatology Services Michael E. DeBakey VA Medical Center Houston, Texas Educational Objectives By completing this educational activity, the participant should be better able to: 1. Recognize endogenous and exogenous risk factors for melanoma development. 2. Expand differential diagnosis of pigmented lesions and improve diagnostic skills. 3. Enhance understanding of controversial areas in melanoma (pregnancy, OCP,

endocrinopathy). 4. Develop comprehensive "sun sense" strategy for patient education.

Speaker Disclosure Dr. Rosen has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company.

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PIGMENTED LESIONS: WHEN TO WORRY

Ted Rosen, MDProfessor of Dermatology

Baylor College of MedicineHouston, Texas

CONFLICT OF INTEREST DISCLOSURE

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無

なし

없음

LEARNING OBJECTIVES

By the end of this educational activity, learners should be better able to:1. Recognize endogenous and exogenous risk factors for

melanoma development. 2. Expand differential diagnosis of pigmented lesions and improve

diagnostic skills.3. Enhance understanding of controversial areas in melanoma

(pregnancy, OCP, endocrinopathy).4. Develop comprehensive "sun sense" strategy for patient

education.


ALWAYS


ALWAYSWhen in doubt: BIOPSY!

PIGMENTED LESIONS: WHEN TO WORRY Patient’s overall risk factors and lesional clinical features may suggest malignancy, but these are

neither absolute nor are they totally reliableEasy to miss “bad” lesion

If uncertain: biopsy/remove

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AUDIENCE POLLING #1PICK THE MELANOMA

A

C

B


A

B

C


A

B

C

AUDIENCE POLLING #4PICK THE BENIGN MOLE

A B C

DIAGNOSTIC ACCURACY

• Dermatologists tend to be better than PCP, BUT…• There is a great deal of overlap among many studies• PCP: 22%-81%• Derm: 75%-94%• Based on visual image examination only• Dermatoscope increases and almost equalizes

diagnostic accuracy (more on this later)

SKIN CANCER: IN PERSPECTIVE

https://www.aad.org/media/stats/conditions/skin-cancer

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SKIN CANCER: IN PERSPECTIVE

https://www.aad.org/media/stats/conditions/skin-cancer

BCC

SCCA

Melanoma

All other cancers

1,400,000

161,800

1,700,000

4,000,000+

SKIN CANCER IN PERSPECTIVEDEATHS!

SCCA + BCC: 3000 Melanoma: 6580

All other cancers599,601

https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2020.html

SKIN CANCER IN PERSPECTIVEDEATHS!

SCCA + BCC: 3000 Melanoma: 6580

All other cancers599,601

0.05% death rate

4% death rate

https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2020.html

PIGMENTED LESIONS: WHAT TO CONSIDER

• PERSON• LESION*• SPECIAL SITUATIONS

PHENOTYPE: WHO IS AT GREATER RISK? PERSON• Phenotype: Fair skin, fair hair, light eyes

• Hawaii and SW USA: 20-30 MM/100,000 pop/year• Gender: Men>Women (3:2) but no exclusion

• Extremities in women, Trunk in men • Age: More typical with age, but no exclusion

• 78% MM 45-84 years old, median age 65; Rare < 10• UV exposure: Chronic and/or blistering sunburn• Solid organ transplant• Other immunosuppression (other than SOTR)

SKINmed 2021;19:280-283JAMA Dermstol 2020;156:553-560https://seer.cancer.gov/statfacts.html.melanma

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PERSON• Number of moles!

• >50 body, > 11 either arm (all >2mm diameter)• Personal/family history pancreatic CA/astrocytoma

• p16/CDKN2A gene mutations• Personal history of Parkinson’s Disease• Familial Melanoma Synd (many dysplastic nevi)

• Family members with melanoma (discuss later)

JAMA Dermstol 2020;156:553-560https://seer.cancer.gov/statfacts.html.melanma

SKIN CANCER: PHENOTYPE = RISK

The Evils of Sunlight

1. Suppression of the immune system, including damage and destruction of Langerhans cells of the skin

2. Direct induction of melanocyte cell multiplication3. Damage of melanocyte DNA, especially suppressor

genes/products (p16)

UV EXPOSURE: UNEXPECTED!

• 20% yearly UV is due to direct• 10% yearly UV is due to reflected

• Water, Sand, Snow• 70% yearly UV is diffuse

Br J Dermatol 2012;167:383-90

• ~Half of adults report sunburn each year• Melanoma risk doubles if >5 sunburns

during lifetime by history• A SINGLE blistering sunburn (age <20)

doubles lifetime risk of melanoma

Br J Dermatol 2001; 144;471-75.MMWR Morb Mortal Wkly Rep 2012; 61:317-22.

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THE LESION: ARE THERE CLUES?

CA Cancer J Clin 1985;35:130-151

ABCD of Melanoma

THE LESION: ARE THERE CLUES?

CA Cancer J Clin 1985;35:130-151JAMA 2004;292;2771-2776Arch Dermatol 2005;141:1032-34Arch Dermtol 2006;142:528-529CA Cancer J Clin 2010;60:301-316

THE LESION: ARE THERE CLUES?ABCD -> ABCCCDEEEEFNPRUU (CHECKLIST)A = AsymmetryB = Border irregularityC = Color variegation (irregular contour, changing)D = Diameter > 6mmE = Evolving, Elevation, Enlargement, ErythemaF = Funny looking N = NewP = Patient concernR = Regression U = Unusual, Ugly Duckling (compared to other lesions)

THE LESION: ARE THERE CLUES?ABCD -> ABCCCDEEEEFNPRUU (CHECKLIST)A = AsymmetryB = Border irregularityC = Color variegation (irregular contour, changing)D = Diameter > 6mmE = Evolving, Elevation, Enlargement, ErythemaF = Funny looking N = New (70-80% MM arise as new lesion)P = Patient concernR = Regression U = Unusual, Ugly Duckling (compared to other lesions)

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J Am Acad Dermatol 2017;77:938-45.)

NEW


PATIENT CONCERN

A AsymmetryB Border irregularC Multiple colorsD Large diameterE Evolving (by hx)


MELANOMA

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MELANOMAA AsymmetryB Border irregularC Multiple colorsD Large diameterE Evolving (by hx)

Regression PRACTICE: UGLY DUCKLING:WALK IN THE ROOM DIAGNOSIS


Father w/ MM

UGLY DUCKLING:WALK IN THE ROOM DIAGNOSIS






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UGLY DUCK

• Ugly duck pigmented lesion always deserves a careful examination

• Ugly duck pigmented lesion may well require a biopsy

• BUT…not all ugly duck pigmented lesions are melanoma, and in fact, MANY ugly ducks are benign!

UGLY DUCK

Benign moles (nevi)Seborrheic keratosisPigmented BCCDermatofibromaBlue nevusForeign body tattooNevus of OtaNevus of Ito

SEBORRHEIC KERATOSIS

UGLY DUCK = SEB KER

SEBORRHEIC KERATOSES AND MM

SK MM

SPECIAL SITUATIONS• Familial Melanoma Syndrome

• Many dysplastic nevi; +FH for melanoma• p16/CDKN2A gene mutations

• Large congenital nevus: > size of patient’s palm• Lentigo maligna: Large, face older, not quite MM• Acral melanoma: 80-90% in skin of color

• Feet, including sole, and Toes• Subungual (under nail)• NOT related to UV exposure

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FAMILIAL MELANOMA: DYSPLASTIC MOLE SYNDROME

• Worrisome lesion• Marked asymmetry• Irregular borders• Multiple colors• 8mm in diameter• Evolving? “Getting bigger”• DYSPLASTIC NEVUS

FAMILIAL MELANOMA:DYSPLASTIC MOLE SYNDROME





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LARGE CONGENITAL NEVUSLARGE CONGENITAL NEVUS

• Lifetime risk of melanoma 5-20%• Early removal recommended as 60% MM occur

before age 10• Staged removal with tissue expanders for larger

lesions, rather than single procedure

LENTIGO MALIGNA ACRAL MELANOMA

Guatemalan

African-American

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ACRAL SUBUNGUAL MELANOMA

• Single streak: Worry• Recent onset: Worry• Enlarging: Worry• Involving nail fold: Worry

MELANOMA: BETTER PROGNOSIS

• Younger age at diagnosis• Female gender• Location on extremities • Neither regional nor distant spread• Lentigo maligna subtype (face/elderly)

SKINmed 2021;288-296

DERMATOSCOPE: ENHANCED DIAGNOSTIC ACCURACY

• Polarized light• Magnification• Allows more accurate

assessment of lesion• Allows identification of

melanocyte patterns and other structures which suggest melanoma

MELANOMA AND DERMOSCOPY

MELANOMA AND DERMOSCOPYLIKELY MELANOMA

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PREVENTION?

• UV avoidance• No “extra” UV exposure (e.g., tanning beds)• Protective clothing when indicated• Sunscreen when indicated• Early detection

• Self examination • Professional exam

SUN SENSEYOUR PATIENTS, YOU, YOUR SPOUSE, YOUR KIDS

• Avoid sun 10am-3pm (especially in summer)

• UV passes thru clouds • UV passes thru 3 feet of water• Sand, snow, water reflect UV• No “extra” UV via tanning beds

• Physical cover-up Hat 3-inch brim Long sleeves Long pants Lightweight sun wear

• Sunscreen SPF at least 15-30 Broad spectrum Apply 30 min prior; then

reapply q2h

HATS: THE BASEBALL CAP

NEARLY USELESS

HATS: THE WIDE BRIM HAT

USEFUL

HATS3” BRIM

Wide Brim

PROTECTIVE CLOTHING: ADULT• Solumbra

• US made• Sunprecautions.com

• Solarsuit• Australian made• Solarsuit.com

• Coolibar• US made

(Aussie material)• Coolibar.com

• Long sleeve, long pant leg• Lightweight• Tight knit• Porous enough for sweat• High SPF, despite washing

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WHAT IS TRUE FOR ADULTS… SUNSCREEN

• Chemical and Physical• Equally effective

• ? Environmental effects • ? Benzene contamination• Consistent use with re-

application every 2 hours• Equally important is use of

physical barriers (hat/clothes)

PERIODIC SELF-EXAMINATION

https://www.skincancer.org/early-detection/self-exams/https://www.aad.org/public/diseases/skin-cancer/find/check-skinhttps://www.cancer.org/healthy/be-safe-in-sun/skin-exams.html

PERIODIC PROFESSIONAL EXAM

HOPE YOU ENJOYED THE PEARLS!

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Notes

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Saturday General Session Pigmented Lesions: When to Worry