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A Rare Case Report of Advanced Stage-Four Malignant Melanoma
Metastatic melanoma is an aggressive and potentially fatal manifestation of neoplastic melanocytes. This cancer accounts for a small percentage of malignant skin lesions; however, a substantial number of deaths are associated with this cancerous process.1-5 In 2019, the United States had approximately 96,000 new cases of melanoma. Overall, the prognosis is poor for metastatic melanoma; however, patients can have long-term survival if they respond to immunotherapy and radical resection.1-5 Early clinical diagnosis is crucial, along with confirmational biopsy of the disease process. The most common sites for malignant melanoma are the scalp, arm, face, and foot, and the clinical manifestations may vary. Excisional biopsy of the lesion is the most definitive technique for accurate diagnosis, and a comprehensive plan with a multidisciplinary team is key for patient care.1-5 Targeted therapies and immune checkpoint inhibitors in combination with radical resection and reconstructive surgery have positively changed the management of metastatic melanoma.1-5
In our case report, a 76-year-old female had a fast-growing lesion on her right heel, subsequently diagnosed as metastatic malignant melanoma. This case report may provide readers insight into a more comprehensive approach to appropriate clinical workup, early diagnosis, and proper treatment for this malignant tumor. Surgical services such as podiatry and surgical oncology provided multidisciplinary care to ensure prompt attention to the patient's challenging case.
When A Patient Presents With A Growing Heel Lesion
A 76-year-old female with a past medical history of hyperlipidemia and hypertension was admitted to the hospital in November 2020 complaining of a discolored lesion on her right plantar heel. The patient explained that she had this lesion for approximately 2 years but that it progressively increased in size over a few months. She previously saw a foot and ankle specialist at an outside facility in September 2020, who recommended admission and workup for malignancy, but she left against medical advice. On her initial clinical examination, there was a discolored, exophytic soft tissue mass noted to the right plantar heel that was asymmetrical with irregular borders.
The mass measured approximately 5.5cm x 5cm and elevated approximately 2cm from the surface of the plantar heel. There was irregular pigmentation extending distally from the lesion and it was firm upon palpation. Magnetic resonance imaging (MRI) demonstrated a heterogeneous, minimally enhancing solid lesion at the medial plantar aspect of the hindfoot, centered at the skin, extending into the subcutaneous tissues without muscular, tendinous, ligamentous, or bony involvement. Given the clinical picture and high suspicion for malignant melanoma, we recommended a tissue biopsy, which we performed bedside alongside our surgical oncology colleagues.
Following sterile skin preparation and consent from the patient, a 4mm punch biopsy obtained three full-thickness samples from highly suspicious regions of the soft tissue mass. We then irrigated the biopsy sites with saline and closed with simple interrupted 3-0 nylon sutures. The pathology report revealed acral skin and no evidence of any sort of malignancy. Despite the negative pathology report, podiatry and surgical oncology were still wary about her diagnosis and recommended a lymph node biopsy. Unfortunately, the patient left the hospital against medical advice and became lost to follow up for several months. However, given worsening clinical symptoms, she scheduled an outpatient visit with surgical oncology in February 2021 and adhered to subsequent recommended treatment options.
Key Components of the Subsequent Therapeutic Course
Based on the initial recommendations from podiatry and surgical oncology, ultrasound-guided fine-needle aspiration of the right inguinal lymph node took place in February 2021, which confirmed the initial suspicion of malignant melanoma. The patient received a formal diagnosis of BRAF-positive, wild type metastatic acral lentiginous melanoma of the right heel. A PET scan performed two days later, revealed a 6mm right pulmonary nodule, an 8mm subpleural nodule in the lateral right lower lobe, multiple enlarged right inguinal lymph nodes (the largest measuring 3.6x3.7cm), right external nodes all metabolically active, a large soft tissue mass at the posterior right heel measuring 4.7x4.5cm, and a small satellite cutaneous nodule at the medial right ankle.
Given the extensive metastasis of the malignant melanoma, surgical oncology initiated nivolumab and ipilimumab treatment. The patient received chemotherapy for approximately two months, but in April 2021 she unfortunately regressed and had confirmed further metastasis to her lungs, and her right heel lesion continued to worsen.
She continued to have severe lower back pain, right groin pain, and acute anemia secondary to blood loss from her right heel lesion. Surgical oncology recommended palliative care and radiologic oncology for further treatment as her condition continues to worsen.
Discussion
Malignant melanoma is an aggressive cancer caused by malignancy of melanocytes.6 Exposure to ultraviolet (UV) light greatly increases the risk of developing malignant melanoma.6 It is the sixth most common type of cancer in females and the fifth among males. Early recognition, diagnosis, and treatment is critical for reducing morbidity and mortality. Types of treatment for malignant melanoma will vary based on the cancer stage but may include surgical excision, radiation therapy, immunotherapy, biochemotherapy, and gene therapy.6
This report demonstrates a case of a patient who presented with an initial right exophytic lesion to the right heel. Despite an initial negative pathology specimen, continued workup revealed stage four malignant melanoma with widespread metastasis. An accurate and thorough history and physical examination is essential for proper diagnosis and treatment as well as a multidisciplinary approach to patient management. Accordingly, we hope this case report adds to the body of knowledge in the literature.
Dr. Mateen is a fourth-year resident at the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia.
Dr. Bik is a third-year resident at the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia.
Dr. Levi is a third-year resident at the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia.
Dr. Pontious is a Clinical Professor in the Department of Podiatric Surgery at Temple University School of Podiatric Medicine in Philadelphia.
References
1. Reed KB, Cook‐Norris RH, Brewer JD. The cutaneous manifestations of metastatic malignant melanoma. Int J Dermatol. 2012;51(3):243-249.
2. Pavri SN, Clune J, Ariyan S, Narayan D. Malignant melanoma: beyond the basics. Plastic and reconstructive surgery, 2016;138(2):330e-340e.
3. Enomoto LM, Levine EA, Shen P, Votanopoulos KI. Role of surgery for metastatic melanoma. Surg Clin. 2020;100(1):127-139.
4. Atallah E, Flaherty L. Treatment of metastatic malignant melanoma. Curr Treat Options Oncol, 2005;6(3):185-193.
5. Key Statistics for Melanoma Skin Cancer, American Cancer Society. Available at: https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html . Published January 12, 2022. Accessed March 23, 2022.
6. Ahmed B, Qadir MI, Ghafoor S. Malignant Melanoma: Skin Cancer-Diagnosis, Prevention, and Treatment. Crit Rev Eukaryot Gene Expr. 2020;30(4):291-297.
