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Figure 1: Lesions of right anterior tibial region.
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Figure 2: Lesion over right lateral malleolus.
Lesion over right lateral malleolus.
An 86-year-old female is brought to the office for assessment of lesions of the right lateral malleolus and right anterior lower leg. The patient first noticed a nonhealing protuberant lesion on her right lateral malleolus about 6 months ago which occasionally bleeds. Her view of the lesion has been limited by both body habitus and lack of mobility. Over the past 2 months, additional purplish lesions have appeared on her right anterior tibial region. She has also been experiencing pain which radiates up her leg in a proximal direction.
Malignant melanoma, nodular type, is the second most common presentation of melanoma following the more common superficial spreading type.(1) The nodular subtype comprises an estimated 14-30 percent of melanoma cases.(1) Nodular melanoma is an important diagnosis which providers should not...
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Malignant melanoma, nodular type, is the second most common presentation of melanoma following the more common superficial spreading type.(1) The nodular subtype comprises an estimated 14-30 percent of melanoma cases.(1) Nodular melanoma is an important diagnosis which providers should not miss because it is aggressive and has the fastest rate of growth.(2)
Nodular melanomas can pose a diagnostic challenge because they often lack the usual ABCD (asymmetry, border irregularity, color changes, diameter) criteria exhibited by other melanoma subtypes.(3) Nodular melanomas can present with symmetric lesions and regular borders, and can oftentimes lack characteristic hyperpigmentation and instead appear pink in color.(3) (4) Though patients are less likely to recognize color change with nodular melanoma, they will often notice bleeding, elevation, catching on clothing, or evolution of the lesion.(4)
The patient in this case was diagnosed via skin biopsy and then treated with a wide local excision including skin and subcutaneous tissue under general anesthesia followed by a split-thickness skin graft. Unfortunately, invasive melanoma was found to be present at the margins of the excised area. The patient also underwent a right inguinal sentinel lymph node biopsy at the time of her procedure which returned positive for metastatic melanoma with extracapsular extension.
Note: All images and cases used with both verbal and written consent of the patient.
Author: Kaitlin McGowan, DO Candidate, is a member of the Rowan University School of Osteopathic Medicine’s Class of 2023.
References
1. Saaiq M, Ashraf B, Siddiqui S. Nodular Melanoma. Iran J Med Sci. 2016;41(2):164-5.
2. Liu W, Dowling JP, Murray WK, McArthur GA, Thompson JF, Wolfe R, et al. Rate of growth in melanomas: characteristics and associations of rapidly growing melanomas. Arch Dermatol. 2006;142(12):1551-8.
3. Warycha MA, Christos PJ, Mazumdar M, Darvishian F, Shapiro RL, Berman RS, et al. Changes in the presentation of nodular and superficial spreading melanomas over 35 years. Cancer. 2008;113(12):3341-8.
4. Chamberlain AJ, Fritschi L, Kelly JW. Nodular melanoma: patients’ perceptions of presenting features and implications for earlier detection. J Am Acad Dermatol. 2003;48(5):694-701.
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