Cases corner – 58 year old with a skin lesion

27th August 2019

John, a 58 year old man, presents to you worried about a mole on his back. It hasn’t bothered him before, and only noticed it because his wife saw it and asked him to get it looked at. He doesn’t know if it’s grown or changed in size; he responds with ‘Maybe it has.’ It’s not itchy and it’s never bled.

He reports his father had skin cancer when he was alive which was small cell carcinoma (of the nose). He has lived in the UK most of his life and worked on a building site. He has paid very little attention to his skin and seldom wears any skin protection. He doesn’t smoke. He mentions that he has a couple of other moles, so if you have time to check them out too.

You examine the patient: he has a pale complexion and you see the lesion here (there are no signs of bleeding/oozing or surrounding skin changes):

What would you do next?

  1. Reassure the patient that it is very unlikely to be sinister and review for changes in 4 weeks
  2. Refer on a non-urgent skin pathway for a suspected basal cell carcinoma
  3. Refer on a 2-week-wait skin pathway for suspected squamous cell carcinoma
  4. Refer on a 2-week-wait skin pathway for suspected melanoma

This patient’s lesion is suspicious of melanoma.

Melanoma is the fifth most common cancer in the UK with around 13,500 new cases each year. A full time GP is likely to diagnose approximately 1 person with melanoma every 3-5 years.

John’s presenting lesion (irregular shape and irregular colour) qualify him for a 2-week-wait suspected cancer referral. The NICE guidelines recommend to refer people if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more:

  • Major features of the lesion (scoring 2 points each):
    • Change in size
    • Irregular shape
    • Irregular colour
  • Minor features of the lesion (scoring 1 point each):
    • Largest diameter 7mm or more
    • Inflammation
    • Oozing
    • Change in sensation

Other reasons to refer if a clinical diagnosis of melanoma was suspected include the following:

  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if dermoscopy suggests melanoma of the skin. [new 2015]
  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma in people with a pigmented or non-pigmented skin lesion that suggests nodular melanoma. [new 2015]

This is why it is so important to be familiar with the features that distinguish melanoma from a benign naevus, as patients can be very poor historians with respect to changes in size, colour and any. Additional symptoms associated with the skin lesion.

Who else is at risk?

Patients with naevi that are greater than 5mm, and who have many naevi, especially those with over 100 are at a greater risk. A small number of melanomas are familial, as a result of an inherited gene known as FAMMM (familial atypical multiple mole melanoma syndrome).

Patients who are immunosuppressed, either through medication or medical condition, are also at a much greater risk.

In women melanoma is most commonly found on the lower legs (42%) and in men, it is usually found on the head, neck, chest and back.

Melanoma in the UK

86% of melanoma cases in the UK can be prevented. The primary cause of melanoma is from UV (ultraviolet) radiation. Half occur from previously normal looking skin; others can develop from a pre-existing mole or freckle. Typically, they are an irregular shape and are more than one colour.

Previously, melanoma has been most prevalent in patients over 65 – accounting for half of all diagnoses. However, it is now the second most common cancer in adults under the age of 50 – with 25% of all skin cancers occurring in people under the age of 50.

At stage 1, 100% of patient will survive 5 year or more, at stage 2, 85% of patients will survive 5 years or more. At stage 3, only 50% will survive 5 years or more, and at stage 4 less than 20% will survive to 5 years.