Dermoscopic findings were consistent with a melanocytic lesion and a scoop shave biopsy revealed a 2.7 mm thick nodular melanoma.
Melanoma is the most lethal skin cancer in the United States. The likelihood of metastatic spread to lymph nodes statistically increases beyond a probability of 5% when patients have primary lesions thicker than 0.8 mm.1 Thus, for patients with tumors thicker than 0.8 mm, or some other high-risk features such as high mitotic index, a sentinel lymph node biopsy (SLNB) is recommended. This patient underwent wide local excision and reconstruction of his ear. An SLNB was also performed and the results were negative.
The patient returned for a complete skin exam every 3 months. Ten months after the excision, he presented with episodes of headache and confusion. Magnetic resonance imaging revealed metastasis to the brain; a biopsy confirmed that it was melanoma. Two months later, after attempts at resection of the brain metastasis, the patient died.
This case demonstrates that patients with thick melanoma are at continued risk for recurrence and poor outcomes; they benefit from close surveillance and work-up of unusual symptoms that might suggest metastases. Phase 3 trials are currently underway to consider the use of adjuvant therapy in patients with advanced stage II melanoma who, on average, have worse outcomes than patients with early-stage III disease.2
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).