General Surgery · Year 3 · from General Surgery

Case 1: Melanoma

Patient Demographics

  • Age: 52 years
  • Sex: Male
  • Occupation: Golf course manager

Chief Complaint

"I noticed a dark mole on my back that has changed over the past several months."

History of Present Illness

The patient's wife noticed a pigmented lesion on his upper back that has been changing over the past 4-5 months. It has become darker, larger, and has developed irregular borders. The patient has had significant sun exposure throughout his life due to his occupation and recreational activities. He has had multiple blistering sunburns in the past. He has not had any prior skin cancers. He has noticed no other changing lesions and has no systemic symptoms.

Past Medical History

  • Hypertension
  • Hyperlipidemia
  • No prior skin cancers
  • Multiple blistering sunburns as youth

Family History

  • Father: Melanoma at age 65 (survived after surgery)
  • Mother: Basal cell carcinoma

Physical Examination

  • General: Well-appearing male with fair complexion, multiple nevi
  • Back: 1.8 cm asymmetric, darkly pigmented lesion with irregular borders and color variation (brown, black, red areas), raised surface
  • Full skin exam: No other suspicious lesions
  • Lymph nodes: No palpable cervical, axillary, or inguinal adenopathy

ABCDE Assessment

  • Asymmetry: Present
  • Border irregularity: Present
  • Color variation: Multiple colors present
  • Diameter: >6 mm (1.8 cm)
  • Evolving: Yes (per history)

Highly suspicious for melanoma

Initial Management

  • Excisional biopsy performed (full-thickness, 1-2 mm margins)
  • Shave biopsy avoided (need full thickness for staging)

Pathology Results

  • Diagnosis: Invasive melanoma
  • Breslow thickness: 2.4 mm
  • Ulceration: Present
  • Mitotic rate: 4/mm²
  • Margins: Positive (biopsy margins)
  • Clark level: IV (reticular dermis)

AJCC Staging (8th Edition)

  • T stage: T3b (2.01-4.0 mm with ulceration)
  • Need SLN biopsy for nodal staging

Staging Workup

Sentinel lymph node biopsy (SLNB) indications:

  • Breslow >0.8 mm OR
  • Breslow <0.8 mm with adverse features (ulceration, high mitotic rate)
  • This patient: 2.4 mm, ulcerated → SLNB indicated

Imaging

  • CT Chest/Abdomen/Pelvis: No evidence of distant metastases
  • PET-CT: May be considered for higher-stage disease

Definitive Surgical Management

Wide local excision + Sentinel lymph node biopsy:

  • Wide excision with 2 cm margins (for T3 disease)
  • Preoperative lymphoscintigraphy: Drainage to left axilla
  • SLN biopsy: Left axilla
  • Primary closure of back wound

Pathology Results - Final

  • Wide excision margins: Negative
  • Sentinel lymph nodes: 2 nodes identified
  • Node 1: Metastatic melanoma (1.2 mm deposit)
  • Node 2: Negative
  • Stage IIIB (T3bN1aM0)

Multidisciplinary Tumor Board Discussion

  • Stage IIIB melanoma with positive sentinel node
  • Options discussed:
  1. Completion lymph node dissection (CLND) - no longer standard
  2. Surveillance with imaging
  3. Adjuvant systemic therapy

Based on MSLT-II trial: CLND does not improve survival in SLN-positive patients who will receive adjuvant therapy

Adjuvant Therapy

Options for Stage III melanoma:

  1. PD-1 inhibitors: Pembrolizumab or Nivolumab (preferred)
  2. BRAF/MEK inhibitors: If BRAF mutation positive (dabrafenib/trametinib)

Molecular testing:

  • BRAF mutation: V600E positive

Treatment decision:

  • Pembrolizumab (1 year) chosen
  • Alternative would be dabrafenib/trametinib combination

Follow-up Schedule

  • Clinical exam every 3-6 months for 2 years, then every 6-12 months
  • CT imaging every 6-12 months for first 2-3 years
  • Patient education on skin self-exam
  • Annual full-body skin exam by dermatologist

Teaching Points

  1. ABCDE criteria help identify suspicious lesions
  2. Breslow thickness is the most important prognostic factor
  3. Excisional biopsy preferred over shave for accurate staging
  4. Sentinel lymph node biopsy for staging intermediate/thick melanomas
  5. Wide excision margins based on Breslow depth
  6. CLND no longer standard for positive SLN with adjuvant therapy available
  7. Adjuvant immunotherapy improves survival in Stage III melanoma

Clinical Image

Image Description: Clinical photograph of a melanoma demonstrating the ABCDE criteria: Asymmetry, Border irregularity, Color variation with multiple shades of brown, black, and red, Diameter greater than 6 mm, and history of Evolution over time.

Attribution: Image from Wikimedia Commons, Category:Melanoma. Source: https://commons.wikimedia.org/wiki/Category:Melanoma

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