An 83-year-old woman is referred for evaluation of a growth on her back. She states that the lesion has been present for many months and recently began to itch and bleed. She denies history of skin cancer and says that several lesions in proximity to this new lesion were removed “by freezing” several years ago. Examination reveals a 2.5cm hyperpigmented nodule. Axillary lymph nodes were not palpable.
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Shave biopsy of the lesion is performed, and a diagnosis of nodular melanoma is confirmed. Pathology report reveals tumor thickness of 9 mm, ulceration, mitotic index of 3 mitosis/mm2, and no signs of microsatellitosis, angiolymphatic invasion, or regression.
According to the American Cancer Society, more than 96,000 new cases of melanoma will be diagnosed in the United States in 2019 and more than 7200 individuals will die from the disease.1 The risk of developing melanoma increases with age, and the average age at diagnosis of melanoma is 65.
Nodular melanoma, which is defined as lesions having a Breslow thickness >4 mm, is the second most common variant of melanoma after superficial spreading melanoma.2 Nodular melanoma often presents with a faster growth rate and higher mitotic index than other melanoma variants.3 Approximately 40% of melanoma-related deaths are related to nodular melanoma.4,5 Poor prognostic factors include greater lesion depth at diagnosis, early ulceration, and increased mitotic rate.6
Once diagnosis has been confirmed, definitive treatment consists of wide local excision with consideration of sentinel lymph node biopsy because of the thickness of the lesion following a discussion of the potential benefits and risks with the patient.7
Rebecca Geiger, PA-C, is a physician assistant on staff at the DermDox Center for Dermatology in Sugarloaf, Pennsylvania. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
1. American Cancer Society. Key statistics of melanoma skin cancer. American Cancer Society website. https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html. Updated 2019. Accessed December 11, 2019.
2. Alhatem A, Lambert WC, Schwartz RA, Chokshi RJ. Multiple thick nodular melanoma: differentiating multiple primaries from the metastasis of a previous single melanoma. Balkan Med J. 2019;36(6):364-365.
3. Shen S, Wolfe R, McLean CA, Haskett M, Kelly JW. Characteristics and associations of high-mitotic-rate melanoma. JAMA Dermatol. 2014;150(10):1048-1055.
4. Corneli P, Zalaudek I, Magaton Rizzi G, di Meo N. Improving the early diagnosis of early nodular melanoma: can we do better? Expert Rev Anticancer Ther. 2018;18(10):1007-1012.
5. Mar V, Roberts H, Wolfe R, English DR, Kelly JW. Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia. J Am Acad Dermatol. 2013;68(4):568-575.
6. Pizzichetta MA, Massi D, Mandalà M, et al; Italian Melanoma Intergroup (IMI). Clinicopathological predictors of recurrence in nodular and superficial spreading cutaneous melanoma: a multivariate analysis of 214 cases. J Transl Med. 2017;15(1):227.
7. Wong SL, Faries MB, Kennedy EB, et al. Sentinel lymph node biopsy and management of regional lymph nodes in melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update. Ann Surg Oncol. 2018;25(2):356-377.