Melanoma — MCQs
What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?
A patient presented with a 1 x 1.5 cm malignant growth (squamous cell carcinoma) on the lateral border of the tongue. The indicated treatment would be:
A patient consults a dermatologist about a skin lesion on her neck. Examination reveals a 1-cm diameter, red, scaly plaque with a rough texture and irregular margins. Biopsy demonstrates epidermal cells with large, pleomorphic, hyperchromatic nuclei. What is the most likely diagnosis?
Patient with pigmented skin lesion shows pagetoid spread of atypical melanocytes. Diagnosis?
Which of the following stages of lip carcinoma does not have nodal involvement?
A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
Elderly man with a long-standing mole on his face that is increasing in size and showing an irregular border. Diagnosis:
A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
Elderly man with long-standing mole over the face which is increasing in size and showing irregular border. Diagnosis:
A giant congenital melanocytic nevus is usually of what size?
Melanoma Indian Medical PG Practice Questions and MCQs
Question 1: What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?
- A. 2 cm (Correct Answer)
- B. 5 cm
- C. 7 cm
- D. 10 cm
Explanation: **2 cm** - For **thick melanomas** with a Breslow thickness greater than 2 mm, a **2 cm excision margin** is recommended to minimize local recurrence risk. - This margin ensures adequate removal of microscopic disease, balancing complete tumor excision with cosmetic and functional outcomes. *5 cm* - A **5 cm excision margin** is not standard for melanoma regardless of thickness and would result in excessive tissue removal. - Such large margins are generally reserved for very rare, extremely aggressive soft tissue sarcomas or other extensive skin malignancies. *7 cm* - A **7 cm excision margin** is significantly wider than current recommendations for any melanoma thickness. - This would lead to unnecessary morbidity, including large wound defects that might require complex reconstructive surgery. *10 cm* - A **10 cm excision margin** is exceptionally wide and not medically indicated for melanoma management. - Applying such a large margin would result in substantial tissue loss and functional impairment without offering additional survival benefit.
Question 2: A patient presented with a 1 x 1.5 cm malignant growth (squamous cell carcinoma) on the lateral border of the tongue. The indicated treatment would be:
- A. Interstitial brachytherapy (Correct Answer)
- B. Chemotherapy
- C. Laser ablation
- D. External beam radiotherapy
Explanation: ***Interstitial brachytherapy*** - This treatment is ideal for small, localized tumors, particularly those with a diameter of 1-1.5 cm on the **tongue**, as it delivers **high-dose radiation directly to the tumor** while sparing surrounding healthy tissue. - Its precision minimizes side effects typical of external radiation, making it suitable for superficial lesions where preservation of function is crucial. *Chemotherapy* - Chemo is typically indicated for **advanced stages of cancer**, metastasized cancer, or as an **adjuvant** to other therapies. - It is not usually the primary standalone treatment for a localized, resectable squamous cell carcinoma of this size. *Laser ablation* - While laser ablation can be used for very superficial or early-stage lesions, a 1.5 cm **squamous cell carcinoma** (SCC) may have deeper invasion that makes laser treatment alone insufficient for achieving **negative margins**. - Its use often depends on the tumor's depth of invasion and histology, which might be missed by superficial ablation. *External beam radiotherapy* - External beam radiotherapy (EBRT) delivers radiation from outside the body, affecting a wider area including healthy tissues, which could lead to more significant side effects like **xerostomia** and mucositis for a tongue lesion of this size. - While effective for larger or recurrent disease, it's generally considered less precise than brachytherapy for **small, localized tumors** where organ preservation is key.
Question 3: A patient consults a dermatologist about a skin lesion on her neck. Examination reveals a 1-cm diameter, red, scaly plaque with a rough texture and irregular margins. Biopsy demonstrates epidermal cells with large, pleomorphic, hyperchromatic nuclei. What is the most likely diagnosis?
- A. Dermal nevus
- B. Actinic keratosis (Correct Answer)
- C. Junctional nevus
- D. Compound nevus
Explanation: ***Actinic keratosis*** - This diagnosis aligns with the description of a **red, scaly plaque** with a **rough texture** and **irregular margins**, which are classic clinical features of actinic keratosis. - The biopsy findings of epidermal and dermal cells with **large, pleomorphic, hyperchromatic nuclei** are consistent with **atypical keratinocytes**, a hallmark of actinic keratosis, indicating **premalignant change**. *Dermal nevus* - A dermal nevus is a **benign melanocytic lesion** that typically presents as a smooth, flesh-colored to light brown papule or nodule, not a scaly or rough plaque. - Histologically, it would show nests of nevus cells primarily in the **dermis** without the significant cellular atypia described. *Junctional nevus* - A junctional nevus is a **benign melanocytic lesion** characterized by nests of nevus cells located at the **dermoepidermal junction**. - Clinically, it appears as a flat or slightly raised, well-demarcated macule or papule, usually uniform in color, lacking the scaly, rough, and irregular features of the presented lesion. *Compound nevus* - A compound nevus is a **benign melanocytic lesion** with nevus cell nests present at both the **dermoepidermal junction** and within the dermis. - It typically presents as a raised, pigmented papule or nodule with a smooth or slightly warty surface, not a scaly plaque with irregular margins.
Question 4: Patient with pigmented skin lesion shows pagetoid spread of atypical melanocytes. Diagnosis?
- A. Lentigo maligna
- B. Superficial spreading melanoma (Correct Answer)
- C. Blue nevus
- D. Nodular melanoma
Explanation: ### Superficial spreading melanoma - This is the most common type of melanoma and is characterized by a **radial growth phase** where atypical melanocytes spread along the **dermo-epidermal junction** and into the epidermis (pagetoid spread) [1]. - **Pagetoid spread**, referring to the upward migration of atypical melanocytes into the spinous and granular layers of the epidermis, is a hallmark histological feature. *Lentigo maligna* - This is a melanoma subtype primarily affecting **chronically sun-damaged skin** in older individuals, typically on the face. - While it has a prolonged **radial growth phase**, the atypical melanocytes tend to be confined to the **basal layer** and do not typically exhibit prominent pagetoid spread like superficial spreading melanoma. *Blue nevus* - A blue nevus is a **benign melanocytic lesion** characterized by the presence of dermal melanocytes that produce melanin deep within the dermis, giving it a characteristic blue or blue-gray color [2]. - It does not involve **atypical melanocytes** or **pagetoid spread** (upward migration of cells into the epidermis). *Nodular melanoma* - This is an aggressive subtype of melanoma characterized by a rapid **vertical growth phase** and minimal or absent radial growth phase [1]. - It presents as a **dark, raised nodule** and typically lacks the prominent pagetoid spread seen in the superficial spreading type, as its growth is primarily downward into the dermis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, pp. 1151-1152. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, p. 1146.
Question 5: Which of the following stages of lip carcinoma does not have nodal involvement?
- A. T2N1
- B. T3N0 (Correct Answer)
- C. T2N2
- D. T1N1
Explanation: ***T3N0*** - The **'N' classification** in the TNM staging system refers to **nodal involvement**. A stage with **'N0' indicates no regional lymph node metastasis**. - A **T3 lesion** signifies a large primary tumor, but if it's accompanied by **N0**, it means there's no evidence of spread to the lymph nodes. *T2N1* - The **'N1' classification** indicates the presence of **regional lymph node metastasis**, specifically in a **single ipsilateral lymph node** that is 3 cm or less in its greatest dimension. - This stage therefore **does have nodal involvement**, contradicting the premise of the question. *T2N2* - The **'N2' classification** signifies more advanced regional lymph node metastasis, such as a **single ipsilateral lymph node** greater than 3 cm but not more than 6 cm. - It could also refer to **multiple ipsilateral lymph nodes**, none greater than 6 cm, or bilateral/contralateral lymph nodes, none greater than 6 cm. In all these cases, **nodal involvement is present**. *T1N1* - Similar to T2N1, the **'N1' component** in T1N1 indicates the presence of **regional lymph node metastasis** in a single ipsilateral lymph node of 3 cm or less. - Therefore, this stage **does involve nodal spread**, despite having a smaller primary tumor (T1).
Question 6: A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
- A. Basal cell carcinoma (Correct Answer)
- B. Melanoma
- C. Squamous cell carcinoma
- D. Nevus
Explanation: ***Basal cell carcinoma*** - The description of a **basaloid appearance with peripheral palisading** on pathological examination is a classic histological feature of basal cell carcinoma (BCC). - BCC commonly presents as a nodule on sun-exposed areas like the **nasolabial fold** and is the most common skin cancer. *Melanoma* - Melanoma is characterized by the **malignant proliferation of melanocytes** and histologically shows atypical melanocytes with pagetoid spread or nest formation. - While it can appear as a nodule, the described **basaloid appearance with peripheral palisading** is not characteristic of melanoma. *Squamous cell carcinoma* - Squamous cell carcinoma typically shows **atypical keratinocytes** with keratinization, intercellular bridges, and sometimes desmoplasia. - It usually presents as an **erythematous, scaly patch** or nodule, often with ulceration, and the described histology does not match. *Nevus* - A nevus (mole) is a benign proliferation of melanocytes, showing **uniform nests of melanocytes** with maturation as they descend into the dermis. - The term **basaloid appearance** refers to cells resembling basal keratinocytes, which is not typical for a nevus.
Question 7: Elderly man with a long-standing mole on his face that is increasing in size and showing an irregular border. Diagnosis:
- A. Superficial spreading melanoma
- B. Nodular melanoma
- C. Acral melanoma
- D. Lentigo maligna (Correct Answer)
Explanation: ***Lentigo maligna*** - This type of melanoma commonly affects **elderly individuals** and presents as a **slowly enlarging, irregularly bordered, flat or slightly raised pigmented lesion** on sun-exposed areas like the face. - It often has a **long radial growth phase** before progressing to invasive lentigo maligna melanoma. *Superficial spreading melanoma* - While common, it typically presents on the **trunk or extremities** and has a faster growth rate compared to lentigo maligna. - It often appears as a **flat, asymmetrical lesion with varied colors and irregular borders**, but the age and location details point away from this. *Nodular melanoma* - This is an **aggressive form** that grows vertically from the start, presenting as a **dark, raised, often ulcerated nodule** and typically has a shorter history of rapid growth. - It lacks the characteristic long-standing, flat growth pattern described in the elderly patient's face. *Acral melanoma* - This rare type occurs on the **palms, soles, or under the nails (subungual)**, not typically on the face. - It often appears as a **pigmented streak or patch** in these acral locations.
Question 8: A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
- A. Superficial spreading melanoma (Correct Answer)
- B. Acral lentigo melanoma
- C. Lentigo maligna melanoma
- D. Nodular melanoma
Explanation: ***Superficial spreading melanoma*** - This is the most common type of melanoma and often presents as a **mole with irregular borders**, varying colors, and a diameter greater than 6mm, consistent with the description. - The lesion typically grows **radially** across the skin surface before beginning vertical growth, indicated by the increase in size. *Acral lentigo melanoma* - This type of melanoma primarily affects the **palms, soles, and nail beds**, which is inconsistent with a lesion on the cheek. - It often appears as a **dark brown or black patch** that slowly enlarges, but its location is characteristic. *Lentigo maligna melanoma* - This melanoma typically occurs in **chronically sun-damaged skin** of the elderly, often on the head and neck, but usually presents as a **flat, irregularly shaped, tan or brown patch** with varying shades, which may not fit the description of a central black lesion within a larger mole. - It has a dominant **radial growth phase** and progresses slowly over many years before developing a nodular component. *Nodular melanoma* - This type is characterized by its **rapid vertical growth** and appearance as a **raised, dark, often dome-shaped lesion** from the outset. - While it can be black, the description of an "increased in size" mole with irregular borders and a central black lesion points more towards a spreading type rather than a rapidly growing nodule from the beginning.
Question 9: Elderly man with long-standing mole over the face which is increasing in size and showing irregular border. Diagnosis:
- A. Lentigo maligna (commonly found on sun-exposed areas in elderly) (Correct Answer)
- B. Nodular melanoma (aggressive and raised lesion)
- C. Acral melanoma (rare, found on palms or soles)
- D. Superficial spreading melanoma (commonly found on the torso)
Explanation: ***Lentigo maligna (commonly found on sun-exposed areas in elderly)*** - This lesion typically appears on **sun-exposed areas** of the elderly, like the face, and is characterized by a **slowly enlarging**, irregularly bordered macule or patch. - It represents melanoma in situ, often referred to as Hutchinson's freckle, and is directly linked to **chronic sun exposure**. *Nodular melanoma (aggressive and raised lesion)* - While aggressive, **nodular melanoma** rapidly grows vertically and usually presents as a **raised, dome-shaped nodule** rather than a slowly enlarging, flat lesion with irregular borders. - It can occur anywhere on the body and is not specific to sun-exposed areas of the elderly. *Acral melanoma (rare, found on palms or soles)* - This is a rare form of melanoma that occurs on the **palms, soles, or under the nails**, not typically on the face. - It is not associated with sun exposure and often presents as a dark, irregular patch on these acral sites. *Superficial spreading melanoma (commonly found on the torso)* - **Superficial spreading melanoma** is the most common type and usually appears on the **trunk in men** and legs in women. - It typically has a radial growth phase followed by vertical growth, but a long-standing, slowly enlarging lesion on the face in an elderly individual is more characteristic of lentigo maligna.
Question 10: A giant congenital melanocytic nevus is usually of what size?
- A. 5-10cm
- B. 10-15 cm
- C. 15-20 cm
- D. 20 cm or greater (Correct Answer)
Explanation: ***20 cm or greater*** - A **giant congenital melanocytic nevus (GCMN)** is defined by its substantial size, typically measuring **20 cm or more in diameter** in an adult. - This large size is a key feature distinguishing it from smaller congenital nevi and is associated with a **higher risk of malignant transformation** and neurological complications such as **neurocutaneous melanosis**. *5-10cm* - A nevus of this size would be classified as a **small to medium congenital melanocytic nevus**, not a giant one. - While these nevi carry some risk of malignancy, it is significantly **lower than that of GCMN**. *10-15 cm* - This range falls under the category of a **medium congenital melanocytic nevus**. - While larger than small nevi, it does not meet the established criteria for a **giant congenital melanocytic nevus**. *15-20 cm* - A nevus of 15-20 cm is considered a **large congenital melanocytic nevus**, but it is still usually classified just below the threshold for a true **giant congenital melanocytic nevus** which is typically 20 cm or more. - Although it approaches the giant classification, the **20 cm demarcation** is critical for defining GCMN.
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