Diagnosis and Management of Melanoma

Clinical Presentation and Diagnosis

A progressive change in the size of a lesion is a major sign that requires referral or excision for melanoma, as recommended by the American Academy of Dermatology 1, 2
Regional lymph node enlargement (preauricular and cervical) is highly suggestive of melanoma with nodal metastasis, as the risk of lymph node involvement correlates with the maximum thickness of the primary tumor, according to the National Comprehensive Cancer Network 3, 4, 5
The number of involved lymph nodes is the most important prognostic factor in melanoma with locoregional lymph node involvement, as stated by the British Journal of Cancer 6, 7

A complete physical examination, including the skin of the head, is recommended to detect primary or metastatic melanoma, as suggested by the British Journal of Cancer 3, 4
Examination of all regional lymph nodes is necessary, as recommended by the British Journal of Cancer 4, 5
A full excision with a 2 mm margin of normal skin is the standard practice for suspected malignant melanocytic lesions, not partial biopsy, according to the American Academy of Dermatology 1, 2
The use of a surgical knife, rather than laser or electrocoagulation, is recommended to avoid tissue destruction that may interfere with diagnosis and assessment of histological prognostic factors, as stated by the British Journal of Cancer 4, 1
Histopathology reports should include the diagnosis of melanocytic nature and confirmation of malignancy, maximum tumor thickness (Breslow method), level of invasion (Clark), and presence or absence of ulceration, as recommended by the British Journal of Cancer 3, 4

For isolated lymph nodes, fine-needle aspiration cytology can be considered as a diagnostic aid, but definitive diagnosis can only be made after histopathological examination of tissue, as stated by the British Journal of Cancer 5, 6
Ultrasonography of superficial regional lymph nodes is indicated in cases with clinical uncertainty, as recommended by the British Journal of Cancer 4, 6

In cases with regional lymph node involvement or metastasis, screening for other metastatic lesions is justified to guide further therapy, as suggested by the British Journal of Cancer 5, 6
CT scans of the abdomen, thorax, and brain appear to be most useful for detecting distant metastases, as recommended by the British Journal of Cancer 5
Approximately 10% of cases are found to have asymptomatic distant metastases at the time of diagnosis of involved lymph nodes, as stated by the British Journal of Cancer 5

The Breslow index is the strongest and most commonly used prognostic factor for single melanomas that can be excised, as stated by the British Journal of Cancer 5, 6
The status of the sentinel lymph node is the most important prognostic factor among patients with localized melanoma who undergo sentinel lymph node biopsy, as recommended by the National Comprehensive Cancer Network 7

The 1 cm lesion shows asymmetry, border irregularity, color heterogeneity, diameter > 6 mm, and recent evolution, fulfilling multiple ABCDE criteria for melanoma assessment【8】【9】【10】.
New‑onset pain in the lesion is an atypical but concerning sign that may reflect deeper invasion or ulceration【11】.
Age 71 places the patient in a high‑risk age group for melanoma development【8】.

Perform a full‑thickness excisional biopsy with a 2 mm margin of normal skin around the lesion; partial or incisional biopsies are inadequate for accurate staging【8】【9】.

Confirm the melanocytic nature and malignancy status of the lesion【11】.
Measure and report the maximum tumor thickness in millimeters (Breslow depth)【9】.
Determine and report the level of invasion (Clark level)【11】.
Include the mitotic rate for thin melanomas【10】.
State whether the excision margins are clear (complete excision)【11】.

Do not use frozen‑section analysis for pigmented lesions, as it is insufficient for definitive diagnosis【11】.
Do not assume that pain indicates a benign process; melanoma can be painful, especially when ulcerated or rapidly growing【11】.

Atypical mycobacterial or fungal infections can present as painful subcutaneous nodules in elderly or immunocompromised patients and should be considered if immune deficiency is present【12】.
Nocardia infection may produce subcutaneous nodules or abscesses, often initially painless, and is more common in immunocompromised hosts【12】.