DIALOGUE

[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma .
[doctor] mrs. jackson , it's good to meet you .
[patient] likewise , wish it were under better circumstances .
[doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ?
[patient] yes , that's what the biopsy said .
[doctor] okay and when did you first notice the spot ?
[patient] my mom noticed it when i was visiting her last month .
[doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ?
[patient] yes , i wanted to be extra cautious because skin cancer does run in my family .
[doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ?
[patient] my mom and her sister , i think they both had melanoma .
[doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ?
[patient] my grandfather had pancreatic cancer .
[doctor] okay , and was that your mom or dad's father ?
[patient] mother's .
[doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ?
[patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before .
[doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ?
[patient] yes , that's correct .
[doctor] okay , and for social history can you tell me what you do for work ?
[patient] i own an auto repair shop .
[doctor] okay and have you ever been a smoker ?
[patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying .
[doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?
[patient] i had gall bladder and appendix .
[doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ?
[patient] no , i've been feelin' great .
[doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind .
[patient] sure .
[doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ?
[patient] okay , that's fine .
[doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam .
[doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .
[patient] okay , i should n't worry too much then ?
[doctor] no , i have a low suspicion that it will show anything .
[patient] okay , good .
[doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision .
[patient] okay , that is fine with me , i ca n't see back there anyways .
[doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else .
[patient] yeah , she did say she wants to see me back .
[doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight .
[patient] yeah , she definitely went over that , um , several times with me .
[doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ?
[patient] um , no i ca n't think of any at this time .
[doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you .
[patient] thank you , nice to meet you as well .
[doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border .
[doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin .
[doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance .
[doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

CLINICAL NOTE

CHIEF COMPLAINT

Melanoma.

HISTORY OF PRESENT ILLNESS

Sophia Jackson is a very pleasant 57-year-old female who presents for a surgical consult for melanoma of the right inferior back. She was referred by her dermatologist who biopsied the 0.7 mm lesion on 04/10 and diagnosed the melanoma. The lesion was initially noticed by the patient's mother when she was visiting her last month. Mrs. Jackson denies a personal history of atypical nevi and reports that she has annual mole checks by her primary care provider at her physicals. She has never seen a dermatologist prior to last month. There is a family history of melanoma in her mother and maternal aunt. The patient reports that she has been in her usual state of health with no unintentional weight changes, headaches, fatigue, nausea, vomiting, or vision changes.

PAST HISTORY

Medical
None reported.

Surgical
Cholecystectomy.
Appendectomy.

SOCIAL HISTORY

Patient owns an auto repair shop.
Current smoker since teens. Actively trying to quit.

FAMILY HISTORY

Mother: melanoma.
Maternal aunt: melanoma.
Maternal grandfather: pancreatic cancer.
No family history of breast or ovarian cancers.

MEDICATIONS

None.

ALLERGIES

Augmentin.

PHYSICAL EXAM

Hematologic/lymphatics: No axillary, cervical, or supraclavicular lymphadenopathy. There is a soft lymph node in the right groin. Nontender.
Skin: On the right inferior back there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation. There's no intrinsic or satellite lesions. No other suspicious moles.

RESULTS

Pathology Report.

Pathology: Shave biopsy of right inferior back malignant melanoma, invasive, superficial spreading.
Histology: Superficial spreading.
Clark level: 4.
Breslow thickness: 0.7 mm.
Radial growth phase: present.
Vertical growth phase: not identified.
Mitotic figures: less than 1 mm2.
Ulceration: not identified.
Regression: not identified.
Lymphatic invasion: not identified.
Perineural invasion: not identified.
Microscopic satellitosis: not identified.
Infiltrating lymphocytes: breast.
Melanocytic nevus: not identified.
Predominant cytology: epithelioid.
Peripheral margin: positive.
Deep margin: Negative.
Stage: 1.

I reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central amelanotic component and irregular border.

ASSESSMENT AND PLAN

The patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE's of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed.