- What is the diagnosis?
This is a malignant melanoma. A "mole" that shows changes over a short period of time (weeks to months) should raise suspicion. Changes in shape, size, and color or features such as pain and bleeding signal a potential for a malignant process.
One technique helpful for selecting lesions for removal because of high risk is dermoscopy (epiluminesence microscopy). Dermoscopy is a non-invasive method for analysis of morphologic features of pigmented skin lesions using incident light magnification with oil immersion. Morphologic criteria including atypical pigment network, gray-blue areas, atypical vascular pattern, radial streaks, blotchy pigmentation, irregular dots and globules, and regression (depigmentation) can be analyzed closely to help distinguish a malignant lesion.
- From examination of the lesion in the image, how could you say something about the prognosis?
The measurement of the depth of the lesion will be useful in predicting the prognosis, as follows:
| Breslow's Thickness | 5 Year Disease-free Interval |
| Less than 0.75 mm | 98% |
| 0.75 - 1.5 mm | 50-90% |
| More than 1.5 mm | 50% |
- If the sentinel nodes had no disease, what is the significance?
The absence of metastases in sentinel lymph nodes (those nodes draining the region where the melanoma was located) suggests a greater probability that he will remain disease free.
- The patient surfs the World Wide Web and finds several sites touting experimental 'cures' for melanoma. What should you tell him?
The Internet is not a controlled environment, and the quality of the information varies considerably. You can indicate that standard practice protocols are being used in treatment. If the disease were advanced and considered incurable, with little hope for standard treatments providing benefit, then alternatives of any kind, legitimate or not, become attractive.
You can find what experimental clinical trials with treatment protocols are available by going to the National Institutes of Health (NIH) website or to http://www.clinicaltrials.gov/ But it is easy to exaggerate the likelihood of these protocols being helpful: some are phase I trials, not seeking therapeutic levels of a new drug, but just safe levels; others may be phase II, seeking therapeutic levels, but of something that will turn out to not be therapeutic, or even could turn out to be dangerous. Furthermore, some of those trials are placebo controlled, so your patient may not get anything of value--less than he might have gotten had he not enrolled in a clinical trial!
Clinical trials can be viewed more as a chance to help future patients than a long shot chance to be cured. Presenting it this way to the patient is more honest and allows the patient to make more realistic plans for the future. If the patient does improve on whatever treatment is chosen, that patient won't be mad that you tried to prepare them for the worst or be disappointed that you were wrong!
