IT'S BEEN ON MY NECK FOR YEARS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Initial patient encounters with patients who are poor historians can be extremely challenging. Physical exam is of utmost importance. The nature, history and prognosis of exophytic melanoma has been extremely controversial and uncertain. CASE PRESENTATION: A 91 year old Caucasian female with no apparent medical comorbidities who had not seen a physician in 30 years presented to the emergency department after her family stated they could no longer care for her. Initial chest X-ray revealed a large mass like opacity over the left lung apex. She also had a urinary tract infection. She was started on Ceftriaxone and admitted to internal medicine. Upon our exam, after examining her neck and removing her bandage, we found an external exophytic, pedunculated mass from the inferior lateral left neck measuring 4.6 x 3.7 x 5.7 cm which was concerning for malignancy. The mass was pulsatile and bleeding from certain areas without evidence of frank hemorrhage. A CT scan was then pursued which reinforced our physical exam findings. Upon further questioning of the patient and her family, it was reported that said mass had been present for 10 + years and they had always covered it up with abdominal pads without seeking medical attention. There was no white blood cell count elevation indicating infectious foci. General surgery was consulted for excision and pathology. She was taken to the operating room the next day and the lesion was excised at skin zone 2 of the neck with a margin of skin and normal subcutaneous tissue around it. The excised mass measured 15 x 15 x 20 cm (L x W x H). The patient was discharged to a nursing home in a stable fashion. Her pathology came back for ulcerated malignant melanoma with negative margins. Histologic type was nodular melanoma. Maximum Breslow thickness of 17mm with no microsatellites. The distance of invasive melanoma from closest peripheral margin of 10mmwith mitotic rate of 8 per mm2. Tumor infiltrating lymphocytes were present with no tumor regression. The tumor cells demonstrated strong positivity for SOX10 and Melan-A stain and focally positive for HMB-45. DISCUSSION: Nodular melanoma accounts for less than 15% of all melanomas. Usual prognostic indicators in melanoma are driven by histologic subtype with thickness being neglected. Nodular melanoma, however, has been known to include thickness as a prognostic factor. Majority of these cases have reported metastasis and poor prognosis. CONCLUSIONS: With our patient being neglected, she still had only local disease and after tumor removal, no adjunctive therapy was needed. Clinicians should be made aware and on the lookout for different types of melanomas and their respective presentations. REFERENCE #1: Clark WH, Elder DE, Guerry D, Epstein MN, Greene MH, Van Horn M. A study of tumor progression: The precursor lesions of superficial spreading and nodular melanoma. Hum Pathol. 1984;15(12):1147-1165. doi:10.1016/S0046-8177(84)80310-X REFERENCE #2: Shaikh WR. The Contribution of Nodular Subtype to Melanoma Mortality in the United States, 1978 to 2007. Arch Dermatol. 2012;148(1):30. doi:10.1001/archdermatol.2011.264 DISCLOSURES: No relevant relationships by Ahmad Abu Hashyeh, source=Web Response No relevant relationships by Mohamed Suliman, source=Web Response no disclosure on file for Toufeeq Suliman