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More than skin deep?

BMJ 2010; 340 doi: (Published 04 March 2010) Cite this as: BMJ 2010;340:c932

This article has a correction. Please see:

  1. Mark J Austin, specialist registrar in gastroenterology
  1. 1Medway Maritime Hospital, Gillingham, Kent ME5 2RU
  1. Correspondence to: drmarkaustin{at}

    A 46 year old man was admitted with a 6 week history of nausea, vomiting, and night sweats, and a weight loss of 2 stone (12.7 kg). His medical history included excision of a malignant melanoma (Breslow’s thickness 1.6 mm) from the left side of his neck 12 months earlier. There was no evidence of local recurrence, or lymphatic or metastatic spread, 6 months after resection. The patient did not smoke.

    Clinical examination was unremarkable. Initial investigations demonstrated mild leucocytosis, neutrophilia, and thrombocytosis. Contrast enhanced computed tomography of the abdomen (fig 1)and barium enhanced radiography of the small bowel (small bowel follow through; fig 2) were performed.

    Fig 1 Computed tomography scan of the patient’s abdomen

    Fig 2 Radiograph of the patient’s small bowel


    • 1 What are the different types of malignant melanoma?

    • 2 What does Breslow’s thickness describe?

    • 3 What abnormalities are demonstrated on the computed tomography and radiograph images?

    • 4 What would be the investigation of choice to enable histological evaluation?

    • 5 What is the likely diagnosis?


    1 What are the different types of malignant melanoma?

    Short answer

    The different types of melanoma are superficial spreading melanoma, lentigo maligna, acral lentiginous melanoma, and nodular melanoma.

    Long answer

    Melanomas fall into four basic categories. Superficial spreading melanoma is by far the most common type, accounting for about 70% of all cases of melanoma. This type of melanoma is seen most often in young people. It has the appearance of an irregular, flat, or slightly raised discoloured pigmented lesion, although the colour can vary between tan, brown, black, red, blue, and white. This type of melanoma can develop in a previously benign mole anywhere on the body, most likely on the trunk in men and the legs in women.

    Lentigo maligna usually appears as a flat or mildly elevated mottled tan, brown, or dark brown discoloured plaque. This type of in …

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