Diagnosis and Work-up of Malignant Melanoma in the Age of Fine Needle Aspiration and Molecular Testing

Abstract

Malignant melanoma is an aggressive form of skin cancer and has demonstrated an increasing mortality among men in the last quarter century. 1 The 5-year survival rate is approximately 15-20 % for stage IV melanoma. 2 Surgical management of primary melanoma remains wide excision with or without the addition of sentinel lymph node biopsy. Clinical History and Initial Physical ExaminationFollowing the identification of a clinically suspicious pigmented lesion, the patient should have a focused medical history taken documenting the presence of any family history of melanoma or other skin cancer as well as whether or not there is a family history of multiple, irregular or prominent moles. The history should also include documentation of the presence or absence of pancreatic ductal carcinoma or astrocytoma within the family. The patient should be specifically questioned about a history of prior personal melanomas.A history of significant prior sun exposure should be documented.The patient should be asked about changes they have noted in other moles specifically regarding alterations in size, colour, shape or the presence of bleeding or ulceration. A personal history or family history of multiple nevus syndrome should be queried.Physical examination should include a total body skin examination with photography of nevi and other suspicious cutaneous lesions. This total body skin examination is performed to assess the number of nevi present and to distinguish between typical and atypical lesions. Biopsy of Primary Lesion and Histological ExaminationThe index atypical pigmented lesion should be excised in total if for BRAF V600-E, CKIT and NRAS.