SK.1. – A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin
mass over the bridge of the nose that has been slowly growing over the past three years. There are no
enlarged lymph nodes in the head and neck.
What is it? – Basal cell carcinoma.
How is it diagnosed? - Full thickness biopsy at the edge of the lesion (punch or knife).
Treatment: Surgical excision with clear margins, but conservative width.
SK.2. – A 71 year old West Texas farmer of Irish ancestry has a non-healing, idolent, punched out, clean
looking 2 cm. ulcer over the left temple, that has been slowly becoming larger over the past three years.
There are no enlarged lymph nodes in the head and neck.
What is it, and what needs to be done? - Same as above. This is another way for basal cell carcinoma to
show up.
SK.3. – A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer n the lower lip, that
has been present, and slowly enlarging for the past 8 months. He is a pipe moker, and he has no other
lesions or physical findings.
What is it? - Squamous cell carcinoma.
How is the diagnosis made? - Biopsy, as described before.
Treatment: he will need surgical resection with wider (about 1 cm.) clear margins. Local radiation therapy
is another option.
SK.4. – A red headed 23 year old lady who worships the sun, and who happens to be full of freckles,
consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is
asymetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms.
What is it? – The classical ABCD that alerts you to melanoma or a forerunner (dysplastic nevus).
Management: full thickness biopsy at the edge of the lesion, margin free local excision if superficial
melanoma (Clarks’ levels one or two, or under 0.75 mm), wide local excision with 2 or 3 cm. margin if
deep melanoma.
SK.5. – A 35 year old blond, blue eyed man left his native Minnesota at age 18, and has been living an
idyllic life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi
all over his body, but one of them has changed recently…
What is it? – Change in a pigmented lesion is the other tip off to melanoma. It may be growth, or bleeding,
or ulceration, or change in color…whatever. Manage as above.
SK.6. – A 44 year old man has unequivocal signs of multiple liver metastasis, but no primary tumor has
been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the
physical exam is a missing toe, which he says was removed at the age of 18 for a black tumor under the
toenail.
What is it? - A classical vignette for malignant melanoma (the alternate version has a glass eye, and history
of enucleation for a tumor). No self-respecting malignant tumor would have this time interval, but
melanoma will.
SK.7. – A 32 year old gentleman had a Clark’s level 5, 3.4 mm. Deep, melanoma removed from the middle
of his back three years ago. He now has…(a tumor in a weird place, like his left ventricle, his duodenum,
his ischiorectal area…anywhere!).
The point of this vignette is that invasive melanoma (it has to be deep) metastasizes to all the usual places
(lymph nodes plus liver-lung-brain-bone) but it is also the all-time-champion in going to weird places
where few other tumors dare to go.