Nodular Melanoma.

Dear Editor,

Nodular melanomas (NMs) constitute the second commonest clinical subtype of melanomas (representing 14%-30% of the cases of melanomas), following the more common superficial spreading melanomas. The less common subtypes are lentigo maligna melanomas and acral lentiginous melanomas. NMs are the most aggressive subtype with early evolution into the vertical growth phase (VGP). The VGP is a hallmark feature of NMs, as was typically seen in our case.[1-3]

Our patient (figures 1 and 2) was a 72-year-old fair-skinned lady who presented with a 9-week history of a bluish-black skin lesion involving her entire right cheek. It had grown rapidly over the 9-week period. The patient had no previous history of pigmented skin lesions or nevi at the site of the lesion. The nodular lesion measured 13×9 cm in its greatest dimensions (T4). The borders were asymmetric and irregular. The neck lymph nodes were clinically and radiologically found involved and matted together (N3). The serum lactate dehydrogenase was elevated. TNM stage IV was thus established. Histopathological examination confirmed it to be a malignant melanoma. The patient and her accompanying attendants were counseled regarding the gloomy prognosis and the limitations of the potential palliative therapies available; however, they requested to continue with comfort care only. She expired 3 weeks later.

Figure 1

A 72-year-old lady who presented with a nodular melanoma involving her entire right cheek (lateral view).

Figure 2

A 72-year-old lady who presented with a nodular melanoma involving her entire right cheek (oblique frontal view).

NMs typically do not adhere to the ABCDE (asymmetry, border irregularity, color variegation, diameter >6 mm, and evolution) warning signs of melanoma screening tools (as was witnessed in our patient), and 5% of NMs are amelanotic and as such carry even a worse prognosis. These factors probably contribute to their advanced stage at initial presentation. NMs not only display an explosive and aggressive growth pattern locally but also spread more aggressively to the sentinel lymph node basins than do the other subtypes of melanomas. Although there has been a rising incidence of melanomas in the United States for the last several decades, the mortality rate has been relatively stable since the early 1990s, owing to the more efficient secondary prevention via improved early detection and better treatment.[1,2]

Given the context of the aggressive progression of NMs, targeted screening of older populations at risk is crucial if melanoma mortality rates are to be reduced in low-income countries like ours (Pakistan). Healthcare practitioners should be proactive about these aggressive tumors and perform total cutaneous examinations in high-risk populations if they present with any pigmented skin lesions. Although NMs typically fail to abide by the golden ABCDE criteria, the emphasis should still be on alerting the patient to the “E” criterion as the evolution of changes remains the most remarkable phenomenon within these lesions. This may serve to ensure early medical consultation, timely diagnosis, prompt treatment, and hence reduced mortality. Our case is a reminder for skin physicians and surgeons to be mindful of the sinister course of advanced NMs and thus be proactive regarding their secondary prevention and management.