One More Unfortunate...

Gina Kaulukukui is a grief counselor on the island of Kauai, Hawaii. She sent me the following text along with these photographs. Your impressions may help to solve this tragic mystery.

“I would like you to review the attached photos and give me your impressions. This 21 y.o woman was found in the water at Tunnels Beach on the north shore of Kauai following a night of partying. She was reportedly in the water about 7-15 minutes when she was pulled out unresponsive. When she was brought to the ER (at least a ½ drive) it was believed that she nearly drowned. She was unresponsive and not expected to survive.

While in the ER she presented on her thighs with unusual markings. The first appeared red jagged rings starting from her bikini line to just above the knee on one side and more toward the inner thigh on the other leg. Both were oval and completely blanched in the middle. There was a slight bruised color line in the center of one of the blanched areas. There were no others marks, lesions, etc.

The next day, the blanching went away and the red ring doubled in size from about 1 inch to about 2 inches. It was very red, raised and angry looking.

Later in the day when I went to check the young lady and convinced the ICU to photograph the area as it was again changing. Where the bruising was, small water blisters began to appear on the one leg, while the markings on the other leg was beginning to disappear. When the doctor was called to look at the blistering, she diagnosed it as a thermal burns.

The attached pictures were taken few hours following her death and as you can see on one side there is no marking left (the red mark on the upper thigh is from her blood pooling and not the original location of the blanching). The other side speaks for it self.

There were never any marks or puncture wounds that would indicate a jelly fish sting. The water was calm that day. She had high levels of cocaine and alcohol in her system. I would love to know what you think. We have yet to receive the biopsy results. I appreciate your time...love and aloha Gina

Distal Onycholysis

Abstract: 76 yo retired nurse with a 1 year history of nail dystrophy.

History: This 76 yo retired registered nurse had distal onycholysis of her right thumb nail a little over a year ago. It eventually "spread" to involve all finger nails. Her medications include lorazepam, citalopram, Premarin and thyroid. All have been taken for many years. She has not used acrylic nails for more than five years. No unusual trauma, but she does use a nail file now. She was seen for around a year by a provider who was treating her with ciclopirox. The patient admits to being very anxious and plays with her nails.

O/E.: The patient is a pleasant, well-groomed woman who appears anxious and concerned. She has distal onycholysis of all finger nails. Toe nails are normal. Scant subungual debris.
Clinical Photos:




Lab: Three KOH preps negative. Fungal cultures were obtained 30 July, 2008.
Pathology: A "few" fungal elements were reported on PASD stained clipping of an affected nail

Diagnosis: Distal onycholysis. I am leaning away from onychomycosis. This would be an unusual presentation. I think this will likely be traumatic onycholysis.

Therapy: Pending culture report, I initiated therapy with 15% sulfactamide in ethanol twice daily. She was asked not to use a nail file and to clip separated portions of nails every day or so. Also, keep hands out of water as much as possible.

Questions: What are your thoughts? Any further work-up?

References:
1. eMedicine.com

Skin Cancer Observation from Baghdad

Case presentation by:
Professor Khalifa Sharquie,
Baghdad, Iraq

I have had the opportunity to see many cases of skin grafting on the face after excision of multiple skin solar keratosis and skin malignancy. Some of these have been in patients with xeroderma pigmentosa (XP). The grafts remained free of actinic disease and have stayed clear for many years, in some cases for more than 20 years. I have never observed them to develop solar damage, solar keratosis or malignancy.

Today, I am presenting one of these cases. A 65 yo man with history of marked sun damage since early life. During the course of his illness, he has developed frequent and multiple solar keratosis and squamous cell carcinoma. Positive family history was seen in his son. Excisions and graftings have been carried out for big cancers since 1982 but he has never developed any solar damage or skin malignancy in the grafts.





Questions:
1. Is it justifiable to excise the skin of such patients with multiple keratosis and malignancies, especially in patients with XP early in life as a part of preventive measures against skin malignancy especially malignant melanoma.
2. What is the mechanism behind this odd observation. Could fibroblasts of the graft share in prevention?
3. Is there any role in the use of imiquimod in these patients? (last question from DJ Elpern)

Erythema Migrans with Pustules

This 27 yo woman was sent from the E.R. with a 5 day history of a solitary 20 cm annular plaque on the right hip. It looks classical for erythema migrans (EM) of Lyme disease. Her three year-old daughter had a tick on her skin 2 weeks ago, but she has no history of tick bite. The patient is well otherwise.
Photos taken June 24, 2008


Clinically, this is Lyme disease, but no reports in literature of pustules. There is one from China with vesicles (which these may have been initially).

Lyme titers are pending (but this is a clinical dx at this point) and a culture of a pustule was taken.

E.R. doc put her on cefuroxime because she can't tolerate doxycycline (bad GI upset). She has a f/u appointment in a week.

Ranula

Abstract: 16 mo girl with mucous cyst of lower lip.
HPI: This 16 mo Chinese girl presented for evaluation of a lip lesion that has been present for two months. It waxes and wanes in size. The lesion does not appear to bother her. Her mother speaks little English and is very worried about this lesion.
O/E: 6 mm translucent cyst lower lip
Clincal Photo:

Lab/Path: N/A
Diagnosis: Mucous Cyst (Ranula)
Questions: How would you approach this patient? I need to find a translator so that I can have a meaningful discussion with the child's mother. In the past, I have treated a few of these with liquid nitrogen and they did well, but that might be very traumatic for this child (and the mother). Might have to find a pediatric ENT (the closest would be ~ 75 miles from here)

Reference: There are two good chapters on eMedicine.com
and eMedicine2.com The latter is more detailed.

This is the largest study I found, and I'll write to the authors.
Clinical review.com2 of 580 ranulas.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Sep;98(3):281-7.
Zhao YF, Jia Y, Chen XM, Zhang WF.

CONCLUSION: Three patterns of ranula have similar clinical and histopathologic findings, although plunging ranula has some different clinical features. Removal of the sublingual gland via an intraoral approach is necessary in the management of various clinical patterns of the ranula. Recurrence rates of ranulas of any type are excessive unless the involved sublingual gland is removed.

Man from Mauritius

Presented by Dr. Philip Li Loong, Quatre Bornes, Mauritius

Abstract: 27 year old man with four year history of a papular eruption.

HPI: This man's lesions began on the face four years ago and later developed in the groins and axillae. Initially macules, they became papular and much more numerous. At onest, they were felt to be verruca plana. Cryotherapy was tried without success.

O/E: The lesions are 2 - 3 mm in diameter brown to yellowish papules. Distribution: Face, crural folds, axillae.

Clinical Photos:





Lab: Full blood count normal, cholesterol 5.2 upper limit, triglycerides normal, LDL HDL also normal, Immumoglobulins normal, plasma electrophoresis normal, thyroid function tests normal.
Pathology: Two biopsies were done.
The first showed a mild chronic inflammatory infiltrate in the upper dermis made up of small lymphocytes and histiocytes with occasional macrophages.
Repeat biopsy from the right axilla was reported as aggregates of foam cells admixed with other histiocytes, lymphocytes and some fibroblasts: "appearance consistent with eruptive xanthomas"

Diagnosis: Do you think this man has xanthoma disseminatum?

Questions: This entity may be associated with paraproteinemia and mucous membrane involvement. Comments for diagnosis and management will be most welcome. What are your thoughts? What further would you do?

Know When to Cut, Know when to Punt

The patient is an 87 yo man with a mild dementia. He lives in an assisted care facility. Has an attentive and caring daughter. In October of 2007 he had a wide-local excision of s large SCC on the left forehead by a general surgeon. Path report showed "clear margins." When seen on May 30, 2008 a 4 x 3 cm recurrence was noted. The picture of the right TMJ area shows a scar from micrographic surgery from a similar lesion the patient had ~ 10 years ago. His daughter said it took 6 months to heal.





Questions:
1. What contributes to the aggressive behavior of this small subset of SCCs?
2. Would you refer to Mohs, XRT, or just watch?
3. Are you comfortable playing God with patients like these?

Comment: There is a subset of SCCs that metastasize and kill patients. MA Weinstock and his collaborators have written on this subject.

Weinstock MA, et. al.
Nonmelanoma skin cancer mortality. A population-based study.
Arch Dermatol. 1991 Aug;127(8):1194-7.

Department of Medicine, Veterans Affairs Medical Center
Providence, RI 02908.

To estimate the magnitude of nonmelanoma skin cancer mortality
and describe itsparameters, we reviewed the medical records of
all deaths certified as due to this cause among Rhode Island
residents from 1979 through 1987. After excluding acquired
immunodeficiency syndrome-associated Kaposi's sarcoma, we
confirmed that nonmelanoma skin cancer was the cause of death
for 51 individuals, a quarter of the number of melanoma deaths
reported. The age-adjusted nonmelanoma skin cancer mortality rate
was 0.44/10(5) per year. Fifty-nine percent were due to squamous
cell carcinoma, and 20% were due to basal cell carcinoma. Most
appeared actinically induced. Among deaths from SCCs, the mean age
was 73 years. At least 80% of the squamous cell carcinomas metas-
tasized, and 47% arose on the ear. None appeared due to refusal of
treatment. Among deaths frombasal cell carcinoma, the mean age was
85 years, and refusal of surgical  intervention was documented in
40%. Study of nonmelanoma skin cancer mortality provides for estimation
of the magnitude of this problem, complements otherstudies of
prognosis, and helps guide prevention, early detection, and treatment.

Two Foot and One Hand Disease

These are the hands of a 35 year-old plumber I saw recently. He was not aware of a dermatitis of his feet, but inspection showed mild moccasin-type T. pedis on both feet and subtle onychomycosis. KOH prep from the right hand was positive for septate hyaline hyphae. We all see two foot and one hand disease regularly. Do you have any theories as to why only one hand is involved? This is a peculiar dermatologic vignette.



Right Hand


Left Hand

Penile Pain

The patient is 40 yo heterosexual male in a monogamous relationship for the last 6 years. Neither he nor his partner has a history of having had sex with anyone else ever before.

Three months ago he had the onset of pain at the tip of his glans during coitus and experienced pain also on pulling at the tip of his foreskin. A month later he noticed a few grouped "vesicles" at the ventral tip of his glans. These lesions have persisted unchanged. The pain in these lesions persists since being first noticed.
Clinical Photo:


The wife is asymptomatic although she had symptoms suggestive of vaginitis 3-4 months back which improved on clotrimazole pessaries (this was almost the same time when the patient developed pain during coitus which has never subsided).

What is the diagnosis?
What would you do at this point?

Note: Two respondents have suggested "Pearly Penile Papules." This does not look like a typical case of PPP. For comparison a picture is below. PPP is usually around the corona and is rarely this symptomatic.

21 yo man with warty plaque on foot

Presented by Henry Foong, Ipoh, Malaysia

A 21 yr old student presented with 5-year history of warty growth on the
right foot. It started as a small lesion which gradually got bigger.

Pertinent findings on examination were raised hyperkeratotic plaque 5 x 3 cm
on the medial border of the dorsum of the right foot. It has a verrucous
surface with blackish dots. Regional nodes were not palpable.




Clinically he has chromoblastomycosis of the right foot.

A biopsy was done and the epithelium shows marked acanthosis with elongation
of rete ridges and intraepithelial collections of neutrophils. The dermis is
densely infiltrated by lymphocytes, plasma cells and few neutrophils.
Culture of organism was not done.

I may repeat the biopsy and perform fungal culture.

I plan to treat him with liquid nitrogen together with some combination
therapy with antifungals: itraconazole 100mg bd ( 200mg bd??) for several
months together with another antifungals. 5FU or IV amphotericin.

Would appreciate your comments on this patient.

No Man is an Island

Thallium poisoning with skin manifestations

Presented by Professor Khalifa Sharquie
Baghdad, Iraq

History: A few weeks ago, an outbreak of thallium poisoning occurred in Baghdad and all of the patients had positive tests for thallium. We had the opportunity to see cases with skin manifestations. All patients gave a history of eating cakes and presented to hospital with nausea, vomiting followed by mental and peripheral neurological complaints. The case I am presenting was that of a 30 yo adult male referred to me two weeks after poisoning. He had severe hair loss, both diffuse and patchy, affecting mainly scalp and body hair. Also he had a non-pruritic rash affecting the face, limbs and groins.

O/E: The striking findings were severe anagen hair loss, diffuse and in patches. The hairs were easily plucked and microscopically were typical anagen phase. The next important finding was dermatitis-like picture that covered the face especially around the mouth and the limbs mainly on the dorsae of both hands. The groins had intertrigo simulating tinea cruris. The rash was dusky red and ecchymotic in appearance.

Photographs:





This picture was strange enough to make one think about the following Differential Diagnosis:
Acquired zinc deficiency
Pellagra
Erythema multiforme
But only suspicion can lead you into right diagnosis. Accordingly, before the definite diagnosis was established, we gave oral zinc sulfate 100mg 3 times a day for some patients. Surprisingly they recovered and resolved.

Reason Presented: Thallium is nice rat poison since it is colorless, tasteless and odourless. It can be used as massive lethal chemical weapon and is practiced this way in Iraq as a way to kill people. It is my opinion that thallium should be prohibited and considered as a chemical weapon like nitrogen mustard. It is better to let rats run free than to kill human beings.

Reference: A good article on this subject appeared in the Archives of Dermatology in January, 2007. Short-term thallium intoxication: dermatological findings correlated with thallium concentration.
Arch Dermatol. 2007 Jan;143(1):93-8.
Lu CI, Huang CC, Chang YC, Tsai YT, Kuo HC, Chuang YH, Shih TS.
Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan.
One can view this free online: Arch Dermatol article

Comment: John Donne wrote: "All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Our Western civilization began in the Fertile Crescent. Iraq was at the epicenter. The strory told here diminishes all of us. Professor Sharquie bravely bears witness as he helps and serves his people.

Stumped...

Abstract: 60 yo man with unusual cutaneous ulcers and erosions
Presented by Dr. Hamish Dunwoodie, Moncton, New Brunswick
HPI: The patient is a disabled physician's assistant who injured his scalp on a low basement ceiling beam around a year ago. When he was first seen he had a thick escar over the area. This was debrided and cultured. It grew Staph aureus with the usual sensitivities and he was treated with wet compresses, dicloxacillin and bactroban ointment. Since his initial visit 4 months back it has not gotten smaller and now the central portion reaches the calvarium. Over the past six weeks, he has developed similar lesions on shoulders and upper back. By history these began at sites of ECG leads.

Pertinent medical history is positive for insulin-dependent diabetes, hypertension and coronary artery disease. His medications include insulin, warfarin, enalapril, furosemide, ASA, oxycodone.

O/E: 3 cm ulcer mid parietal area of scalp. Erosions on both shoulders, surface somewhat escharotic. Some with irregular borders.

Photos:


4 months later








Lab: Occasional skin cultures positive for S. aureus (not MRSA), CBC shows mild normochromic normocytic anemia. (Hct 32.6.Hgb 11.2).

Pathology: "Ulceration with scar. No evidence of malignancy." Repeat biopsy April 18, 2008 from new lesion on shoulder send to Canadian National Pathology Lab.

Diagnosis: Non-healing erosions etiology unclear. One always considers factitial disease in health care professionals with atypical skin lesions and this man also has free access to needles as a diabetic. In a year, the scalp lesion has shown no tendency to improve.

Further Treatment: He was treated with topical corticosteroids in case this was erosive pustular dermatitis of the scalp (no response) and imiquimod in case erosion might have been hypergranulation tissue. (no response) We ordered Duoderm dressings, but they were too expensive for the patient.

Questions: Where would you go from here? Diagnostic and therapeutic suggestions.

A Leg to Stand On

Abstract: 85 yo man with cellulitis and lymphedema s/p bypass surgery

HPI: In 2000, this retired professor had CABG surgery with saphenous vein harvesting of the left leg, In 2002, while visiting Vienna, he was hospitalized for cellulitis of the left leg and treated with i.v. antibiotics. In the subsequent years, he has had progressive lymphedema of the left leg with the development of elephiantiasis nostra verrucosa. In the past 6 months he has had four documented episodes of cellulitis which have necessitated antibiotics. Recently, he has developed a generalized dermatitis. His medications include: atenolol, amiodarone, digoxin, diovan, thyrpid, Coumadin, Lovastatin, ASA. He has a possible allergy to penicillin (has not taken it in 40 years). He is otherwise quite healthy and intellectually alert.

O/E: Chronic lymphedema left leg with erythema, scale and some honey-colored crust. The leg in involved from just below the knee to the foot. The left leg is only minimally warmer than the right leg. In addition, he has a wide-spread dermatitis consisting of erythematous scaly patches on legs, arms and abdomen -- sparing the face.

Photos:






Lab: His internist did a skin culture and CBC b efore sending him here (results not back) . He was on Bactrim at the time of the culture.

Diagnosis: Recurrent Cellulitis s/p saphenous veif harvesting wit the development of chronic lymphedema and early elephiantiasis nostras. This was reported in 1982 (see Reference). The wide-spread dermatitis may be an "id" reaction.

Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Follow-up: The patient was treated with compression stockings, cephalexin 250 mg qid for two weeks (based on sensitivities), desoximetasone 0.25% cream and lymphatic massage. There was no evidence of tinea pedis. He has improved markedly.
Photos taken June 10, 2008





Reference:

Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.

Recurrent Cheilitis in a 37 yo Woman

Abstract: 37 yo woman with 18 year recurrent cheilitis

HPI: This 37 yo woman has had recurrent cheilitis for 18 – 20 years. She works as a medical assistant. At one time, she was thought to be latex sensitive because blowing up balloons makes her feel sick, but a RAST test was negative. The episodes last five to six days. The day before the present episode she had eaten a “Mediterranean Dip” which included cucumber, garlic, feta, tomato, and horseradish. She noted nothing till the next morning when there was mild erythema of upper lip. She may have a history of mild atopic dermatitis. She can recall no meds she took before this or other episodes.

O/E: Erythema and mild crusting of lips and adjacent glabrous skin. Remainder of exam normal. Occasionally she’ll have mild erythema around outer canthi.

Photos:




Lab/Path: N/A

Diagnosis: ? Allergic Cheilitis. Role of Foods? Doubt Fixed Drug Eruption. To me this looks like an allergic contact cheilitis.

Questions: What would be the best way to work this up? This woman has 3 - 4 episodes per year, so it is unlikely that her cheilitis is related to something whe uses daily, and she does not recall anything she applies only intermittently.

Reference:
Allergic contact cheilitis in the United Kingdom: a retrospective study.
Strauss RM, Orton DI.
Am J Contact Dermat. 2003 Jun;14(2):75-7.

Abstract: Environmental and Contact Dermatitis Unit, Amersham Hospital, Whielden Street,
Amersham, Buckinghamshire, HP7 0JD, United Kingdom. strauss@strauss.karoo.co.uk

BACKGROUND: To date, only a few cohorts of patients with allergic cheilitis have
been described, most of them from Australia and Asia. OBJECTIVE: To establish the
prevalence of cheilitis in a UK specialist contact dermatitis clinic and to
identify the most common allergens. METHOD: We analyzed our patch-test database
in a tertiary referral center in the United Kingdom, retrospectively. All
patients presenting with cheilitis over a 19-year period (1982 to 2001) were
included. RESULTS: Data were available from a total of 146 patients. A positive
allergic patch-test reaction was thought to be relevant in 15% of the patients (n
= 22) and to be of possible relevance in 6.8% (n = 10). Of the 22 patients with
relevant allergic results, 95% (n = 21) were women. The most common allergens
included fragrance mix (mainly cinnamaldehyde, oak moss, and isoeugenol) in 41%
of patients, shellac in 18%, colophony in 18%, and Myroxylon pereirae in 14%. For
half of the patients, the allergen was believed to stem from lipsticks or lip
products. Eighteen percent of patients with allergic cheilitis reacted to only
their own products. CONCLUSIONS: Patients should be tested to extended
lipstick/cosmetic vehicle series in addition to standard series. As a significant
percentage of patients react to their own products only, a thorough clinical
history and testing to patients' own products are important.

Double Helix

We often see problems for which there may be no simple solution. Ear lobe keloids are encountered with regularity; but keloids of the helix and triangular fossae are unusual. Some of you may have a simple trick for patients like these:

Patient # 1.
Abstract: 25 yo woman with ear keloid.

HPI: This 25 yo Asian woman pierced the triangular fossa of her right ear 2 years ago and developed a keloid which is pruritic and whose appearance bothers her.

O/E:


Patient # 2
As I was getting case # 1 ready to publish on this site, a second patient presented for evaluation and treatment.
This is a 16 yo girl with a one year history of a keloid of the left triangular fossa. She had a professional piercing done two years ago. This lesion is painful.




This patient had an "Industrial Piercing" with a 14 guage stainless steel rod.

Comment: Earlobe keloids are commonly seen and reported. But I could find no helpful articles about helix and triangular fossa keloids. I suspect that these lesions are not rare, since I have seen two in a few weeks in a small New England town. Perhaps, these are harbingers of an epidemic! One of these young women pierced her own ear, and the other was a professional job.

Questions:
These can not be simply excised and then injected with TAC like the more common ear lobe keloid. Wound closure would be problematic.
How would you approach these women?
Any role for shave excision followed by imiquimod?
Do you think TAC alone will work? 20 mg per cc, 40 mg per cc?
Does anyone have experience with similar lesions?

Weird Erythema

Presented by Omid Zargari
Rasht, Iran

This patient referred to me with a weird erythema on his frontal area for the past two years.
He is a 45 y.o. kidney transplant patient whose medications include cellcept, cyclosporine, erythropoetin alpha and simvastatin. He believes that this began after he started simvastatin.



Your thoughts will be appreciated.

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.