Nodular Melanoma

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What is a good primary care geared derm reference?

I was trying to find more specific info on nodular melanoma, and Up to Date/MDconsult aren't cutting it. All I can find are one paragraph blurbs in most texts, which is frustrating, because when I see something concerning that is benign by ABCDE stuff, this is the thing still in the back of my mind.

Specifically, everything say "characterized by rapid vertical growth phase" but what is "rapid" days, weeks, months? And is this followed by a horizontal growth phase, or does the lesion just become invasive and cease local growth?

I guess the final answer would always be "just Bx/excise" but I would still like to get a better idea of the natural history involved.

Medical advice related question and I'm guessing this thread will get locked. I would consult with a dermatology colleague instead of posing the question here.

This is not asking for medical advice; it's asking a clinical question I can't find a good answer to via the sources I've looked at. I'm asking for a good source for an issue that confuses me.

Originally Posted by ztaw15

This is not asking for medical advice; it's asking a clinical question I can't find a good answer to via the sources I've looked at. I'm asking for a good source for an issue that confuses me.

The appropriate source is a trusted dermatologist.
There is a reason why it is an entire field of medicine. Borderline stuff is not for the novice, derm is difficult.

:-)

Granted it is difficult. Hence the question. I think it's pretty strange to suggest that a difficult issue should not be explored by someone not going into Derm though. I'm not saying I want to be comfortable seeing a patient a making a Dx based on eyesight only though. Obviously this is an issue which in practice gets a dermatology referral.

Still, it is something I would like to know about. Is it necessary that I learn this exact piece of information? No. Just like it probably isn't necessary when I see a patient with Dax1 duplication to read about that topic. I probably won't see it again, and I certainly won't treat it, but color me curious. I guess that's the type of thing that draws one into medicine.

Originally Posted by ztaw15

Granted it is difficult. Hence the question. I think it's pretty strange to suggest that a difficult issue should not be explored by someone not going into Derm though. I'm not saying I want to be comfortable seeing a patient a making a Dx based on eyesight only though. Obviously this is an issue which in practice gets a dermatology referral.

Still, it is something I would like to know about. Is it necessary that I learn this exact piece of information? No. Just like it probably isn't necessary when I see a patient with Dax1 duplication to read about that topic. I probably won't see it again, and I certainly won't treat it, but color me curious. I guess that's the type of thing that draws one into medicine.

My post wasn't meant to dissuade you from learning more about it. Nothing wrong at all with being curious but I really do feel that you would be better served by asking a dermatology colleague in person so that you could have the discussion about various clinical scenarios.

Shaikh WR, Xiong M, Weinstock MA. The Contribution of Nodular Subtype to Melanoma Mortality in the United States, 1978 to 2007. Arch Dermatol. 2012 Jan;148(1):30-6.

It would be nice to get some attending input into this, as a resident, I would tell you I'm still not confident what early nodular melanoma looks like. I have ideas of what lentigo maligna melanoma, superficial spreading melanoma, even late nodular melanoma looks like but what is the prototypical image of an early nodular melanoma? I'm not sure if there actually is one. As such, it makes it difficult to recommend a great text on melanocytic lesions, especially for primary care doctors. Even if you refer to the primary literature (see above), it's clear that no one has a 100% grasp on the issue: we have not made a dent in incidence or mortality of nodular melanomas over a 29 year window

At the end of the day, I would have to echo everyone else's advice, this would be an issue that warrants referral to a dermatologist. And more often than not (given the legal climate), the patient will receive a biopsy or primary excision. Dermatologists in Europe/Australia may counter that dermoscopy is the next step but again, not in this legal climate.

Originally Posted by asmallchild

Shaikh WR, Xiong M, Weinstock MA. The Contribution of Nodular Subtype to Melanoma Mortality in the United States, 1978 to 2007. Arch Dermatol. 2012 Jan;148(1):30-6.

It would be nice to get some attending input into this, as a resident, I would tell you I'm still not confident what early nodular melanoma looks like. I have ideas of what lentigo maligna melanoma, superficial spreading melanoma, even late nodular melanoma looks like but what is the prototypical image of an early nodular melanoma? I'm not sure if there actually is one. As such, it makes it difficult to recommend a great text on melanocytic lesions, especially for primary care doctors. Even if you refer to the primary literature (see above), it's clear that no one has a 100% grasp on the issue: we have not made a dent in incidence or mortality of nodular melanomas over a 29 year window

At the end of the day, I would have to echo everyone else's advice, this would be an issue that warrants referral to a dermatologist. And more often than not (given the legal climate), the patient will receive a biopsy or primary excision. Dermatologists in Europe/Australia may counter that dermoscopy is the next step but again, not in this legal climate.

All these distinctions between 'superficial spreading', 'early nodular', 'late nodular' melanomas are completely bogus and made up. It's invasive melanoma, period. Look at breslow depth, etc to characterize it better. I diagnose average of 2 of these puppies per day so I know this subject inside out.

Learn how to recognize melanoma on human skin, and don't worry about the rest.

Deleted.

At Dermathalon; My last post was more directed at drdan's post.

At asmallchild; Thanks. This explains why I was having such a difficult time finding good info.

At nilf; I think, for me anyhow, is that the issue is how to recognize this particular form on skin in the first place, as well as how it behaves.

Originally Posted by ztaw15

At Dermathalon; My last post was more directed at drdan's post.

At asmallchild; Thanks. This explains why I was having such a difficult time finding good info.

At nilf; I think, for me anyhow, is that the issue is how to recognize this particular form on skin in the first place, as well as how it behaves.

I am glad you are interested, i am also interested in derm. I just meant that you are best served talking to a dermatologist in person, not posting on a derm forum. I also plan on asking my attendings the same questions about nodular melanoma. However, i expect some answer variation.

Pigmented skin lesions are quite an involved topic that happens to interest me as well. I also am not trying to dissuade you from learning. I just think your questions were outside the scope of primary care and warrant referral for both your patient and yourself. I am sure you know of a local derm that would be happy to discuss their impression of your patient and educate you as to why they feel the way they do. I don't think you are going to get a straight forward answer to your well thought, but very complicated melanoma questions on this forum

My 2 cents, no offense intended. I love hearing that other fields consider derm worth learning.

:-)

Nodular melanoma is the one that looks like two bearcubs in a knapsack fighting over a tuna fish.

SSM looks almost exactly the same, but it's a rainbow trout. The speckling is the key.

This ain't your mothers dots and globules, sonny. This is real world dermoscopy.

I will let this slide for now. But this forum should not be considered a definitive source of Dermatologic authority, on any level. Medical advice, clinical question... Same is same. My patients ask clinical questions all the time, seeking medical advice.

Originally Posted by Nilf

All these distinctions between 'superficial spreading', 'early nodular', 'late nodular' melanomas are completely bogus and made up. It's invasive melanoma, period. Look at breslow depth, etc to characterize it better. I diagnose average of 2 of these puppies per day so I know this subject inside out.

Learn how to recognize melanoma on human skin, and don't worry about the rest.

Agreed. Nodular, in my mind, is a clinical presentation that may portend a more aggressive tumoral biology from the outset, but it's still an invasive melanoma and prognosis should be similar compared to like Breslow's depth lesions.