What is the appropriate approach to diagnosing and managing a patient with suspected skin malignancy, considering their medical history, demographic information, and treatment options?

Educational Questions for Skin Malignancies

Diagnostic Assessment Questions

What are the critical ABCDE criteria for melanoma identification?

• Asymmetry: One half of the lesion does not match the other half 1, 2, 3
• Border irregularity: Edges are ragged, notched, or blurred 1, 2, 3
• Color: Non-uniform pigmentation with multiple shades of brown, black, tan, red, white, or blue 1, 2, 3
• Diameter: Greater than 6 mm (approximately the size of a pencil eraser) 1, 2, 3
• Evolution: Changes in size, shape, color, elevation, or new symptoms like bleeding, itching, or crusting over time 1, 2, 3

The "ugly duckling" sign—identifying pigmented lesions that appear different from the patient's other moles—is an additional valuable screening tool 2, 3.

Which patient populations require heightened surveillance for skin malignancy?

• Patients over age 40 years with tobacco use, alcohol abuse, or immunocompromised status are at increased risk for head and neck squamous cell carcinoma 1
• Fair-skinned individuals with light-colored eyes, red or blond hair, history of frequent sunburns, extensive UV exposure, or indoor tanning bed use 2
• Patients with dysplastic nevi (atypical moles), multiple (≥100) nevi, or family history of melanoma 1
• Personal history of any prior skin cancer (basal cell, squamous cell, or melanoma) 2
• Patients with familial melanoma syndromes: those with ≥3 relatives affected by melanoma and/or pancreatic cancer, or multiple primary melanomas (≥3 invasive melanomas) with early age of onset (<45 years) 1

Management and Treatment Questions

What is the appropriate surgical approach for confirmed melanoma based on Breslow thickness?

• For melanoma with Breslow thickness 1-2 mm: perform wide excision with 1 cm margins 3
• For melanoma thicker than 2 mm: perform wide excision with 2-3 cm margins 3
• Complete excisional biopsy with 2 mm clinical margin and cuff of subcutaneous fat should be performed initially for suspected melanoma to allow accurate Breslow thickness measurement 3
• Routine elective lymphadenectomy is not recommended; sentinel lymph node biopsy should only be performed by experienced teams 1, 3

When should patients with melanoma be referred for genetic testing?

• Patients with ≥2 relatives affected by melanoma and/or pancreatic cancer (≥3 in the kindred total) should undergo genetic risk assessment, especially if a first-degree relative is involved 1
• Patients with multiple primary melanomas (≥3 invasive melanomas) and early age of onset (<45 years) should be evaluated for hereditary melanoma phenotype 1
• BAP1 mutation carriers have 13% risk of developing cutaneous melanoma and should be counseled accordingly 1

Follow-Up and Surveillance Questions

What is the recommended follow-up schedule for patients treated for melanoma?

• Clinical examinations every 3 months during the first 3 years after treatment 1, 2
• Clinical examinations every 6-12 months thereafter 1, 2
• For high-risk patients with thick primary tumors or following treatment of metastases, ultrasound of lymph nodes, CT, or whole body PET/PET-CT scans may be considered, though no consensus exists on routine imaging 1
• Rising serum S100 has higher specificity for disease progression than lactate dehydrogenase (LDH) and is the most accurate blood test if any monitoring is performed 1

What dermatologic monitoring is required for patients receiving BRAF/MEK inhibitor therapy?

• Dermatologic assessment every 2-4 weeks for the first 3 months of BRAF inhibitor monotherapy is recommended for patients with numerous squamoproliferative neoplasms 1
• Baseline dermatologic assessment and pre-treatment of actinic keratosis is warranted before initiating BRAF inhibitor therapy 1
• Cutaneous squamous cell carcinoma/keratoacanthoma development typically occurs within 8 weeks of starting therapy in older patients with pre-existing actinic damage 1
• Most cutaneous SCCs/keratoacanthomas can be managed with liquid nitrogen cryotherapy or deep shave/saucerization followed by electrodesiccation rather than complete surgical excision 1

Risk Stratification Questions

Which historical features increase suspicion for malignancy in a patient presenting with a neck mass?

• Age >40 years, tobacco use, alcohol abuse, or immunocompromised status increase suspicion for head and neck squamous cell carcinoma 1
• Symptoms including hoarseness, otalgia, hearing loss, intraoral swelling/ulceration, new numbness in oral cavity or cheek, dyspnea, odynophagia, dysphagia, weight loss, hemoptysis or blood in saliva, nasal congestion, and unilateral epistaxis 1
• History of prior head and neck malignancy, including skin cancer of the scalp, face, or neck 1
• For lymphoma: fever, night sweats, weight loss, lymphadenopathy distant from head and neck, or immunosuppressive/immunomodulating medications 1

What physical examination findings suggest malignancy in a skin lesion?

• Nontender neck masses are more suspicious for malignancy than tender masses 1
• Changes in skin lesion symmetry, border, color, or diameter, or presence of ulceration may suggest melanoma or other cutaneous malignancy 1
• Limited tongue mobility may indicate muscle or nerve invasion from tumor 1
• Tonsil asymmetry or mass/ulcer in oropharynx 1
• For melanoma specifically: lesions meeting ABCDE criteria, diameter >6 mm with recent changes, or "ugly duckling" appearance warrant specialist referral 3

Treatment Complications Questions

What are the common dermatologic toxicities of immune checkpoint inhibitor therapy for advanced melanoma?

• Dermatologic assessment should occur within the first month of immune checkpoint inhibitor therapy and continue as needed for management of skin side effects 1
• Patients with atopic dermatitis, psoriasis, or other autoimmune dermatoses should be seen before initiation of therapy by a dermatologist for pre-emptive counseling and treatment 1
• Appropriate recognition and control of skin side effects may improve quality of life and avoid unnecessary interruption of medication 1

What is the appropriate management approach for non-melanoma skin cancers?

• Surgical excision is the gold standard treatment for basal cell carcinoma 4
• Complete surgical excision with histological confirmation of clear margins is recommended for squamous cell carcinoma 4
• Mohs micrographic surgery should be considered for high-risk lesions including recurrent tumors, poorly defined borders, and high-risk anatomic sites 2, 3
• For basal cell carcinoma in H-zone of face with diameter ≥6 mm, moderate-risk location with diameter ≥10 mm, infiltrative or morpheaform histology, perineural invasion, or recurrent tumors: refer to specialist 3

Prevention and Screening Questions

What preventive measures should be recommended to all patients regarding skin cancer?

• Minimize sun exposure during peak UV hours and seek shade 2
• Wear protective clothing and sunglasses blocking 99% UV-A/UV-B radiation 2
• Apply broad-spectrum sunscreen SPF >15 2
• Completely avoid sunlamps and tanning beds, which are classified as carcinogenic 2
• Children, adolescents, and young adults aged 10-24 years with fair skin should be counseled about minimizing ultraviolet radiation exposure 1
• Oral nicotinamide shows early evidence for reducing squamous cell carcinoma risk in patients with history of keratinocyte carcinoma 2

What is the evidence for routine skin cancer screening in asymptomatic adults?

• The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in asymptomatic adults 1
• The SCREEN study found that between 20 and 55 excisions were performed to detect 1 case of melanoma, depending on patient age, with an estimated >4,000 excisions required to prevent 1 death from melanoma 1
• Overdiagnosis and overtreatment are important potential harms, though current evidence is insufficient to reliably determine the magnitude of this effect 1
• Visual skin examination remains the primary screening method for high-risk patients despite insufficient evidence for population-wide screening 2