Exploring A Melanomatous Lesion In A Financially Underserved Patient

Given that financial concerns can be a barrier to healthcare, these authors discuss the workup of a patient with a painless, pedunculated mass, which had grown increasingly larger over a decade.   

Financial barriers can often delay patients from seeking medical care. This creates an unfortunate dilemma for doctors and patients alike. Consequently, the abilities of doctors to provide these patients with life-saving treatment options become increasingly limited.

A 62-year-old male with a past medical history of hypertension and hypercholesterolemia presented to our clinic with a painless, pedunculated mass on his left lower leg that had been increasing in size over the past ten years. The patient’s hypertension and hypercholesterolemia were under control with prescriptions to amlodipine (Norvasc, Pfizer) and lovastatin (Mevacor, Merck). The only allergy the patient reported was to penicillin. The patient was a former smoker with a ten-year history of tobacco use. He previously smoked approximately one pack per week. There was no remarkable family history of disease.

Upon the physical examination, there was a raised, firm, soft tissue mass measuring 7.3 cm by 7.5 cm with surrounding erythema on the lateral aspect of the distal third of the left lower leg. The skin lesion had a granulomatous appearance with irregular borders and areas of hyperpigmentation with surrounding erythema (see Figures 1 and 2). Radiographs revealed increased a soft tissue density consistent with a mass but no periostitis or osseous changes were present.

Due to the large size and evolution of the lesion, we immediately admitted the patient to the hospital for excision and biopsy of the lesion. The patient consented to an excisional biopsy, which we performed with the patient under general anesthesia. After making two converging, semi-elliptical skin incisions, we freed the lesion with sharp and blunt dissection, tagged the mass and sent it to pathology (see Figure 3). After carefully exploring the remaining tissue deficit, we reapproximated the surgical site, leaving the central aspect of the incision open to heal by secondary intention.

The patient's pathology report cited a “nodular malignant melanoma that is 3.5 cm in greatest dimension with a Breslow thickness of 1.2 cm and Clark level IV. All resection margins were free of involvement by malignant melanoma.”

A chest X-ray revealed a 1.3 cm nodule in the lingula of the left lung. A computed tomography (CT) scan subsequently revealed “multiple nodules within the bilateral lungs (with the) largest nodule measuring 1.2 cm in size, which may represent granuloma. Metastasis is not entirely excluded and further PET scan may be needed ...”

Due to financial barriers, the patient had to forgo a positron emission tomography (PET) scan, a surgical oncology consult and further specialty care because he fell outside the boundaries of the county care system. Although the patient was unable to afford further specialty care, he did receive assistance from social workers, which enabled him to receive the appropriate outpatient follow-up care. He had monitoring on a biweekly basis for dressing changes and to ensure healing of the surgical site.

Differentiating Between The Various Types Of Melanoma

The diagnosis of melanoma presents as a challenge because melanoma resembles other cutaneous lesions. Due to its variable presentation both clinically and histopathologically, melanoma is divided into the following subtypes: superficial spreading, lentigo maligna, acral lentiginous and nodular melanoma.¹

Superficial spreading melanoma is the most common subtype and may be associated with a dysplastic or congenital nevus. Lentigo maligna melanoma initially presents as a small macule and is associated with areas of skin that have been damaged due to increased sun exposure. The least common subtype is acral lentiginous melanoma, which presents at distal regions such as palmar, plantar and subungual regions of skin.¹

The most aggressive form (and the form our patient presented with) is nodular melanoma. Ten to 15 percent of all melanomas are nodular and the presentation often consists of a pigmented, often ulcerated, nodule.² Nodular melanoma is the most aggressive because it usually presents in the vertical growth phase. The radial growth phase is of very short duration, if at all.¹

Melanoma subtypes with rapid progression to the vertical growth phase carry an increased risk of metastasis to other organ systems including the liver, lungs and brain.³ The American Joint Committee on Cancer (AJCC) performed an analysis on patients with melanoma and classified them into three groups based on distant metastasis and survival rates.³ Those with melanoma metastasis to visceral sites had a median survival rate of seven months. Those with lung metastases had a median survival rate of 12 months and those with metastases to non-visceral sites, particularly to the skin, subcutaneous tissue and distant lymph nodes, had a median survival of 18 months. In general, patients with lung, liver, brain or bone metastasis have poorer outcomes with a median survival rate between three and six months.

It is of paramount importance to differentiate a melanotic lesion on the lower extremity from an ulcer of an unknown etiology, especially in patients presenting with multiple comorbidities. In recent literature, Gumaste and colleagues presented a case report of a patient with acral lentiginous melanoma, which was originally misdiagnosed as a traumatic ulcer.³ A lesion that does not heal with treatment or continues to worsen despite continuous treatment should raise concern. Therefore, one should always consider malignancies as a differential diagnosis.

A Closer Look At Melanotic Lesion Staging

Without early workup and biopsy, an untreated melanoma can rapidly progress as demonstrated by this case study. We used Breslow’s depth as a prognostic factor in the diagnosis of melanoma of the skin. However, the standard Breslow’s depth measurement has been replaced by the AJCC depth system.² Previously, clinicians viewed Breslow’s depth based on stages and depth of the tumor as one can see in the table at right.

Currently, AJCC staging of malignant melanoma reports that depth of a lesion correlates directly with prognosis more than staging. Clinicians can use cutoffs of 1 mm, 2 mm, and 4 mm to divide patients into stages according to the new AJCC guidelines (see table at left).²

Tumor depth is the most significant criterion for evaluating risk of death due to metastatic disease. People with melanomas measuring less than 0.76 mm have an eight-year survival rate of 93 percent while those with tumors greater than 3.6 mm thick have a 33.3 percent survival rate.⁵ Therefore, one must discuss the topic of sentinel node biopsy with patients presenting with tumors greater than 0.75 mm deep. Our patient had a Breslow thickness of 12 mm. In addition to surgical excision, lymphadenectomy is an option after a positive sentinel node biopsy. Note that only early lymphadenectomy can reduce lymphedema.⁶

Previously, Clark’s level staging was the primary factor in staging for melanoma. However, studies have shown that Clark’s level staging is more operator-dependent, less reproducible and has a lower predictive value in comparison with Breslow’s depth staging.² Recent studies have shown that Clark’s level staging is only of significance in patients with a Breslow’s depth measuring <1 mm.² Our patient had a Clark stage IV melanoma with a Breslow’s depth of 12 mm. Therefore, there was too low of a predictive value for accurate assessment.

Does The Type Of Biopsy Affect The Patient’s Survival Rate?

It is important to consider whether transection of a lesion via biopsy will affect a patient with melanoma and his or her mean survival rate.

In a retrospective study, Mir and colleagues retrospectively reviewed the initial diagnostic biopsies of melanoma in 479 patients.⁷ The study analyzed excisional biopsy, punch biopsy and deep shave biopsy performed on 1.5 percent, 4.1 percent and 9 percent of patients respectively. The overall survival rate was approximately 1,012 days with transection of the lesion and approximately 1,073 days without transection. This did not yield any significant difference in either group.

Martires and coworkers evaluated 714 patients with melanoma and compared the patients’ mean age, Breslow’s depth and sentinel lymph node tests in transected and non-transected tumors.⁸ This study also found no significant difference in overall survival rates between the two groups. Based on these results, one may utilize several biopsy techniques without the risk of spreading malignancy.

What You Should Know About Melanoma Treatment Options

In regard to treatment, the options are plentiful for those who can afford them. There are numerous pharmacological therapies available for the treatment of melanoma.

For adjuvant treatment for a resected stage II or III melanoma, the treating physician may consider high-dose interferon alfa-2b and radiation therapy. For metastatic melanoma or unresectable lesions, one might consider systemic treatment options such as immunotherapy with nivolumab (Opdivo, Bristol-Myers Squibb), pembrolizumab (Keytruda, Merck Oncology), or nivolumab plus ipilimumab (Yervoy, Bristol-Myers Squibb); targeted therapy with dabrafenib (Tafinlar, Novartis), dabrafenib plus trametinib (Mekinist, Novartis), vemurafenib (Zelboraf, Genentech); or enrollment in clinical trials.

Other options include isolated limb perfusion/infusion or metastasectomy. Isolated limb perfusions and infusions are forms of regional chemotherapy that allow for site-specific delivery of toxic medication without subjecting the patient to the systemic consequences of the cytotoxic drug circulating through the rest of the body. This method of treatment has yielded a median five-year survival rate of 36.5 percent in patients with locally advanced melanoma of the limb.^9,10 However, studies have shown that isolated limb infusion is a well-tolerated alternative to isolated limb perfusion, as it appears to be as effective and yields fewer complications and deaths.^9,10 Metastasectomy is associated with increased overall survival in comparison to systemic therapy in patients with stage IV melanoma.¹¹ For patients with unresectable advanced melanoma, treating physicians may consider immunotherapy with intralesional herpes vaccine, vaccines stimulating cytotoxic T and helper T lymphocytes, and dendritic cell therapy.^12-14

In Conclusion

This case exhibits a scenario that has become commonplace in medical practice. When health insurance premiums are at an all-time high, physicians face the added difficulty of arranging appropriate, yet affordable, treatment plans for high-risk patients without insurance.

Priya Patel is a third year podiatry student at Dr. William M. Scholl College of Podiatric Medicine in North Chicago. She served as Research Coordinator of the American College of Foot and Ankle Surgeons, Scholl Chapter during the 2014-2015 academic year. She earned a bachelor of science degree from Loyola University of Chicago in 2012.

Mira Pandya is a third year podiatry student at Dr. William M. Scholl College of Podiatric Medicine. She served as President of the American College of Foot and Ankle Surgeons, Scholl Chapter during the 2014-2015 academic year. She earned a bachelor of science degree from the University at Buffalo in 2013.

Justin Singh is a third year podiatry student at Dr. William M. Scholl College of Podiatric Medicine. He served as Vice President of the American College of Foot and Ankle Surgeons, Scholl Chapter during the 2014-2015 academic year. He earned a bachelor of arts degree from Augustana College in 2013.

Kathryn Alleva is a third year podiatry student at Dr. William M. Scholl College of Podiatric Medicine. She served as Secretary of the American College of Foot and Ankle Surgeons, Scholl Chapter during the 2014-2015 academic year. She earned a bachelor of science degree from Purdue University in 2013.

Elizabeth Neubauer is a third year podiatry student at Dr. William M. Scholl College of Podiatric Medicine. She served as Treasurer of the American College of Foot and Ankle Surgeons, Scholl Chapter during the 2014-2015 academic year. She earned a bachelor of science degree from the University of Michigan in 2013.

Dr. Yorath is the Medical Director of the Rosalind Franklin University Health System and Associate Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. He is also the Residency Director of the Advocate Illinois Masonic Medical Center Podiatric Residency Program in Chicago.    

Dr. Wu is the Associate Dean of Research, a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine, and Professor of Stem Cell and Regenerative Medicine at the School of Graduate Medical Sciences at the Rosalind Franklin University of Medicine and Science in Chicago. She is also the Director of the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.

References

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