Monday, March 10, 2008

Acrolentiginous Melanoma from Malaysia

Here is a case from Jahor Baru, Malaysia. In North America, Europe and Australia the patient would have had more extensive studies; but one must keep in mind that there are disorders in Malaysia that are better handled there than here. Melanoma is far less common in SE Asia and their resources are allocated differently.

Abstract:
70 yo woman with ALM right sole

Presented by S.E. Choon, Consultant Dermatololgist

HPI: This 70 year-old Chinese lady presented in April 2006 with a 1-year history of a growth on right sole which was biopsied and diagnosed as melanoma. We do not have level and thickness. She refused below knee amputation and hence was referred to us in July 2006. She had radiotherapy in Sep/Oct 2006 in private centre.

P.M.H: Diabetes mellitus of 10 years, well-controlled with metformin 500 mg bd and glibenclamide 5mg daily.

O/E: see figure Fig. This shows her lesion in 2006 before XRT. There were no other positive findings. The current lesion very similar. Patient coming back next week.

















Work UP:
CXR and CT neck, thorax and abdomen were clear in 2006 - in February 2008 CT scan last week showed several small right obturator lymph nodes. I was not too happy without a repeat CT and get one done last week. Size of LN not mentioned.

Pathology:
2006: Superficial spreading type (apparently down to subcutis for initial biopsy. Pathologist in Singapore wrote: "nodular type with vertical growth and ?superficial spreading"
2008: Recent lesion biopsy report was short and sweet-recurrent melanoma

Diagnosis: Acrolentigious Melanoma

Questions:
1. How would you classify this patient?
2. What would you recommend for this patient?
3. The patient initially refused amputation. Is there a lesser procedure that might help her now?

Your answers and comments are welcome.

7 comments:

  1. I am answering your questions:
    1. T3N1M0. In Clark's classification: level III.
    2. This patient is 70 and has diabetes, so chemotherapy or biological therapies are controindicated. At the moment, I would not recommend any specific therapy for the cancer.
    3. No, there is not. Unfortunately, a surgical excision of the lesion would not change the prognosis.

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  2. samer A dhaherMarch 11, 2008

    nodular growth in melanoma with regional LN involvement indicate advanced stage.. chemotherapy for this old age woman who refuse amputation is not recommended..alternatively I suggest to excise the tumor in stages using Mohs surgical technique plus sentinal LN excision..this proceedure looks more conservative & may save the limb from amputation

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  3. This patient would benefit foremost from decision-support counseling.Discuss with her in the presence of family/friends who can assist her in her decision. Let her voice her worries and concerns. Ask her:
    • What it is that worries her most?
    • What does she hope that you can help her with?

    Then discuss the following with her:

    1. Does she understand the risks of the condition?
    2. Is she seeking further therapy at this point?
    2. What does she fear? Amputation? Feeling sick from chemo? Local debulking with grafting may be reasonable, not necessarily below knee amputation. Provide her options that are dependent on best outcomes so she knows that it’s not all or none.

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  4. There's an old saying, "Sometimes, it is more important to treat the patient who has the disease than the disease the patient has." This woman refused surgery (as is her right). She may prefer to live and die with her melanoma than be subjected to mutilating surgery or difficult chem. That is her choice. It's not clear to me that chemo "cures" melanoma -- it can extend life (but what is the financial and physical cost to the patient?) I think you have to spend time with this patient and perhaps her family to see if irrational fear is driving them, or if they have made a reasoned and informed decision.
    Dylan Thomas wrote: "Wise men at their end know dark is right." Perhaps, this woman is prepared for what may come -- and then, perhaps not. You need to spend time with her to parse that out.
    Regarding the radiotherapy she had -- it is my opinion that melanoma is fairly radioresistant, but that may have been the only treatment the patient consented to.

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  5. Ian McCollMarch 12, 2008

    Assuming the obturator nodes represent melanoma spread then this is Stage 4 disease and surgery will do very little. Dacarbazine after all these years is still the best of the chemotherapy drugs. Vincristine has been combined with other cytotoxic drugs in treating metastatic melanoma but the supposed benefit was at the expense of severe side effects and was not verified by other users. The initial tumour was thick with a large number of mitoses and would have been aggressive.

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  6. Medicine might be more harmful than the disease itself especially aggresive surgery and chemotherapy.This elderly diabetic patient has melanoma beyond surgery and probably beyond chemo ,both of them miht kill her quickly or leave her hanicaped.So please let the patient spend the rest of her life among her family and friends and keep her away from doctors.
    khalifa sharquie

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  7. Start aldara although surgery maybe the first thought...possibly gain confidence by initiating a treatment that is acceptable for the patient and may induce an immune response. Support her medically and emotionally....brenda

    ReplyDelete

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