View source for WBR0802

 {{WBRQuestion
|QuestionAuthor=[[User:Gonzalo Romero|Gonzalo A. Romero, M.D.]] [mailto:gromero@wikidoc.org]
|ExamType=USMLE Step 2 CK
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|MainCategory=Surgery
|MainCategory=Surgery
|SubCategory=Dermatology, Dermatology
|Prompt=A 42-year-old blond man originally from Portland at age 17 and has been working as a fisherman in the Caribbean. He comes to the clinic complaining of multiple nevi. He recently noticed that one of them has changed in appearance and is enlarging.  The nevus has multiple colors within the lesion, irregular borders and measures 1.9 cm.  A picture of the lesion is shown below.  Which of the following is the most important prognostic predictor?
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[[File:Melanoma_malignum.jpg|300px|center]]
|Explanation=Features that affect prognosis are tumor thickness in millimeters (Breslow's depth), depth related to skin structures (Clark level), type of melanoma, presence of ulceration, presence of lymphatic/perineural invasion, presence of tumor infiltrating lymphocytes (if present, prognosis is better), location of lesion, presence of satellite lesions, and presence of regional or distant metastasis.

Certain types of melanoma have worse prognoses but this is explained by their thickness. Interestingly, less invasive melanomas even with lymph node metastases carry a better prognosis than deep melanomas without regional metastasis at time of staging. Local recurrences tend to behave similarly to a primary unless they are at the site of a wide local excision (as opposed to a staged excision or punch/shave excision) since these recurrences tend to indicate lymphatic invasion.
[[File:Melanoma_2.jpg|200px|center|]] This is an example of a black, irregularly shaped, uniformly brown pigmented nevus on a 19-year-old man's right cheek. The Breslow index measured 2.88 mm, and a thorough medical evaluation revealed no evidence of metastases. The scar was reexcised with a 2-cm margin, and the skin was repaired with a graft.
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<font color="MediumBlue"><font size="4">'''Educational Objective:''' </font></font>
# Breslow's depth is used as a prognostic factor in melanoma of the skin. It is a description of how deeply tumor cells have invaded.
'''References:''' http://www.ncbi.nlm.nih.gov/pubmed/16258493?dopt=Abstract
 {{See also|Melanoma|Breslow's depth}}
|AnswerA=Diameter
|AnswerAExp=<font color="red">'''Incorrect.'''</font> A nevus larger than 5mm in diameter is suspected to be melanoma.  The characteristics of melanoma are '''ABCDE''':  asymmetry or abnormal shape, irregular borders, several colors within the lesion, and diameter larger than 6 mm and enlargement.  It can also present with itchiness or tenderness.
|AnswerB=Color
|AnswerBExp=<font color="red">'''Incorrect.'''</font>
|AnswerC=Depth of invasion
|AnswerCExp=<font color="Green">'''Correct.'''</font> See overall explanation
|AnswerD=Multiple nevi
|AnswerDExp=<font color="red">'''Incorrect.'''</font> Multiple nevi is not a sign of malignancy nor a prognostic factor for melanoma.
|AnswerE=Lymph involvement
|AnswerEExp=<font color="red">'''Incorrect.'''</font>  Less invasive melanomas even with lymph node metastases carry a better prognosis than deep melanomas without regional metastasis at time of staging
|RightAnswer=C
|WBRKeyword=melanoma, skin cancer,
|Approved=No
}}