Of malignant melanoma, the evolution criterion, and lessons learned from patients

If something shows up on the skin,

Is it new?  How long has it been?

            The biopsy answer     

            Came back as cancer

The size of the head of a pin.

A couple decades ago, I walked into an exam room with a paper chart in my hand.  The patient, wearing Bermuda shorts, sat on the exam table.  Before I could say ‘hi’, the forefinger started stabbing at the knee, and the patient said (and I have never been able to speak as fast as the patient did, even with practice)  “Mysisterjustgotdiagnosedwithmalignantmelanomaandthisthingwasn’theresixmonthsagoandIwantitoffandIwantitoffNOW!”

I looked closely at the spot the patient pointed to, it was about the size of the period at the end of this sentence.  At the time, we used the ABCD criteria to determine whether or not to biopsy, and it failed all four. Asymetry: it was perfectly symmetric, a perfect circle. Border: the border of a perfect circle, there was no hint of irregularity. Color: it was completely, smoothly black, with no hint of variation of pigmentation.  Diameter: at the time we were using 8 millimeters as the dividing line.  So that the most suspicious lesion would have been big, with an irregular border, inhomogeneous pigmentation (red, white, blue, and black are the classic ones), and asymmetric; the lesion in question was the complete opposite.

But I also listened to the patient with a face covered with fear.  I saw the unique chance to amputate anxiety, and even if insurance weren’t going to pay me, and even if it went against convention, a biopsy was the right thing to do.  In less than four minutes, I had scrubbed the area, numbed up the spot, used a disposable 2 mm biopsy punch to cut a plug from the skin, and cauterized the base with silver nitrate. 

A week later the pathology report came back “malignant melanoma.”  The patient went on to a wide excision by a surgeon, and achieved complete cure. 

On a personal basis, I added the E criterion to the ABCD: Evolution (=changing); the medical literature followed a few years later.

Since my squamous cell skin cancer surgery, I’ve had a dressing on the center of my forehead, my patients have been asking, and I’ve been telling.  On Monday one of those patients asked in the middle of the story of fatigue and malaise.  I answered frankly, the patient pointed to the side of the nose and said, “This thing isn’t anything, is it?  It started out as a pimple, about a year and a half ago, and it’s just growing slowly.  You don’t have to do anything, do you?”

Even without looking, I knew I would do a biopsy.  Only about 4 mm around, it was raised, firm, pearly, surrounded by tiny blue and red blood vessels, and interrupted the surrounding skin lines.  It took about a minute to prep, anesthetize, shave, and cauterize. 

The report came back today in record time: basal cell skin cancer.  Before three my nurse had contacted the patient and had set up an appointment for definitive therapy.

A front line doc like me should have biopsy criteria so low that 95% of the reports come back non cancerous.  I can’t lower my criteria any further, and I’m getting back more than 10% malignant.

I almost never use asymmetry, border, color, or diameter as criteria because evolution trumps: if it’s new, if it has changed, it needs to come off. 

And I listen carefully to my patients.


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