In the United States, the most common malignant tumors are cutaneous neoplasms. It is estimated that the incidence of melanoma is about 1.4 million new cases a year. Of the skin cancers, melanoma accounts for 4% of them while causing 75% of all skin deaths 4. Melanoma is the fifth leading cause o f cancer in men and seventh in women1. The occurrence is rising worldwide dramatically and mortality rates remain constant. We present a case of metastatic melanoma in a 46- year-old male who has undergone a left arm biopsy for the presence of a pigmented lesion that first presented one year prior. The lesion had begun to grow, darken, and bleed episodically. The pathology report revealed atypical melanocytes with a nodular pattern and a depth of 2.1 mm. He was diagnosed with malignant melanoma and wide excision with split skin graft was performed. After fifteen years without any trace of disease, metastatic melanoma appeared in multiple left axillary lymph nodes.

Figure 1: Left axillary masses with the largest lymph node measuring 4 x 4 cm. Suggestion of 2 cm necrotic lymph node.

A 46-year-old Caucasian male with history of HTN, DM, CAD, dyslipidemia, CABG, metastatic melanoma and recurrent pleural effusions presented to the ER with shortness of breath. He had been having recurrent pleural effusions and had several thoracenteses performed. The patient denied any pain and his ECOG baseline level was grade 0. The patient was diagnosed with malignant melanoma in 1995 with a lesion on the left deltoid muscle for which he underwent wide excision with skin graft. He was followed quite carefully, until 06/2009 when he palpated a mass in the left axillary area (Figure 1 & 2). A left axillary lymph node dissection demonstrated metastatic melanoma involving 13/19 axillary lymph nodes. Postoperatively the patient did reasonably well except for some engorgement of his left breast. The patient then received Interferon from 10/2009 until 03/2010.

Figure 2: Small lymph nodes in the right axilla and mediastinum.

During the same time, he was found to have a palpable lymph node in the left supraclavicular area and an excisional biopsy demonstrated metastatic melanoma. On 5/2011, he received chemotherapy and high dose radiation therapy to his left hemithorax. He had some difficulty with recurrent pleural effusions and had several thoracenteses (Fig. 3). Further evaluation was performed and PET, CT scan, Brain MRI, and bone scans (Fig. 4) failed to demonstrate any evidence of metastatic melanoma.

Figure 3: Moderate amount of pleural fluid in the left pleural space with dependent atelectasis posteriorly.

Melanoma is a serious form of skin cancer with a rapidly increasing incidence with age3. Most result from a superficial tumor confined to the epidermis, where they remain dormant for several years. At this stage, the melanoma is curable by surgical excision. However, those that begin to expand below the dermis have increased metastatic potential. Of the four major types of melanoma, nodular melanoma was diagnosed in our patient. Nodular melanoma is the second most common type and has been recognized as a more severe form of melanoma due to its later time of detection upon diagnosis. The treatment strategy for primary cutaneous melanomas can be approached per the AJCC recommendations. The major prognostic factors include tumor microstaging (i.e. Breslow thickness), ulceration, nodal status, and distant metastasis1. Specifically, metastatic melanoma has the potential to disseminate to any organ with certain organs more prone for involvement. Most common sites of recurrence include skin, subcutaneous tissues, and distant lymph nodes. Visceral sites of dissemination are lung, liver, brain, bone, and gastrointestinal tract. For metastatic melanoma, there is a role for palliative surgical treatment, such as chemotherapy, radiation, and immunotherapy (i.e. interferon). The five-year survival rate for patients with melanomas is highly dependent on disease stage and the time of diagnosis. There are five stages: stage 0 is in situ melanoma, stage I and II are localized cutaneous disease, stage III is regional nodal disease and stage IV is distant metastatic disease1. Patients with stage I disease have a better expected cure rates and survival. Stages II thru IV lesions represent more advanced disease associated with poorer prognosis. The stage of melanoma directly affects the surgical management. Definitive surgical treatment for less advanced disease can involve wide local excision with efforts at negative margins.

Figure 4: No evidence of metastatic lesions.

Nodular melanomas are typically asymptomatic and thus are diagnosed at a later stage. Normally, they have already progressed to greater than two millimeters upon discovery. Studies reveal that even after complete excision, patients should have life-long surveillance to prevent recurrence2. Some even suggest adjuvant therapy immediately following primary excisional surgery in effort to eliminate disseminated cells. When dealing with more aggressive forms of melanoma, surgery is used as more of a palliative effort, with more response rates from chemotherapeutic agents and immunotherapy.

1. Trinh, V. Current management of metastatic melanoma. American Journal of Health-System Pharmacy 2008; 65: 54-59.
2. Ossowski, L., Aguirre-Ghiso, J. Dormancy of metastatic melanoma. Pigment Cell & Melanoma Research 2010; 23:41-56.
3. Tejera-Vaquerizo, A, et al. Thick Melanoma: the problem continues. Journal of the European Academy of Dermatology & Venereology 2008; 22:575- 579.
4. Medscape Reference. Cutaneous Melanoma: Edpidemiology. Medscape Reference. http://emedicine.medscape.com/article/1100753- overview#a0199. Published: October 8, 2012. Accessed: October 12, 2012.