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.