PMC5198629_01
A 59-year-old female with malignant melanoma. (A). Preoperative assessment of left heel lesion showing (3 cm x 3 cm) area of hyperpigmentation with color variation, ill-defined boarders and variation in symmetry, April 2014. (B). A clinical reoccurrence of the left heel lesion in September 2016 with multiple foci of raised, hyper pigmented lesions scattered throughout the distal third of the left leg and foot. The previous excision site with split-thickness skin graft (STSG) is noted at the posterior aspect of the heel.
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She first consulted a general practitioner then presented at the EWMSC 2 years later with a 5 mm left heel pruritic lesion, which fit the clinical presentation of the "ABCD rule" in that it exhibited Asymmetry, Border irregularities, Color heterogeneity, and Dynamics in colors, elevation, and size (Fig. 1A). A follow up appointment, six months later revealed the presence of numerous hyper-pigmented lesions scattered throughout her left leg and foot with characteristics similar to that of her initial presentation (Fig. 1B).
(A, B). Nevus cells. (A). Type A. Magnification 4x and (B). Type B nevus cells demonstrating Schwannian differentiation. Magnification,10x. (C, D). Microscopic images (H&E) of malignant melanoma. (C). At low magnification (40x), the tumor is noted to comprise nests and sheets of pigmented cells infiltrating deep into the dermis. Foci of nests of intra epidermal tumor epidermal nests are also seen ( ). (D). Higher magnification (200x) highlights the atypical tumor cells with prominent nucleoli and "dusty" intracytoplasmic melanin pigment. H & E staining on all panels.
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With no melanocytic atypia recognized, it was determined that the findings were consistent with a junctional melanocytic nevus (Fig. 2A, B). The histopathological findings was that of malignant melanoma (Fig. 2C, D) at stage pT3a pN1a M0 according to the American Joint Committee on Cancer system (AJCC) 7th edition guidelines.
Intra and postoperative images (A). Intraoperative photograph of left inguinal region after regional lymphadenectomy with exposed femoral artery. Sartorius muscle is seen detached from the anterior superior Iliac spine in preparation for transposition of the muscle flap. (B). Transposed sartorius muscle flap covering femoral artery (C). Postoperative excision of left heel lesion showing depth and width of excision before split-thickness skin graft (STSG).
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STSG without post-operative complications (Fig. 3A, B, C). She was advised on to start adjuvant therapy immediately but she delayed for 5 months before commencing on Dacarbazine (Bayer) (5 cycles).
(A). Lymph node architecture completely effaced by heavily pigmented tumor cells. H&E staining. Magnification, 4x. (B). and (C). Subcapsular and sinusoidal location of pigmented tumor cells. Magnification, 4x. (D, E). Characteristic pleomorphic tumor cells exhibiting vesicular chromatin and prominent eosinophilic macronucleoli. (D). Magnification, 40x. (E). Magnification, 10x.
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The section from the lymph node showed an effaced architecture of heavily pigmented cells in the subcapsular, sinusoidal and focal capsular pattern with the heavily pigmented cells obscuring the nuclear features (Fig. 4A-C). There were a few areas that showed pleomorphic tumor cells with vesicular chromatin and prominent eosinophilic macronucleoli (Fig. 4D, E).
Patient chest radiographs. (A). Normal posterioranterior chest radiograph from January 2016. (B). posterioranterior chest radiograph 8 months later. Red arrows, multiple bilateral pulmonary nodules with no calcification or cavitation consistent with pulmonary metastases; blue arrow, fluid in right horizontal fissure; green arrow, loculated right pleural effusion; yellow arrows, cardiomegaly; purple arrows, right mid and lower zone consolidation with some obscuration of the right heart border. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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A chest X-ray showed multiple bilateral pulmonary nodules with no calcification or cavitation consistent with pulmonary metastases (Fig. 5A, B).