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A 40-year-old woman noticed a new dark spot on her neck (Figure 172-1). On examination the spot was 8 mm in its longest diameter, was asymmetrical with irregular borders, and had variation in color. A scoop shave biopsy demonstrated melanoma in situ. The spot was excised with 0.5 cm margins and no residual tumor was found in the excised ellipse. She has a near 100% chance of complete cure.

Figure 172-1

Melanoma in situ on the neck of a 40-year-old woman. Note the central regression. (Courtesy of Richard P. Usatine, MD.)

The wife of a 73-year-old man noticed that a “mole” on his back was enlarging and bleeding. (Figure 172-2). It had been there for years. Even though a year earlier a doctor had told him not to worry about it, his wife sent him to have it rechecked. Figure 172-2B shows a close-up of the pigmented lesion showing ulceration and bleeding. An elliptical excision was performed and the tissue appeared to be a nodular melanoma with dark pigment into the subcutaneous fat (Figure 172-2C). Histology revealed a nodular melanoma with a Breslow depth of 22 mm. The patient was referred to surgical and medical oncology. He underwent wide excision with 2-cm margins and a sentinel lymph node biopsy. The sentinel node was positive and further nodal dissection showed a total of another 4 axillary lymph nodes positive (1 on right and 3 on left). The lymph nodes on the left were black and enlarged. No distant metastases were found. Because more than 2 regional nodes were macroscopically positive, he was stage IIIC. He received radiation treatment to the original site and both axillae. Despite advances in targeted chemotherapy and immunotherapy, his prognosis was poor.

Figure 172-2

A. A 73-year-old man presents with bleeding “mole” on his back. Elliptical excision demonstrates this to be a nodular melanoma of 22-mm depth. B. Closeup of the nodular melanoma showing it to be thick with ulcerations and bleeding. C. Nodular melanoma after initial resection showing dark pigment into the subcutaneous fat. The Breslow depth is 22 mm with Clark level V. (Courtesy of Richard P. Usatine, MD.)

Melanoma is the third most common skin cancer and the most deadly. The incidence of melanoma and the mortality from it are rising. Most lesions are found by clinicians on routine examination. When discovered early, surgical treatment is almost always curative. However, deeper lesions are prone to metastasize and have a much poorer prognosis. New therapies directed at the known gene changes in melanoma are beginning to show some promise, but ...

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