Laboratory Data

Section shows a malignant skin tumor composed of nests of large melanocytic cells distending the papillary dermis and infiltrating deep into the reticular dermis with early involvement of the superficial subcutaneous tissue. The tumor cells show pleomorphic and hyperchromatic nuclei with frequently seen mitoses and abundant pale cytoplasm with melanin pigmentation seen in places. The surgical margin is free from tumor.

Malignant melanoma, nodular type. Clark's level IV. Breslow's tumor thickness >22mm

Section of the right lobe of thyroid show an infiltrating papillary carcinoma. The cells have optically clear nuclei, nuclear grooves and intranuclear eosinophilic inclusions. Histological grade - well differentiated. Capsular invasion by the tumor is seen. Surgical margins clear.

Nine lymph nodes were isolated from the axillary fat. Metastatic melanoma cells are present in two nodes. The remaining seven nodes showed features of reactive hyperplasia.

The tumor was excised with a wide margin of 2cm with axillary nodes clearance and sampling done which was positive 2/9. Further evaluation noted that the right thyroid gland was enlarged and complete removal of the lobe performed. Histology of the lobe proved to be papillary carcinoma of the thyroid gland.

Clark defined 4 major histological types of melanoma based on growth pattern of the intraepithelial portions. These include superficlal spreading melanoma, (SSM), nodular melanoma(NM), lentigo malignant melanoma(LMM) and acral lentiginous melanoma (ALM).(1)

All nodules of MM begin as macules. The macules extend horizontally to form patches then vertically to form papules and nodules. Since the prognosis of melanomas is dependent upon thickness, NMs portend a greater risk of metastasis than other types of melanoma. However when corrected for thickess, the prognosis of the four histogenetic types of melanoma is equivalent (2)

Malignant melanoma is inherently a chemoresistant tumor. Adjuvant trials in melanoma may benefit from the use of RT-PCR (reverse transcriptase polymerase chain reaction) of peripheral blood for MRP(melanocytes-/melanogenesis-related proteins)such as tyrosinase. (3)

Questions:

What surgical margin would you recommend for his melanoma? Does it matter?

Would you recommend adjuvant therapy with alfa interferon? What dose would you use?

How would the presence of a second tumor - papillary carcinoma of thyroid affect his overall management?

1. Clark WH et al.The biologic forms of malignant melanoma. Hum Pathol. 1986.17:443-450
2. Koh HK et al. Lentigo malignant melanoma has no better prognosis than other types of melanoma. J Clin Oncol 1984 9:994-1001
3. Carlson JA et al. Molecular diagnostics in melanoma. JAAD 2005: 52;743-755

David Elpern MD, Williamstown, MA, USA on June 2, 2007

This is an extraordinary important case to present. Your unfortunate patient needs to be managed by a dermatological oncologist. The surgical margins of 2cm were adequate. A thorough physical examination (you have probably done this already) as well as CT and PET scans are indicated to discover distant mets. Interferon may prolong this patient's life but is not curative. One wonders about the patient's immune system with him developing two separate malignancies. He has a poor prognosis but melanoma is a strange tumor and he may surprise you and do well.

Khaled el-hoshy MD, Troy, Michigan, USA on June 2, 2007

2cm adequate margin. Interferon adjuvant therapy recommended. Best managed by oncologist with surgery/dermatology visits every 1-3 months to start with.