A 53-year-old man with fair skin presents for evaluation of a skin growth that has been gradually increasing in size over the past few months affecting his left elbow. The patient is unable to define a more precise duration of growth. The lesion does not bleed but is frequently traumatized, resulting in pain. He reports no personal or family history of skin cancer and denies tobacco use. He states that as a child, he spent ample time outdoors and frequently experienced sunburns. Examination reveals a 3.5cm hyperpigmented, hyperkeratotic plaque. No similar lesions are noted elsewhere, and axillary lymph nodes are nonpalpable.
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The incidence of melanoma has been increasing in the United States, and melanoma remains the most deadly of the skin cancers, resulting in more than 9000 deaths per year.1 The majority of cases are linked to ultraviolet light exposure from either the sun or artificial tanning beds.2,3
Nodular melanoma is the second most common subtype of melanoma after superficial spreading melanoma.4 Although it makes up 14% of all melanomas, it has the highest mortality risk, accounting for 40% of melanoma-related deaths.4,5 Nodular melanoma lesions often do not exhibit the classic ABCD criteria associated with the superficial spreading variant (asymmetry, border irregularity, color variation, and diameter >6 mm); these lesions are more likely to be of uniform color, without irregular borders, and more biologically aggressive.6-8 As such, these neoplasms may mimic a range of benign growths, which can cause delay in early detection.5
Dermoscopic features associated with nodular melanoma may be more suggestive of malignancy than clinical findings.8 The strongest predictor of outcome is the Breslow thickness.4
Shereen Timani, MD, is a board-certified dermatologist and dermatopathologist and is director of Johns Creek Dermatology in Johns Creek, Georgia. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
1. Guy GP Jr, Thomas CC, Thompson T, Watson M, Massetti GM, Richardson LC. Vital signs: melanoma incidence and mortality trends and projections – United States, 1982-2030. MMWR Morb Mortal Wkly Rep. 2015;64(21):591-596.
2. Gilchrest BA, Eller MS, Geller AC, Yaar M. The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med. 1999;340:1341-1348.
3. Le Clair MZ, Cockburn MG. Tanning bed use and melanoma: establishing risk and improving prevention interventions. Prev Med Rep. 2016;3:139-144.
4. Green AC, Baade P, Coory M, Aitken JF, Smithers M. Population-based 20-year survival among people diagnosed with thin melanomas in Queensland, Australia. J Clin Oncol. 2012;30(13):1462-1467.
5. Corneli P, Zalaudek I, Magaton Rizzi G, di Meo N. Improving the early diagnosis of early nodular melanoma: can we do better? Expert Rev Anticancer Ther. 2018;18(10):1007-1012.
6. Warycha MA, Christos PJ, Mazumdar M, et al. Changes in the presentation of nodular and superficial spreading melanomas over 35 years. Cancer. 2008;113(12):3341-3348.
7. Greenwald HS, Friedman EB, Osman I. Superficial spreading and nodular melanoma are distinct biological entities: a challenge to the linear progression model. Melanoma Res. 2012;22(1):1-8.
8. Kalkhoran S, Milne O, Zalaudek I, et al. Historical, clinical, and dermoscopic characteristics of thin nodular melanoma. Arch Dermatol. 2010;146(3):311-318.