SURGICAL CASE REPORTS | ISSN 2613-5965

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Case Report Amelanotic Acral Lentiginous Melanoma of the Heel: A Case Report of Misdiagnosis. José M. Furlaneto Jr1*, Gaurav Agnihotri2, Mark E. Juhl2 and Maria M. Tsoukas2

1Centro Universitário do Estado do Pará (CESUPA), School of Medicine, Av. Almirante Barroso 3775, 66613-903, Belém-PA, Brazil 2University of Illinois at Chicago, College of Medicine, Department of Dermatology, 808 S Wood Str., 60612, Chicago, Illinois

A R T I C L E I N F O A B S T R A C T

Article history: Acral lentiginous melanoma is an uncommon skin cancer that usually affects palms, soles, and nail Received: 15 May, 2019 apparatus of elderly Black and Asian individuals. Diagnosis is difficult, as it may mimic benign or traumatic Accepted: 19 June, 2019 lesions such as plantar warts or diabetic ulcers, especially if it is amelanotic. For this reason, detection is Published: 30 August, 2019 challenging, and proper diagnosis and treatment is often delayed, ultimately resulting in a poor prognosis. Keywords: We report an 83-year-old Hispanic female with a two-year history of a painful, non-healing, glistening, Acral lentiginous melanoma exophytic mass on her left heel that was previously treated as a wart prior to proper biopsy and management. amelanotic melanoma Patient education, complete physical exam and greater knowledge about this tumor, whether pigmented or foot ulcer not, are an important weapon to prevent its aggressiveness, increasing patients’ survival rate by decreasing verruca plantaris the risk local invasion and metastasis. Biopsy should always be considered, especially in the setting of unresponsiveness to the treatment. © 2019 José Márcio Furlaneto Júnior Hosting by Science Repository. All rights reserved.

Introduction Case Synopsis

Melanoma is a cancer that arises from melanocytes, which An 83-year-old Hispanic female presented to clinic with a two-year embryologically derive from neural crest cells and can be found within history of a painful, non-healing wound on her left heel. Past medical the epidermis, mucous membranes, eyes and meninges [1]. Currently the history was non-remarkable. She had previously undergone treatment 6th and 7th most common malignancy in men and women respectively in with topical wound care dressing as well as offloading by a community the United States, cutaneous melanoma (CM) has an incidence rate rising provider. After two years of unsuccessful treatment and growth of the faster than any other cancer [1, 2]. Cutaneous melanoma accounts for wound, the patient was referred to the dermatology clinic. On physical approximately 90% of cases of melanoma and has an estimated exam, a 4x4 cm glossy, red to pink, exophytic nodule clinically incidence of over 90,000 cases and resulted in 9,320 mortalities in the appearing as granulation tissue was noted (Figure 1). The lesion lacked United States thus far in 2018 [1, 3].Melanomas at uncommon sites and cutaneous coverage and was protruding from the sole of her left heel those lacking classical clinical features are often diagnosed later than (Figure 2). A 4 mm punch biopsy was performed with histopathology typical CM [4]. Although acral lentiginous melanoma (ALM) represents revealing an ulcerated mass of epithelioid, amelanotic melanocytes only 5% of all CM, it has the lowest survival rates, usually due to (Figure 3, 4, 5, 6, 7 and 8). Based on these findings, the diagnosis of misdiagnosis, which delays treatment and increases the risk of mortality acral lentiginous melanoma was made. The tumor was invasive, with a [2, 5, 6]. Amelanotic melanomas (AM) carry poor outcomes due to Breslow depth of at least 2.6 mm, (limited by the depth of the biopsy), delays in diagnosis and also have a lower survival rate when compared in a vertical growth phase and had 9 mitotic figures per mm2. Clark level to pigmented melanomas [7]. We report an 83-year-old patient with a was IV (bordering on V) and no regression, angiolymphatic invasion, two-year history of an amelanotic ALM on her left heel that was perineural invasion, microscopic satellitosis, or associated melanocytic previously misdiagnosed and treated as a plantar wart. nevi were identified. Following diagnosis, the patient was referred to the

*Correspondence to: José Márcio Furlaneto Júnior, School of Medicine, Centro Universitário do Estado do Pará Avenida Almirante Barroso 3775, 66613-903, Belém-PA, Brazil; Tel: +55 91 99325-4661; E-mail: [email protected]

© 2019 José Márcio Furlaneto Júnior. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository. All rights reserved. http://dx.doi.org/10.31487/j.SCR.2019.03.11 Amelanotic Acral Lentiginous Melanoma of the Heel: A Case Report of Misdiagnosis 2

Surgical Oncology service where wide local excision together with Plastic Surgery was recommended. Two weeks later, a 2 cm wide excision and a sentinel lymph node biopsy were performed by the Surgical Oncology team, and skin graft placement was done by the Plastic Surgery team. Further investigation revealed negative lateral and deep margins as well as a Breslow depth of 10 mm, and a negative sentinel node biopsy lead to a final stage of IIC. There were no postoperative complications, and the skin graft healed well, with continued Wound Care and Surgical Oncology follow up. The patient is currently undergoing monitoring with Oncology and considering adjuvant therapy.

Figure 4: Hematoxylin and eosin stain 20x. The mass was composed of pale to blue, dyskeratotoic, epithelioid cells with interspersed lymphovascular spaces.

Figure 1: On physical exam, the left heel had a 4x4 cm ulcerated, glossy, red to pink, exophytic nodule appearing similar to granulation tissue.

Figure 5: Hematoxylin and eosin stain 40x. Further inspection revealed polychromasia, an increased nuclear, cytoplasmic ratio, marked atypia, and many mitotic figures. There was absence of melanin.

Figure 2: There were focal areas of hemorrhage and a collarette of Fig. 6 macerated epidermis.

Figure 3: Hematoxylin and eosin stain 4x histopathology revealed a Fig. 7 fully ulcerated mass.

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Conclusion

We present a case of a diagnostically challenging amelanotic ALM. Acral lentiginous melanomas and AM both independently lead to a poor prognosis when compared to CM, and when both features are present, the results can be disastrous for the patient. The increasing prevalence of ALM and the diagnostic challenge warrants extra attention in dark- skinned patients regardless of the presence of pigment. This risk can be minimized with greater awareness of these tumors, a thorough physical exam, proper patient education and early biopsy when acral lesions do not behave as expected. Fig. 8 Competing interests Figure 6, 7 and 8: HMB-45 and Melan A stains were diffusely positive. One third to one half of the cells were positive for Ki-67. The authors have no competing interests to declare.

Case Discussion Funding

Hispanic patients have the highest incidence of ALM (2.5 new cases per Not applicable. 1,000,000 persons per year), followed by Black and Asian persons [2]. Although typically presenting as an asymmetric brown-to-black macule Ethics approval and consent to participate with color variation and irregular borders, ALM is not easily diagnosed due to the unusual location and difficulty in clinically distinguishing it Not applicable. from other lesions, such as plantar warts, diabetic ulcers, benign nevi or infections [5, 6]. This delaying postpones proper treatment and Authors’ Contributions ultimately leads to increased mortality [2, 6]. Breslow depth is the single most important prognostic indicator in all types of melanoma [1, 5]. The José M. Furlaneto: Elaboration of the text. frequent misdiagnosis of ALM causes a median delay of 12 months in Gaurav Agnihotri: Elaboration of the text. the diagnosis of palmoplantar melanomas and 18 months of subungual Mark E. Juhl: Elaboration of the text, patient consulting and follow-up. melanomas, leading to a worse prognosis compared to CM [6]. Delayed Maria M. Tsoukas: Orientation, patient consulting and follow-up diagnosis allows ALM to be more invasive than CM at diagnosis, with a large study by Bradford et al. showing that 70% of CM are diagnosed at List of abbreviations 0.01-1 mm in depth and 14.3% at > 2 mm, in opposition to 41% and 37% for ALM, respectively [2]. Regarding the stage at diagnosis, Stage I ALM: Acral lentiginous melanoma accounted for 38% of ALM in contrast to 68% of CM. Acral lentiginous AM: Amelanotic melanoma melanoma in Hispanic patients is often diagnosed in Stage III (40.2%) CM: Cutaneous melanoma and with a tumor thickness > 2 mm in 34.1% of cases. PET-CT: Positive emission tomography

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