Acral Lentiginous Melanoma During the COVID Pandemic

presented by Dr. Henry Foong, 

Ipoh, Malaysia

During the pandemic, clinical services in general hospitals were disrupted and patients tend to delay treatment due to lockdown and restriction in movement.  Here is one such example where the tumor had progressed to an advanced stage before the patient sought treatment from healthcare service.

This is the case of a 65-year-old housewife from Sungai Siput who presented with a 2-year history of an asymptomatic  pigmented growth on the left foot. It started as a pigmented macule which gradually increased in size.  She tried topical creams and traditional topical ointments without any improvement. She denied any excessive sun exposure. There was no family history of skin cancer.  Her medical history included hypertension, diabetes mellitus and hypercholesterolemia. She is not on any immunosuppressive drugs. She is married and has 4 children.

Examination showed a darkly pigmented nodular growth 4 x 5 cm on the interdigital webspace of the 2nd/3rd left toe. The lesion was well demarcated, and hard in consistency. The regional nodes were not enlarged.  There were no surrounding satellite lesions.

Clinically this patient has an acral lentiginous melanoma

A skin biopsy was performed. 

MICROSCOPIC APPEARANCE

Sections of the ulcerated epidermis show irregular nevus nests at the epidermis as well as the dermis. The irregular nevus cells are distributed along the basal layer of the epidermis and Pagetoid spread of these atypical nevus cells are noted. The dermis shows irregular distribution with lack of maturation. The nevus cells exhibit nuclear enlargement, contour angulation, nuclear hyperchromatic and prominent nucleoli. Moderate lymphocytic upper dermal infiltrate is present. The mitosis figure is 3 per mm squared. Maximum Tumor Thickness Breslow: 4.0 mm

INTERPRETATION

Skin punch biopsy Left foot: Malignant melanoma.

Maximum Tumor Thickness Breslow thickness Specify: 4.0 mm.

Ulcerated

No immunohistochemisty was done.

 

 

 

Follow-up: She is doing well at the moment.  She was seen at the Department of Orthopedic Surgery, Ipoh General Hospital and had surgical ray amputation of the toes. She is due for follow-up by the chemotherapy team from Kuala Lumpur Hospital, a Malaysian government-owned public hospital later this month.

Discussion:

While acral lentiginous melanoma is rare in the Western population, it is among the commonest type of malignant melanoma in the South East Asian countries (29-46% of melanomas in Asians).  Accurate pathological staging of the melanoma is useful to guide the treatment and management of the tumor.  

Questions:
Is sentinel node biopsy necessary in this patient?  

In Malaysia, it is commonly managed by orthopaedic surgeons together with the oncology team, most of the time partial amputation of the fore foot with the preservation of the ankle is done.
What approaches would a dermatological surgeon have?

References:

1.  J Pailoor et al Malays J Pathol 2012 Dec;34(2):97-101 Cutaneous malignant melanoma: clinical and histopathological review of cases in a Malaysian tertiary referral centre

2. A I Zainal et al. Med J Malay 2012:67;1:60-65 Acral melanoma of the extremities: A study of 33 cases in Sarawakian patients

3. F Durbec , L Martin, C Derancourt, F Grange. Melanoma of the hand and foot: epidemiological, prognostic and genetic features. A systematic review. Br J Dermatol. 2012 Apr;166(4):727-39.
Abstract
Background: While early recognition and prognosis of melanoma as a whole have improved, particular forms of rarer, under-recognized or more severe tumours require increasing attention. Among them, melanomas located on the hand and/or foot (hand and foot melanoma, HFM) have been the subject of few and heterogeneous studies, with variable and sometimes confusing results, and have not been targeted to date by comprehensive literature reviews.

Objectives: To perform a formal, systematic review of the literature, focusing on epidemiology, risk factors, prognosis and genetic characteristics of HFM. Methods All data sources were identified through searches on Medline, Scopus and Cochrane databases. Articles were selected and evaluated according to predefined quality criteria

Results: Among 1185 articles screened for relevance, 37 met the inclusion criteria. Data analysis brought to light important particularities of HFMs: they are rare in all ethnic groups of developed countries, but have been insufficiently studied in the developing world. About half are of the specific acral lentiginous melanoma (ALM) subtype. Previous trauma and naevi on the soles/toes were identified as two main risk factors in case-control studies. Genetic or environmental factors other than sun exposure are likely to play a role but require further investigation. Compared with melanoma at other sites, their prognosis is poor mainly as a consequence of later diagnosis, but possibly also because of an intrinsic negative effect of the HFM/ALM subtype. Standard prognostic factors of melanoma have been insufficiently validated to date in HFM. Finally, their molecular genetic particularities could lead to specific targeted therapies in the near future.

Conclusions: Overall, HFM could represent a particular subgroup of rare, potentially severe melanomas, requiring specific management from their prevention up to their treatment.

Melanoma Neglecta

Presented by Jorge Delgado, M.D.
Brownsville, Texas

 

The patient is a single 65 yo man who lives alone.  He does not have a physician and has received no medical care in years.  His sister, who lives outside of the country, came to visit and noted that his shirts were stained by a malodorous exudate of blood and pus. Questioning, led to the discovery of a tumor on his back that apparently had been growing for months to years.

 

Usually fastidious about his personal hygiene, she also observed that he’d become forgetful, unsteady on his feet and had fallen recently.

 

The examination showed a 5 cm tumor on his back, portions of which had ulcerated.  No pigment was discernable.

 

 

She took him to a dermatology clinic where a biopsy was done.  It was reported as melanoma, greater than 4 mm thick with many mitoses.  We don’t have the path report.

 

This represents an example of Melanoma Neglecta.  People who lack basic medical care, who are isolated or who live in undeserved areas are recognized to be at risk for tumors that are detected at a late stage.

 

References:

1. Ana-Maria Forsea. Melanoma Epidemiology and Early Detection in Europe: Diversity and Disparities. Dermatol Pract Concept. 2020 Jun 29;10(3):e2020033.  PMC

 

2. Sauaia A , Dellavalle RP. Health care inequities: an introduction for dermatology providers. Dermatol Clin. 2009 Apr;27(2):103-7, PMC

 

3. Rachidi S, Deng Z, Sullivan DY , Lipson EJ. Shorter survival and later stage at diagnosis among unmarried patients with cutaneous melanoma: A US national and tertiary care center study. J Am Acad Dermatol. 2020 Oct;83(4):1012-1020.
Conclusions: Unmarried patients, especially men and those younger than 68 years, are diagnosed at more advanced stages, even in readily visible sites such as the face. They also experience worse survival independent of stage.

Pumped and Tanned

Pumped and Tan, Melanotan Man

Presented by Dr. M. Chester Morris

Cosmetic and Aesthetic Dermatology Centre

Nanaimo, British Columbia, Canada

 

A 42 yo Man presented with a history of new naevi on torso a few months

 

He was in good general health.  His only medication was oral minoxidil, 5 mg a day, for male pattern alopecia.

 

O/E:  About a dozen naevi, 5 – 7 mm in diameter,

were scattered on his torso..  They were clinically benign appearance, but as it is unusual for a 42 year-old individual to have eruptive naevi. The most atypical one was biopsied.

 Pathology shows a junctional and compound nevus without atypia.

The patient is well-known to our clinic.

He has a history of

• Ongoing mild alopecia areata of the bearded area and receives ILK every few months. 
• Mild male-pattern alopecia.  He’s had 3 hair transplants, 2 locally and one at a specialty clinic in Southern California where they do PRP
• Expensive cosmetic dental capping

 

He spends lots of time in the gym (uses supplements)

 

Further history reveals that he bought Melanotan. a synthetic analogue of the peptide hormone α-melanocyte-stimulating hormone (α-MSH) that stimulates melanogenesis and is purported to increases sexual arousal among other things, at his gym and has been injecting himself with it for a few months.  When I asked to see the product, he said he couldn’t find it.

 

Diagnosis: This 42 yo man developed Eruptive Melanoytic Naevi after the use of Melanotan obtained from a contact at his gym.  When I expressed interest in the drug; he disappeared. I have known him for a few years and he appears to have body dysmorphic syndrome (BDD) and that may have induced him to purchase Melanotan.  His form of BDD has been called “Muscle Dysmorphia” or The Adonis Complex.

 

 

Teaching points:

1. Use of Melanotan may be more widespread than we realize.

2. Patients such as this may have BDD, specifically the Adonis Syndrome

3.  There is an online literature on Melanotan and although it is risky, some patients nonetheless seek it out.

 

The medical literature contains references to various possible side-effects of Melanotan. These include: darkening of previous naevi, eruptive melanocytic naevi, isolated cases reports of melanoma and melanoma in situ, renal infarcts, and priapism.

 

Reference:

1. Ewa A Burian  1 , Gregor B E Jemec  Eruptive Melanocytic Nevi: A Review. Am J Clin Dermatol. 2019 Oct;20(5):669-682.

Abstract: Eruptive melanocytic nevi (EMN) is a phenomenon characterized by the sudden onset of nevi. Our objective was to compile all published reports of EMN to identify possible precipitating factors and to evaluate the clinical appearance and course. We conducted a systematic bibliographic search and selected 93 articles, representing 179 patients with EMN. The suspected causes were skin and other diseases (50%); immunosuppressive agents, chemotherapy or melanotan (41%); and miscellaneous, including idiopathic (9%). The clinical manifestations could largely be divided into two categories: EMN associated with skin diseases were frequently few in number (fewer than ten nevi), large, and localized to the site of previous skin disease, whereas those due to other causes presented most often with multiple small widespread nevi. In general, EMN seem to persist unchanged after their appearance, but development over several years or fading has also been reported. Overall, 16% of the cases had at least one histologically confirmed dysplastic nevus. Five cases of associated melanoma were reported. We conclude that the clinical appearance of EMN may differ according to the suggested triggering factor. Based on the clinical distinction, we propose a new subclassification of EMN: (1) widespread eruptive nevi (WEN), with numerous small nevi, triggered by, for example, drugs and internal diseases, and (2) Köbner-like eruptive nevi, often with big and few nevi, associated with skin diseases and most often localized at the site of previous skin disease/trauma. The nature of the data precluded assessment of risk of malignant transformation.

 

2. Melanotan https://en.wikipedia.org/wiki/Melanotan_IIWikipedia

 

3. Harrison G Pope Jr, Katharine A Phillips & Roberto Olivardia, The Adonis Complex: The Secret Crisis of Male Body Obsession (New York: Free Press, 2000)

 

4. Muscle Dymorphea: https://en.wikipedia.org/wiki/Muscle_dysmorphia

 

5. Louis Habbema  et. al.  Risks of unregulated use of alpha-melanocyte-stimulating hormone analogues: a review. Int J Dermatol. 2017 Oct;56(10):975-980.

Abstract

Recently, the unregulated use of untested synthetic alpha-melanocyte-stimulating hormone (α-MSH) analogues, commonly known as melanotan I and II, appears to have increased. These analogues are primarily used for their tan-stimulating effects. Dermatologists see many patients in their clinic who tan. This review provides an overview of the risks of the unregulated use of these substances.  Although afamelanotide has been thoroughly tested and deemed safe, illegal melanotans are likely risky for several reasons. There are questions regarding the preparation, administration, and dosage of these substances. In addition to these general risks, increasing numbers of case reports indicate that the unregulated use of both melanotan I and II is associated with cutaneous complications, particularly melanocytic changes in existing moles and newly emerging (dysplastic) nevi. Four case reports have described melanomas emerging from existing moles either during or shortly after the use of melanotan. Although conclusive evidence linking these phenomena is lacking, publications have stressed the importance of awareness that melanotan is a part of a 'tanning culture' in certain subpopulations. Multiple national health organizations have issued safety warnings regarding the use of melanotan I and II.