Dermatology Online Journal

Patient presenting with left arm complaint has hidden melanoma on the sole
Patrick E Prath¹ BS, Daniel J Aires² MD JD, Stephen Squires² MD
Dermatology Online Journal 19 (1): 13

1. School of Medicine, University of Kansas, Kansas City, Kansas
2. Department of Dermatology, University of Kansas Medical Center, Kansas City, Kansas

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Abstract

Some insurance companies argue that complete skin examination is not justified if the presenting complaint can be fully visualized without having the patient disrobe. This might be especially true if such a patient is a member of a group at relatively lower risk for skin cancer. We present a case in which complete skin examination revealed a large melanoma in situ, indicating that skin examinations can be justified in such patients.

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Introduction

Acral Lentiginous Melanoma (ALM) can be seen in Asians and African Americans. It does not appear to be linked to ultraviolet light exposure [1]. We describe a patient who presented to clinic with a chief complaint of an arm lesion, but was diagnosed with ALM only after a complete skin examination was performed.

Case report

A 68-year-old African-American female was referred to the dermatology clinic with a 12-month history of “an itchy, growing mole” on her left lateral arm. Past medical history was significant for hypertension, systemic lupus erythematosus, and breast cancer, but no skin cancer. Family and social history were unremarkable. Review of systems was negative. The patient was offered and consented to a complete skin examination. In addition to the papule on the left arm, skin exam revealed a light brown patch with over twenty small black macules on the left sole. The patient had been aware of the light brown patch since young adulthood, but she denied having noticed the black macules prior to this visit. The remainder of the physical exam was unremarkable.

Figure 1	Figure 2
Figure 1. Result of cutaneous shave biopsy of the lesion on the left posterior upper arm is consistent with dermatofibroma. Figure 2. Result of cutaneous punch biopsy of the lesions B and C on the left sole is consistent with Acral Lentiginous Melanoma in situ.

Figure 3
Figure 3. Lesions on the left sole, unmarked.

Biopsy of the papule on the left lateral arm showed it to be a dermatofibroma (Figure 1) Punch biopsies were performed on two of the black macules on the left sole. Pathology revealed atypical melanocytes crowding the basal layer in both specimens, consistent with a diagnosis of acral lentiginous melanoma in situ (Figures 2 and 3). Pan CT/PET scan revealed non-specific bilateral inguinal lymph nodes which were felt to be reactive, with no clear cut evidence of metastatic disease. The patient was referred to surgery and underwent complete excision and grafting.

Discussion

Complete skin examination involves inspection of the entire body for suspicious growths [2, 3]. It is a quick and simple method to reduce morbidity and mortality from skin malignancies. Early detection of melanoma, in particular, is associated with higher cure and survival rates. The five-year survival rate for stage IV melanoma is an abysmal 13 percent compared to 92 percent for stage I disease [4, 5].

In this patient, the diagnosis of ALM would have been missed had a complete skin examination not been offered. The patient would have had a greater risk of metastatic melanoma, especially since ALM is usually more aggressive. This may be because of the subtype of melanoma or secondary to being missed in the early stages; patients or physicians may not examine this location routinely. This case illustrates that complete skin examinations should be performed at least in new or referred patients.

References

1. Rigel D. Cutaneous ultraviolet exposure and its relationship to the development of skin cancer. J Am Acad Dermatol. 2008;58(5 suppl 2):S129-S132. [PubMed]

2. Losina E, Walensky RP, Geller A, Beddingfield FC, Wolf LL, Gilchrest BA, Freedberg KA. Visual screening for malignant melanoma. Archives of Dermatology. 2007;143(1):21-28. [PubMed]

3. Riker AI, Zea N, Trinh T. The Epidemiology, Prevention, and Detection of Melanoma. Ochsner Journal. 2010;10:56-65. [PubMed]

4. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, Fleming ID, Gershenwald JE, Houghton A Jr, Kirkwood JM, McMasters KM, Mihm MF, Morton DL, Reintgen DS, Ross MI, Sober A, Thompson JA, Thompson JE. Final Version of the American Joint Committee on Cancer Staging System for Cutaneous Melanoma. Journal of Clinical Oncology. 2001;19(16):3635-3648. [PubMed]

5. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer Statistics 2009. CA A Cancer Journal for Clinicians. 2009;59(4):225-249 [PubMed]

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