Skin Lesion Station

Presenting Complaint: Jordan is concerned about the skin lesion on his right shoulder which has recently been rapidly enlarging and bleeding. He is worried that this might be skin cancer.

Quote: “I have a mole on my shoulder that’s always been there. It had been getting larger, but I thought it was fine. However, my partner noticed a bloodstain on my shirt and realised the mole was bleeding, which made us both worried that something might be wrong.”

Symptoms (SOCRATES):

Site: on the right shoulder:  “It is on my right shoulder”

Onset: 3 months ago: “This mole has been small and flat since I was a child and never caused any issues, but over the past three months, it has grown to about the size of a small pea”.

Character: bumpy, and black colour. “I’ve noticed a small bump, and it has turned black in colour”

Radiation: No similar lesions at anywhere of the body

Associated symptoms: itchy and bleeding “Sometimes it gets itchy, and the other day, my partner noticed it was oozing blood”.

Time: Enlarging over last 3 months, previously static

Exacerbating/Alleviating factors: Not exacerbated by sun exposure, no use of topical medications to alleviate the lesion and itchiness “It doesn’t seem to have gotten larger or changed colour with sun exposure. I haven’t used any topical treatments to try to make it go away”.

Severity: N/A

Others negative findings: no ulceration on the lesion, no mouth ulcers, no nail or hair changes.

Systemic review brief (metastatic approach)

• Weight loss, loss of appetite, night sweats - No
• Fever - No 
• Fatigue - No
• Headache - No
• Bone pain - No
• Lymphadenopathy or masses - No
• Cough or dyspnoea - No
• Change in bowel habit - No
• Urinary symptoms - No

Past Medical History

• No skin disease.
• No autoimmune disease.
• No previous history of hospitalisation or surgery

Drug history

• Not on any regular medications including OTC medications, or topical medication.

Allergies

• No known drug allergies.
• No atopy or allergy history such as hay fever

Social history

• Occupation - Farmer
• Has significant sun exposure due to outdoor nature of work, especially in summer. Minimal use of sun-cream and UV protection.
• Smoking - 10 cigarettes/day since age 20.
• Alcohol - Nil

Family History

• No family history of cancer
• No family history of skin disease

Ideas, Concerns, and Expectations:

- Ideas: Thinks that the recent growth must mean something is abnormal

- Concerns: Anxious about the possibility of this being cancer, and if so fear of treatment side effects

- Expectations: Expects a clear diagnosis of the lesion and a treatment plan

Observations:

- Respirations: 18 /min

- SPO2: 99 % on air

- Blood Pressure: 132/78mmHg

- Pulse: 82 bpm

- Consciousness: Alert and oriented.

- Temperature: 36.8 degree Celsius.

- NEWS Total Score: 0

General Inspection:

Appears mildly anxious, Jordan is white British, and has pale white skin and light brown hair. 

Inspection of the lesion:

• Distribution of the lesion –  Ugly duckling sign is present: one black nodule clearly stands out on the right shoulder, many freckles on the back present
• Site – on the right shoulder
• Size – 0.8 x 1cm  in diameter
• Symmetry - slightly asymmetrical 
• Shape – irregular rounded shape
• Colour - uneven black colour of varying shades
• Margin – irregular margin
• Any bleeding – no active bleeding however bleeds on touch
• No scaling, crusting or ulceration. Skin around the lesion is normal
• Normal mucosa, normal nails and hair appearance
• Lymph node examination - no palpable lymph nodes

Choose EITHER examiner viva questions OR patient communication questions

Patient questions 

• Is this cancer? 

The lesion looks suspicious and has some signs that might indicate melanoma, a type of skin cancer. These signs include things like an uneven shape, irregular borders in your lesion, diameter larger than 0.5 cm, and changing size. This doesn’t mean it’s definitely cancer, but we need to investigate further to rule out anything serious. I'll refer you urgently to see a dermatologist with a 2 weeks wait pathway for the further investigation and management.

• What are the outcomes like with melanoma?

Outcomes with melanoma, like most cancers, vary greatly and depend on several factors, such as how advanced the lesion is, and the extent of its spread throughout structures in the body, such as lymph nodes and other organs. We will have a better idea once we’ve done some more assessment and investigations. First of all we need to confirm whether this is a cancerous lesion or not. The deeper the melanoma and the more it has spread, the worse the outcome. If detected early on, outcomes can be very good.

• What is the next step?

When you see the dermatologist, they will examine your lesion closely using a dermatoscope. They will perform an excisional biopsy, which involves removing the entire lesion to look under the microscope. Once the biopsy results are available, the treatment options will depend on what they find. This could involve further removal of the lesion with wider margins and additional treatments like chemotherapy or immunotherapy. Today, treatments are becoming more personalized, and your case will be discussed by a team of specialists (MDT) to decide the most appropriate plan for you.

• What is that MDT for?

A multidisciplinary team is made up of dermatologists, surgeons, pathologists, oncologists, radiologists, and specialist nurses. These experts will meet to discuss the best treatment options for you. A member of the MDT will explain your treatment options to you, and you will be put in contact with a melanoma/skin cancer clinical nurse specialist (CNS) who will act as a point of contact for you if you have any queries or concerns.

Examiner Questions

1. What is your differential diagnosis?

• Malignant melanoma - This is the top differential due to the isolated nature of this unusual, evolving skin lesion, which has an irregular margin, changes in color with uneven distribution, and surface bleeding. Remember ABCDE: 
  • Asymmetry
  • Border irregularity
  • Colour variation and change
  • Different (to surroundings) + Diameter (>6mm)
  • Evolving
• Benign melanocytic naevus (mole) - This is the most common differential due to its pigmented appearance and high prevalence. May be removed for diagnosis to rule out melanoma or other malignancy.
• Pigmented basal cell carcinoma - This is a common skin cancer in the population, and a possible differential given the history of sun exposure, especially in areas most exposed to the sun. When pigmented it may be challenging to differentiate clinically from melanoma.
• Pigmented seborrheic keratosis - Should be considered due to the history of sun exposure, oozing from the lesion, and its size being greater than 7mm.
• Pigmented dermatofibroma - Considered due to the nodular shape of the lesion and pigmentation.
• Haemangioma - Also a differential due to the nodular shape, with thrombosed haemangioma potentially mimicking this presentation.

2. How will you manage this patient

I will refer him to the dermatologist under the urgent 2-week wait pathway for further assessment using a dermatoscope. The plan will include a wide excisional biopsy, and the case will be discussed at an MDT meeting. 

I will also inform the patient about the importance of self-examination for skin lesions, being aware of UV radiation, and avoiding vitamin D depletion. Additionally, I will discuss a referral to smoking cessation services.

3. Describe the staging of malignant melanoma?

Stage 0: in situ melanoma

Stage I A/B: thin melanoma (< 0.8 mm), or 0.8 mm to 1 mm non-ulcerated melanoma with no nodal or metastatic disease

Stage II A/B/C: 0.8 mm to 1 mm ulcerated melanoma, or > 1 mm thick melanoma with no nodal or metastatic disease

Stage III: regional nodal metastases or in transit metastases

Stage IV: systemic metastases.

The staging classification uses a combination of histological features and Breslow thickness. Melanoma confined to the epidermis is termed “melanoma in situ.”

4. What is Breslow thickness and the prognosis?

On excisional biopsy of the specimen (excised with 2mm margins), we can see the Breslow thickness as the depth of invasion of a lesion. This is measured with a micrometre on a microscope during histopathological evaluation, in millimetres from the top of the granular cell layer to the point of deepest tumour penetration in the dermis or subcutis:

• Thin: < 1 mm
• Intermediate thickness: 1 mm - 4 mm
• Thick: > 4 mm.

A wide excision will be performed with a margin ranging from 1 cm to 2 cm, depending on the Breslow thickness of the melanoma. The Breslow thickness plays a crucial role in prognosis. The shallower the melanoma, the better the survival rate. A thinner melanoma generally indicates a lower risk of spread and a more favourable outcome.