An 83-year-old woman came to the emergency department complaining of chest pain for several days. She had a 10 month history of biopsy proven melanoma of her left lower leg. She had refused treatment in past, but opted for excision during the subsequent hospitalization since the lesion was foul-smelling, bleeding, and painful. Evaluation for metastatic disease including computed tomographic scans of the head, chest, abdomen, and pelvis with and without contrast showed no evidence of tumor (Melanoma: T4bN0M0, stage IIIB). The calf lesion was excised ensuring that at least 2 cm wide margins were obtained. Radical excision was performed by extending the incision vertically down to the fascia and entering a subfascial plane. The tumor was then sent to pathology after suitably marking the lesion to ensure that the margins were negative. A split-thickness skin graft about 1/14th of a thousandth of an inch was taken with the dermatome from the right thigh. The graft was meshed to 1:1.5 in dimension, placed over the recipient area, and fixed to the skin by means of staples. Compression dressings with mineral oil and Xeroform was placed tightly over the graft and a suitable dressing applied. The left lower extremity was immobilized by means of a slat placed posteriorly and extending from the ankle to the knee joint. Estimated blood loss was 150 ml. Lymph node mapping was not performed as patient would not be a good candidate for any adjuvant therapy. Note that maging studies of distant organs, such as CT scans, magnetic resonance imaging studies, or positron emission tomographic scans are not indicated unless history or physical exam suggests possible metastasis to those organs. Early excision remains the most important determinant of outcome. Excisional margins increase with depth of invasion. For a depth of greater than 2 mm, a 2 cm margin is indicated. Radiolymphatic sentinel node mapping and biopsy are used for melanomas greater than 1mm in thickness in patients with clinically negative lymph nodes. Sentinel node biopsy is also indicated in patients whose melanomas display ulceration, Clark’s level IV or V invasion, regression, a vertical growth phase, or a positive deep margin on initial biopsy. In this way, those patients who may benefit from regional lymphadenectomy and adjuvant immunotherapy may be identified, and prognostic information collected. For metastatic melanoma, dacarbazine, alone or in combination with other chemotherapeutic agents garners a response rate of 20-30%. Radiation is used for palliation of bone and brain metastases. Immunotherapeutic approaches such as interferons, interleukins, monoclonal antibodies, autologous lymphocytes, and specific immunization are used in patients with melanomas with nodal involvement or melanomas that are greater than 4mm in depth, ulcerated, or Clark’s Level IV or V. Some forms of adjuvant therapy such as interferon-A-2b may cause significant toxicity.
8 x 6 cm exophytic, fungating, irregular, ulcerated, fixed tumor arising from a violaceous indurated plaque and no local adenopathy