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Peripheral Arterial Disease: Interview With Dr James M. Grichnik
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Peripheral Arterial Disease: Interview With Dr James M. Grichnik
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>> Hello and welcome to JAMAevidence, our monthly podcast focused on the core issues in evidence-based medicine. This is Ed Livingston, Deputy Editor of Clinical Reviews in Education at JAMA. Thanks for joining us. So as you're doing the clinical exam, you may come across a lesion that has features requiring further investigation that might lead you to ask, does this patient have a mole or melanoma? That question is discussed in the Rational Clinical Examination and is the basis for today's conversation.
Joining me on the program is Dr. Jim Grichnik, Director of the Anna Fund Melanoma Program at the Sylvester Comprehensive Cancer Center, and Chief of the Frankel Family Division of Melanocytic Tumors in the Department of Dermatology and Cutaneous Surgery at the University of Miami, Miller School of Medicine. Dr. Grichnik is also co-author of a chapter in the Rational Clinical Examination on this topic. Let's start with the diagnosis. Dr. Grichnik, could you tell us what the typical patient looks like who might have a melanoma or a concern for melanoma, who presents to his primary care physician?
>> Well you know, melanoma is a disease that basically can affect anybody. In young adults 25 to 29, melanoma is the leading cancer. Sometimes that's overlooked, and it is very important to keep that in mind. And there are actually different types of melanoma, so there are different racial predispositions. The most common forms of melanoma, superficial spreading melanoma, nodular, and lentigo melanoma tend to occur in more fair-skinned individuals. So a typical person may be a more fair-skinned individual, history of sun damage, sunburns, and having evidence of sun damage on their skin surface through numerous lentigines or other skin lesions.
Particularly high-risk patients also may have numerous moles in addition to the lesion of concern. >> What about freckles? Does somebody with a lot of freckles have a higher risk? >> So that is another risk marker. Basically, there are a number of things that we look for. One is, you know, a red hair phenotype, light eye color, sun damage that might be reflected in freckles or in solar lentigines. Certainly, numerous moles, particularly the larger, more dysplastic nevi are of concern.
And then other factors. Have they had a prior melanoma? Have they had other skin cancers? Basal or squamous cell skin cancers? And then of course, family history can play in as well, if there's a family history of melanoma or possibly pancreatic cancer might be other things that we would integrate into kind of that risk equation. >> So we tend to view the typical patient as fair-skinned, red hair, freckles, blue eyes, but what's the risk for dark-skinned patients to get melanoma?
And what do you do about it? >> So everybody has a risk potentially of developing melanoma. Clearly the more fair-skinned individuals are at greater risk for certain types of melanoma, including superficial spreading melanoma, lentigo maligna melanoma, which we see in the more sun-damaged elderly population, and nodular melanoma. But acral lentiginous melanoma, or melanoma that often occurs in the hands and feet, or mucosal melanoma, is less racially biased if you will.
aIt's a melanoma that occurs in all skin types and skin colors. So it's really important that everybody pay attention to their skin surface, and if they have a spot that doesn't match the others, and is growing or changing, get it checked. >> When a patient comes to you in your clinic, how do you do the exam? >> So basically, a melanoma can occur everywhere. So we start from the top and move on through. In general, it's best to have the patient fully disrobe and put on a gown. I tend to start on the scalp.
I make sure there's not something covered up by the hair. I'll ask them whether a hairdresser or a barber has noted anything. I'll ask them if there's anything if they drag a comb or a brush across and have noted. Then move to the face. Basically, we're looking for basal cells and squamous cells as well as melanoma. You look for lesions that may be more clear in appearance, and have telangiectasias. Those might be the more basal cell-type lesions, particularly if there's something that is ulcerated, or the patient notes has bled and healed and bled again.
That'd be something that I'd pay particularly close attention to, and particularly with concern for basal cell. Scaly, firm lesions often on a little bit of an erythematous base, you'd worry about being a squamous cell. A pigment lesion on the face, particularly one that doesn't match other lesions on the face or is isolated is something you'd look at very closely. Make sure you're not looking at an early lentigo maligna-type melanoma. I do look quickly at the conjunctiva. Look quickly in the mouth.
Then generally go to the backside. I'd look at the back of the ears, and then look at the upper back, and really spend a fair amount of time on the back because if there are a number of melanomas that are hidden in that area, and it's a hard area for patients to see. At the same time making sure you're checking the back of the arms. I tend to move around to the front at that point. Complete the exam on the arms, checking the palms, checking the fingernails. Go down the chest and for female patients, often we'd have them disrobe on one side, look at the right side first, and then re-robe there and look at the left side next.
Often next I have a patient stand up, look at the buttock area, the back of the legs, have them sit back down, and then complete the leg exam. Thighs, if there's a lesion in the groin, have them point that out. And then really complete the exam with the feet while they're sitting down. I certainly do ask them if there's a certain spot or something that they were focused on or worried about, and make sure we put a little extra effort into that. It's not uncommon that a patient has noticed a change, and sometimes it's a subtle lesion, so it's important to ask them if there's something they're particularly focused on.
Essentially that would be the at least initial part of the clinical exam. And we can talk later about tools, but while we're doing that exam, if there are spots of concern, we tend to use our dermascope on those, which allows us to get a real close-up surface view of the structures of the lesion. And most of the time, very quickly we can determine hey, this is just a benign seborrheic keratosis. Or just a benign nevus, but occasionally we'll get a lesion where it's somewhat questionable, and then we'll want to spend more time trying to figure out if that's something we want to biopsy or not.
>> Dr. Grichnik, the crux of this Rational Critical Exam article is the ABCDE scoring system for melanoma. Could you tell us about that? >> So as melanomas grow, they progressively become more and more non-uniform. And that is largely based on the fact that melanomas are genomically unstable, whereas normal nevi are genomically stable. So as you grow and you produce different clones of cells. They grow at different rates, and they produce different amounts of pigment.
So these scoring systems are really kind of based on this abnormal non-uniform growth that occurs as the melanoma expands, and the ABCDEs are looking at the asymmetries of the lesion, the border regularity of the lesion, color changes, diameter in both the systems is roughly 6 or 7 millimeters. And this may be a magic number at which the non-uniform features become more evident in melanomas, and possibly a lot of moles stop growing at that point.
We don't necessarily wait to 6 millimeters. And we'll kind of get back to that in a moment. And then E has been added for evolution. So it's an important kind of teaching point to look at these lesions. Is it asymmetrical? Does it have border regularity? Does it have multiple colors? How big is it? Is it enlarging?
And those all do help you determine whether a lesion's melanoma or not. Actually, in the clinical setting, what we tend to do for early melanoma detection is really look for the lesion that doesn't match the others. Benign nevi are very common. There's something on the order of 200,000 benign nevi for every melanoma. While the driving mutation may be the same in the benign nevi as well as the melanoma, the melanomas tend to have other genetic defects that impact the cell cycle controls.
So as a normal mole grows, it's going to grow in a uniform manner and stop. But a melanoma will start growing and it might look like a normal mole early on. But because it doesn't have appropriate cell cycle controls and becomes genomically unstable as it continues to grow, it develops more and more of those non-uniform features. So early on it may look like another mole, but it tends to be unusual. So a spot that doesn't match the other spots on the patient, we already are worried about, particularly if it's growing.
But as it continues to develop, it will develop those additional features. >> So I'm a surgeon, and in my clinical practice, I've seen a fair amount of melanoma. Admittedly the ABCDE scoring system described in this Rational Clinical Examination is not one that I've really used. However, the ABCDE features are very important. So from my perspective, if you see any one of those features, it would be a signal to the physician to go on to the next step.
Is that a fair statement? >> Yeah. I think so. And I think that's how we look. But I think we have to be a little bit careful in trying to control how we approach these lesions, because again there's 200,000 to 1. And in patients with dysplastic nevi, they have a lot of these features. Matter of fact, their moles may actually have more ABCDEs than some melanomas. And for us in the clinic really making the decision to biopsy, we have to take that lesion in the context of what are the other lesions on the patient.
So if the patient has lots and lots of asymmetrical lesions, but they all kind of look similar, chances are he has dysplastic nevi and not necessarily melanoma. But that same lesion on a patient with no other similar lesions could very well be a melanoma. So you're right, if it's a non-uniform lesion, it is something we have to be concerned about. But in the clinic, we often base our degree of concern on how unusual that lesion looks compared to the patient's other lesions. And I will say that there are some melanomas that don't have a lot of these features.
Nodular melanomas, or one that's coming up in the dermis, may not have any of the ABCDE features, and really the only way we can find those is by recognizing this spot isn't normal, it doesn't match the other lesions on the patient. And particularly if we know it's growing, that's reason enough to remove it. >> So once you have suspicion that a melanoma is present, are there new technologies that help avoid having to biopsy everybody? >> Yeah, absolutely. So you know, the first step is the clinical exam.
You go head to toe, you ask the question, is there a lesion here that doesn't match the patient's other lesions, or lesions that I might be worried are different types of skin cancer in addition to melanoma? But once you identify those lesions, the first thing we tend to use now is called a dermascope. It's essentially a surface microscope, which we can place directly on the lesion, and it has a polarized or non-polarized light. And essentially it allows us to look at the surface growth pattern of these lesions. Look at the blood vessels.
Look at how the pigment is being laid out in the epidermis. It allows us to actually see the fine structures which does further allow us to discriminate a benign from malignant lesion. And physicians that use dermoscopy really have much higher accuracy rates in identifying whether it's a benign or malignant lesion, which allows you to focus on removing the lesions that are of greatest concern. Another tool we can use for patients that have lots of these atypical nevi is total body photos, which allows us to kind of look back in time and ask whether a lesion has changed or not.
You know, all melanomas will continue to grow in size. So a lesion that doesn't look right, that's growing in size, is clearly worrisome for melanoma. I do point out though that all acquired nevi were new at some point. So just because a lesion is growing, doesn't mean it's bad. But a lesion that is unusual for the patient, that's growing, particularly if it's growing in a non-uniform manner, is very worrisome for melanoma. So in addition to total body photos and dermoscopy, there's a third tool on the block right now called confocal microscopy.
And basically, this is real confocal microscopy that we can do on the patient without doing a biopsy. And it allows us to look into the skin about 100 microns or so, maybe 150 microns. But it allows us to actually see cellular detail through the epidermis and into the superficial papillary dermis. And this will allow us to look at what type of cells are there, what the architecture of the area is, and it's really a very cool tool that allows us to further discriminate a real melanoma from something that might just have a worrisome clinical pattern, but not really have melanoma within it.
>> So is the confocal microscopy approach what people call optical biopsies? >> That term may be a little bit more generic than just referring to just confocal. You know, it is a way of getting microscopic detail optically without removing a piece of skin. So in a sense it is an optical biopsy, but I'm not sure if that term is also applied to other techniques. >> So once you've assessed the patient and there's a suspicion of melanoma by whatever means that you've arrived at that suspicion, what's the best way to approach biopsy?
>> So if you're worried it's melanoma, the best way to approach it is if it's melanoma. So for many of these lesions, although it may be quicker just to shave, it really is more appropriate to excise. And you know, I would spend the time trying to do your best to discriminate the lesions that you're worried are melanoma from benign nevi. And then the lesion that you're worried is melanoma should be excised with a normal skin margin, a 1 to 2-millimeter skin margin, and down to fat.
And by doing that, you give the pathologist really the whole specimen to look at. Partial biopsies, removing part of the lesion, sometimes it's possible to remove the part that might have been a nevus that the melanoma developed in, so you might get a benign diagnosis back, when the lesion really is melanoma. So ideally, excise the whole lesion. Now having said that, some lesions are going to be too large for that to be done. And it's certainly fine and appropriate to do an incisional biopsy in those.
And there are situations such as lentigo maligna, which is an in situ sun damage-type of melanoma often present on the face, in which it may actually be appropriate to do a little more or less a shave excision on those, where you give the pathologist a larger portion of the epidermis, which will help them to make the diagnosis, as opposed to a smaller incision, which may not give them the length of the epidermis they need to be able to make the call.
So I guess in short, in general, if you can, try to excise the lesion fully. If it's a lentigo maligna, it may be appropriate to use more of a shave approach to give the pathologist the material she needs to make the diagnosis. But it would be best not to just shave the top off nevi [laughs]. >> Is it ever appropriate to do a punch biopsy? >> A punch excision would be best. So if you've got a 5-millimeter lesion on the patient that you're worried is melanoma, it might be best to put an 8-millimeter punch around that, and remove the lesion fully.
If you're looking at a centimeter large lesion, and you just do a 3-millimeter punch in it, you're only giving the pathologist a small portion of the sample, and he or she may not be able to render an accurate diagnosis. So I would say punch excisions are fine, but you really don't want to be doing small focal punch biopsies because you're potentially sending material to the pathologist that might not allow them to make the full diagnosis >> So I know some internists that freeze basal cell carcinomas in their clinic.
And is the difference between melanoma and basal cell carcinoma obvious enough that you can do that without having to biopsy these lesions first? >> So one, I'd start with I'm not recombining cryo for basal cell [laughs]. So you know, we would still recommend doing a shave and clearing the margin, or at least excising a lesion. But there's certainly is some risk that you might mistake an amelanotic melanoma for a basal cell. Use of dermoscopy helps. The basal cells will have these more telangiectatic vessels, whereas melanoma will have either a dotted vessel pattern or more of a polymorphous vessel pattern.
So if you do use these tools, you can actually do a better job of discriminating an amelanotic melanoma from a basal cell. Confocal microscopy of course does a marvelous job of segregating those tumors. So there are a lot of basal cells out there. The majority of the time, if it looks like a basal cell, it's probably basal cell. But clearly, we've all been surprised with an amelanotic melanoma. So if you're going to do that, certainly my preference would be you know, try to use as many tools as you can.
Learn the vessel pattern, use dermoscopy, and wouldn't be my recommendation at this point to be freezing basal cells. I would still go with, at a minimum, doing a superficial shave, and have the pathologist just check the margins on that. >> What sort of education do you provide for your patients regarding self-screening for melanoma? >> Really the key issue for patients and all of us is to pay attention to our skin surface. Once a month take a quick look. If you have a spot that doesn't really match your other spots, you don't remember, it seems to be growing and changing, those are the spots that you really want the dermatologist to take a look at.
The ABCDE features will develop, but I personally don't want to leave lesions on patients until they develop. So if you have a spot that doesn't look right, it's growing or changing, please get it checked. >> How do you counsel patients about sun exposure? >> So the first thing is know the time of day. As the sun goes higher in the sky, more and more mutagenic rays come through. And that four-hour period in the middle of the day, when the sun is right above you is when about 75% of the mutagenic rays hit the Earth. So if you can do activities earlier in the day, or later in the day, you reduce the number of mutations in your skin.
And the second point is wear clothing. People in the desert don't run around in bikinis or swim trunks. They cover up. They reflect the light away from their skin, and we should be doing the same thing. Wearing a tight-weave clothing that reflects the light away, particularly if you can use that with your fashion sense as far as going out golfing or gardening. It's also a very good way to protect yourself. And then as far as sunscreens, I do prefer the physical blockers. The ones based on zinc or titanium dioxide.
And certainly, I would recommend if you're going to be out there getting a lot of exposure, to have sunscreen on. >> Well, thank you Dr. Grichnik for this informative discussion. More information about this topic is available in the Rational Clinical Exam, and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm Ed Livingston, and I'll be back with you soon for another edition of JAMAevidence.
Segment:0 .
>> Hello and welcome to JAMAevidence, our monthly podcast focused on the core issues in evidence-based medicine. This is Ed Livingston, Deputy Editor of Clinical Reviews in Education at JAMA. Thanks for joining us. So as you're doing the clinical exam, you may come across a lesion that has features requiring further investigation that might lead you to ask, does this patient have a mole or melanoma? That question is discussed in the Rational Clinical Examination and is the basis for today's conversation.
Joining me on the program is Dr. Jim Grichnik, Director of the Anna Fund Melanoma Program at the Sylvester Comprehensive Cancer Center, and Chief of the Frankel Family Division of Melanocytic Tumors in the Department of Dermatology and Cutaneous Surgery at the University of Miami, Miller School of Medicine. Dr. Grichnik is also co-author of a chapter in the Rational Clinical Examination on this topic. Let's start with the diagnosis. Dr. Grichnik, could you tell us what the typical patient looks like who might have a melanoma or a concern for melanoma, who presents to his primary care physician?
>> Well you know, melanoma is a disease that basically can affect anybody. In young adults 25 to 29, melanoma is the leading cancer. Sometimes that's overlooked, and it is very important to keep that in mind. And there are actually different types of melanoma, so there are different racial predispositions. The most common forms of melanoma, superficial spreading melanoma, nodular, and lentigo melanoma tend to occur in more fair-skinned individuals. So a typical person may be a more fair-skinned individual, history of sun damage, sunburns, and having evidence of sun damage on their skin surface through numerous lentigines or other skin lesions.
Particularly high-risk patients also may have numerous moles in addition to the lesion of concern. >> What about freckles? Does somebody with a lot of freckles have a higher risk? >> So that is another risk marker. Basically, there are a number of things that we look for. One is, you know, a red hair phenotype, light eye color, sun damage that might be reflected in freckles or in solar lentigines. Certainly, numerous moles, particularly the larger, more dysplastic nevi are of concern.
And then other factors. Have they had a prior melanoma? Have they had other skin cancers? Basal or squamous cell skin cancers? And then of course, family history can play in as well, if there's a family history of melanoma or possibly pancreatic cancer might be other things that we would integrate into kind of that risk equation. >> So we tend to view the typical patient as fair-skinned, red hair, freckles, blue eyes, but what's the risk for dark-skinned patients to get melanoma?
And what do you do about it? >> So everybody has a risk potentially of developing melanoma. Clearly the more fair-skinned individuals are at greater risk for certain types of melanoma, including superficial spreading melanoma, lentigo maligna melanoma, which we see in the more sun-damaged elderly population, and nodular melanoma. But acral lentiginous melanoma, or melanoma that often occurs in the hands and feet, or mucosal melanoma, is less racially biased if you will.
aIt's a melanoma that occurs in all skin types and skin colors. So it's really important that everybody pay attention to their skin surface, and if they have a spot that doesn't match the others, and is growing or changing, get it checked. >> When a patient comes to you in your clinic, how do you do the exam? >> So basically, a melanoma can occur everywhere. So we start from the top and move on through. In general, it's best to have the patient fully disrobe and put on a gown. I tend to start on the scalp.
I make sure there's not something covered up by the hair. I'll ask them whether a hairdresser or a barber has noted anything. I'll ask them if there's anything if they drag a comb or a brush across and have noted. Then move to the face. Basically, we're looking for basal cells and squamous cells as well as melanoma. You look for lesions that may be more clear in appearance, and have telangiectasias. Those might be the more basal cell-type lesions, particularly if there's something that is ulcerated, or the patient notes has bled and healed and bled again.
That'd be something that I'd pay particularly close attention to, and particularly with concern for basal cell. Scaly, firm lesions often on a little bit of an erythematous base, you'd worry about being a squamous cell. A pigment lesion on the face, particularly one that doesn't match other lesions on the face or is isolated is something you'd look at very closely. Make sure you're not looking at an early lentigo maligna-type melanoma. I do look quickly at the conjunctiva. Look quickly in the mouth.
Then generally go to the backside. I'd look at the back of the ears, and then look at the upper back, and really spend a fair amount of time on the back because if there are a number of melanomas that are hidden in that area, and it's a hard area for patients to see. At the same time making sure you're checking the back of the arms. I tend to move around to the front at that point. Complete the exam on the arms, checking the palms, checking the fingernails. Go down the chest and for female patients, often we'd have them disrobe on one side, look at the right side first, and then re-robe there and look at the left side next.
Often next I have a patient stand up, look at the buttock area, the back of the legs, have them sit back down, and then complete the leg exam. Thighs, if there's a lesion in the groin, have them point that out. And then really complete the exam with the feet while they're sitting down. I certainly do ask them if there's a certain spot or something that they were focused on or worried about, and make sure we put a little extra effort into that. It's not uncommon that a patient has noticed a change, and sometimes it's a subtle lesion, so it's important to ask them if there's something they're particularly focused on.
Essentially that would be the at least initial part of the clinical exam. And we can talk later about tools, but while we're doing that exam, if there are spots of concern, we tend to use our dermascope on those, which allows us to get a real close-up surface view of the structures of the lesion. And most of the time, very quickly we can determine hey, this is just a benign seborrheic keratosis. Or just a benign nevus, but occasionally we'll get a lesion where it's somewhat questionable, and then we'll want to spend more time trying to figure out if that's something we want to biopsy or not.
>> Dr. Grichnik, the crux of this Rational Critical Exam article is the ABCDE scoring system for melanoma. Could you tell us about that? >> So as melanomas grow, they progressively become more and more non-uniform. And that is largely based on the fact that melanomas are genomically unstable, whereas normal nevi are genomically stable. So as you grow and you produce different clones of cells. They grow at different rates, and they produce different amounts of pigment.
So these scoring systems are really kind of based on this abnormal non-uniform growth that occurs as the melanoma expands, and the ABCDEs are looking at the asymmetries of the lesion, the border regularity of the lesion, color changes, diameter in both the systems is roughly 6 or 7 millimeters. And this may be a magic number at which the non-uniform features become more evident in melanomas, and possibly a lot of moles stop growing at that point.
We don't necessarily wait to 6 millimeters. And we'll kind of get back to that in a moment. And then E has been added for evolution. So it's an important kind of teaching point to look at these lesions. Is it asymmetrical? Does it have border regularity? Does it have multiple colors? How big is it? Is it enlarging?
And those all do help you determine whether a lesion's melanoma or not. Actually, in the clinical setting, what we tend to do for early melanoma detection is really look for the lesion that doesn't match the others. Benign nevi are very common. There's something on the order of 200,000 benign nevi for every melanoma. While the driving mutation may be the same in the benign nevi as well as the melanoma, the melanomas tend to have other genetic defects that impact the cell cycle controls.
So as a normal mole grows, it's going to grow in a uniform manner and stop. But a melanoma will start growing and it might look like a normal mole early on. But because it doesn't have appropriate cell cycle controls and becomes genomically unstable as it continues to grow, it develops more and more of those non-uniform features. So early on it may look like another mole, but it tends to be unusual. So a spot that doesn't match the other spots on the patient, we already are worried about, particularly if it's growing.
But as it continues to develop, it will develop those additional features. >> So I'm a surgeon, and in my clinical practice, I've seen a fair amount of melanoma. Admittedly the ABCDE scoring system described in this Rational Clinical Examination is not one that I've really used. However, the ABCDE features are very important. So from my perspective, if you see any one of those features, it would be a signal to the physician to go on to the next step.
Is that a fair statement? >> Yeah. I think so. And I think that's how we look. But I think we have to be a little bit careful in trying to control how we approach these lesions, because again there's 200,000 to 1. And in patients with dysplastic nevi, they have a lot of these features. Matter of fact, their moles may actually have more ABCDEs than some melanomas. And for us in the clinic really making the decision to biopsy, we have to take that lesion in the context of what are the other lesions on the patient.
So if the patient has lots and lots of asymmetrical lesions, but they all kind of look similar, chances are he has dysplastic nevi and not necessarily melanoma. But that same lesion on a patient with no other similar lesions could very well be a melanoma. So you're right, if it's a non-uniform lesion, it is something we have to be concerned about. But in the clinic, we often base our degree of concern on how unusual that lesion looks compared to the patient's other lesions. And I will say that there are some melanomas that don't have a lot of these features.
Nodular melanomas, or one that's coming up in the dermis, may not have any of the ABCDE features, and really the only way we can find those is by recognizing this spot isn't normal, it doesn't match the other lesions on the patient. And particularly if we know it's growing, that's reason enough to remove it. >> So once you have suspicion that a melanoma is present, are there new technologies that help avoid having to biopsy everybody? >> Yeah, absolutely. So you know, the first step is the clinical exam.
You go head to toe, you ask the question, is there a lesion here that doesn't match the patient's other lesions, or lesions that I might be worried are different types of skin cancer in addition to melanoma? But once you identify those lesions, the first thing we tend to use now is called a dermascope. It's essentially a surface microscope, which we can place directly on the lesion, and it has a polarized or non-polarized light. And essentially it allows us to look at the surface growth pattern of these lesions. Look at the blood vessels.
Look at how the pigment is being laid out in the epidermis. It allows us to actually see the fine structures which does further allow us to discriminate a benign from malignant lesion. And physicians that use dermoscopy really have much higher accuracy rates in identifying whether it's a benign or malignant lesion, which allows you to focus on removing the lesions that are of greatest concern. Another tool we can use for patients that have lots of these atypical nevi is total body photos, which allows us to kind of look back in time and ask whether a lesion has changed or not.
You know, all melanomas will continue to grow in size. So a lesion that doesn't look right, that's growing in size, is clearly worrisome for melanoma. I do point out though that all acquired nevi were new at some point. So just because a lesion is growing, doesn't mean it's bad. But a lesion that is unusual for the patient, that's growing, particularly if it's growing in a non-uniform manner, is very worrisome for melanoma. So in addition to total body photos and dermoscopy, there's a third tool on the block right now called confocal microscopy.
And basically, this is real confocal microscopy that we can do on the patient without doing a biopsy. And it allows us to look into the skin about 100 microns or so, maybe 150 microns. But it allows us to actually see cellular detail through the epidermis and into the superficial papillary dermis. And this will allow us to look at what type of cells are there, what the architecture of the area is, and it's really a very cool tool that allows us to further discriminate a real melanoma from something that might just have a worrisome clinical pattern, but not really have melanoma within it.
>> So is the confocal microscopy approach what people call optical biopsies? >> That term may be a little bit more generic than just referring to just confocal. You know, it is a way of getting microscopic detail optically without removing a piece of skin. So in a sense it is an optical biopsy, but I'm not sure if that term is also applied to other techniques. >> So once you've assessed the patient and there's a suspicion of melanoma by whatever means that you've arrived at that suspicion, what's the best way to approach biopsy?
>> So if you're worried it's melanoma, the best way to approach it is if it's melanoma. So for many of these lesions, although it may be quicker just to shave, it really is more appropriate to excise. And you know, I would spend the time trying to do your best to discriminate the lesions that you're worried are melanoma from benign nevi. And then the lesion that you're worried is melanoma should be excised with a normal skin margin, a 1 to 2-millimeter skin margin, and down to fat.
And by doing that, you give the pathologist really the whole specimen to look at. Partial biopsies, removing part of the lesion, sometimes it's possible to remove the part that might have been a nevus that the melanoma developed in, so you might get a benign diagnosis back, when the lesion really is melanoma. So ideally, excise the whole lesion. Now having said that, some lesions are going to be too large for that to be done. And it's certainly fine and appropriate to do an incisional biopsy in those.
And there are situations such as lentigo maligna, which is an in situ sun damage-type of melanoma often present on the face, in which it may actually be appropriate to do a little more or less a shave excision on those, where you give the pathologist a larger portion of the epidermis, which will help them to make the diagnosis, as opposed to a smaller incision, which may not give them the length of the epidermis they need to be able to make the call.
So I guess in short, in general, if you can, try to excise the lesion fully. If it's a lentigo maligna, it may be appropriate to use more of a shave approach to give the pathologist the material she needs to make the diagnosis. But it would be best not to just shave the top off nevi [laughs]. >> Is it ever appropriate to do a punch biopsy? >> A punch excision would be best. So if you've got a 5-millimeter lesion on the patient that you're worried is melanoma, it might be best to put an 8-millimeter punch around that, and remove the lesion fully.
If you're looking at a centimeter large lesion, and you just do a 3-millimeter punch in it, you're only giving the pathologist a small portion of the sample, and he or she may not be able to render an accurate diagnosis. So I would say punch excisions are fine, but you really don't want to be doing small focal punch biopsies because you're potentially sending material to the pathologist that might not allow them to make the full diagnosis >> So I know some internists that freeze basal cell carcinomas in their clinic.
And is the difference between melanoma and basal cell carcinoma obvious enough that you can do that without having to biopsy these lesions first? >> So one, I'd start with I'm not recombining cryo for basal cell [laughs]. So you know, we would still recommend doing a shave and clearing the margin, or at least excising a lesion. But there's certainly is some risk that you might mistake an amelanotic melanoma for a basal cell. Use of dermoscopy helps. The basal cells will have these more telangiectatic vessels, whereas melanoma will have either a dotted vessel pattern or more of a polymorphous vessel pattern.
So if you do use these tools, you can actually do a better job of discriminating an amelanotic melanoma from a basal cell. Confocal microscopy of course does a marvelous job of segregating those tumors. So there are a lot of basal cells out there. The majority of the time, if it looks like a basal cell, it's probably basal cell. But clearly, we've all been surprised with an amelanotic melanoma. So if you're going to do that, certainly my preference would be you know, try to use as many tools as you can.
Learn the vessel pattern, use dermoscopy, and wouldn't be my recommendation at this point to be freezing basal cells. I would still go with, at a minimum, doing a superficial shave, and have the pathologist just check the margins on that. >> What sort of education do you provide for your patients regarding self-screening for melanoma? >> Really the key issue for patients and all of us is to pay attention to our skin surface. Once a month take a quick look. If you have a spot that doesn't really match your other spots, you don't remember, it seems to be growing and changing, those are the spots that you really want the dermatologist to take a look at.
The ABCDE features will develop, but I personally don't want to leave lesions on patients until they develop. So if you have a spot that doesn't look right, it's growing or changing, please get it checked. >> How do you counsel patients about sun exposure? >> So the first thing is know the time of day. As the sun goes higher in the sky, more and more mutagenic rays come through. And that four-hour period in the middle of the day, when the sun is right above you is when about 75% of the mutagenic rays hit the Earth. So if you can do activities earlier in the day, or later in the day, you reduce the number of mutations in your skin.
And the second point is wear clothing. People in the desert don't run around in bikinis or swim trunks. They cover up. They reflect the light away from their skin, and we should be doing the same thing. Wearing a tight-weave clothing that reflects the light away, particularly if you can use that with your fashion sense as far as going out golfing or gardening. It's also a very good way to protect yourself. And then as far as sunscreens, I do prefer the physical blockers. The ones based on zinc or titanium dioxide.
And certainly, I would recommend if you're going to be out there getting a lot of exposure, to have sunscreen on. >> Well, thank you Dr. Grichnik for this informative discussion. More information about this topic is available in the Rational Clinical Exam, and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm Ed Livingston, and I'll be back with you soon for another edition of JAMAevidence.
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