Melanoma: An FP’s guide to diagnosis and management
This review details the latest recommendations on dermoscopy and excision techniques, indications for sentinel lymph node biopsy, and Tx options.
PRACTICE RECOMMENDATIONS
› Consider adding dermoscopy to the physical exam to increase sensitivity and specificity in diagnosing melanoma. A
› Perform wide local excision for invasive cutaneous melanoma: 1-cm margin for tumors up to 1 mm thick; 1 to 2 cm for tumors > 1 mm to 2 mm thick; and 2 cm for tumors > 2 mm thick. A
› Do not hesitate to consider, as needed, hormone replacement therapy or hormonal contraception for women with a prior diagnosis of melanoma, as this form of contraception does not confer an increased risk of melanoma. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE
You perform an elliptical excisional biopsy on your patient. The biopsy report comes back as a nodular malignant melanoma, Breslow depth 2.5 mm without ulceration, and no evidence of lymphovascular invasion or microsatellitosis. The report states that the biopsy margins appear clear of tumor involvement.
Further evaluation when the biopsy result is positive
Key steps in initial patient care include relaying pathology results to the patient, conducting (as needed) a more extensive evaluation, and obtaining appropriate consultation.
Clearly explain the diagnosis and convey an accurate reading of the pathology report. The vital pieces of information in the biopsy report are the Breslow depth and presence of ulceration, as evidence shows these 2 factors to be important independent predictors of outcome.22,23 Also important are the presence of microsatellitosis (essential for staging purposes), pathologic stage, and the status of the peripheral and deep biopsy margins. Review Breslow depth with the patient as this largely dictates treatment options and prognosis.
Evaluate for possible metastatic disease. Obtain a complete history from every patient with cutaneous melanoma, looking for any positive review of systems as a harbinger of metastatic disease. A full-body skin and lymph node exam is vital, given that melanoma can arise anywhere including on the scalp, in the gluteal cleft, and beneath nails. If the lymph node exam is worrisome, conduct an ultrasound exam, even while referring to specialty care. Treating a patient with melanoma requires a multidisciplinary approach that may include dermatologists, surgeons, and oncologists based on the stage of disease. A challenge for family physicians is knowing which consultation to prioritize and how to counsel the patient to schedule these for the most cost-effective and timely evaluation.
Expedite a dermatology consultation. If the melanoma is deep or appears advanced based on size or palpable lymph nodes, contact the dermatologist immediately by phone to set up a rapid referral. Delays in the definitive management of thick melanomas can negatively affect outcome. Paper, facsimile, or electronic referrals can get lost in the system and are not reliable methods for referring patients for a melanoma consultation. One benefit of the family physician performing the initial biopsy is that a confirmed melanoma diagnosis will almost certainly get an expedited dermatology appointment.
Continue to: Wide excision and sentinel node biopsy
