CLINICALLY SPEAKING
Malignant Melanoma Presenting as a Nonhealing Heel Ulceration Jacqueline Nicole Fussell, MD* David Lee Troutman, DPM† Eric Hossler, MD‡ Shilpa Agarwal, MD§ Malignant melanoma is responsible for more than three-fourths of skin cancer deaths in the United States. Melanomas presenting on acral surfaces are frequently misdiagnosed initially, leading to progression of disease and worse prognosis. This case is presented to reinforce the significance of careful physical examination and early biopsy of atypical ulcerations of the foot. (J Am Podiatr Med Assoc 104(3): 295-297, 2014)
Malignant melanoma is a malignancy of melanocytes that currently ranks the fifth most common cancer in men and the sixth most common cancer in women in the United States.1 Although it accounts for only about 4% of all skin cancers, malignant melanoma is responsible for approximately 79% of skin cancer deaths. Malignant melanomas of the foot and ankle are frequently misdiagnosed as ulcerations, tinea pedis, and verrucae, leading to a delay in diagnosis and progression of disease.2 Previous case reports and case series highlight the pitfalls in delayed diagnosis of foot malignant melanoma,3,4 and malignant melanomas in this area tend to have a worse prognosis.5 Acral malignant melanoma may be a diagnostic challenge because the classic criteria of diagnosing pigmented lesions (asymmetry, border irregularities, color variegation, change in diameter) are often not apparent. Misdiagnosis is thought to occur in about 40% of malignant melanomas in acral locations.6 Additionally, plantar surfaces are prone to traumatic injury, leading to hemorrhagic changes that are often absent in other areas of the body, sometimes leading to a confusing clinical picture. *Department of Dermatology, Geisinger Medical Center, Danville, PA. †Department of Podiatry, Geisinger Medical Center, Danville, PA. ‡Departments of Dermatology and Dermatopathology, Geisinger Medical Center, Danville, PA. §George Washington University School of Medicine, Danville, PA. Corresponding author: Jacqueline Nicole Fussell, MD, Department of Dermatology, Geisinger Medical Center, 115 Woodbine Lane, Danville, PA 17822-5206. (E-mail: jnfussell@ geisinger.edu)
Biopsy of acral sites is challenging because of an elevated risk of complications including pain, scarring, and infection, especially in the setting of common comorbidities such as diabetes and venous insufficiency. We report a case of malignant melanoma that was misdiagnosed as a traumatic ulcer.
Case Report A 74-year-old male presented to Geisinger Medical Center with a chief complaint of a nonhealing wound on the left heel. He noted the area 2 months prior, and attributed the ulcer to stepping on something. His wife felt that his shoes rubbed his heel the wrong way, causing the wound. He had presented to his primary care physician 2 weeks earlier; radiographs were taken at that time and showed no evidence of a foreign body or osteomyelitis. Treatment consisted of daily application of topical antibacterial cream and Epsom salt soaks. The patient had a history of congestive heart failure, coronary artery disease with bypass repair in 2001, sleep apnea, and basal cell carcinoma of the face. He also had a family history of nonmelanoma skin cancer. Upon examination, the patient was a well-appearing, healthy male in no acute distress, and was comfortable and cooperative. The pedal pulses were palpable and strong, and there were no signs of gross foot deformity. There was a 1.0 3 1.2cm superficial wound noted to the plantar aspect of the left heel (Fig. 1). The wound was irregularly shaped with a dark grayish-purple base (Fig. 2). The lesion was mildly tender with palpation. The patient
Journal of the American Podiatric Medical Association Vol 104 No 3 May/June 2014
295
Figure 1. Photograph showing melanoma on heel at
presentation.
Figure 3. Nests of atypical melanocytes extending
was seen in conjunction with the Geisinger Medical Center Department of Dermatology, and a scoop shave biopsy of the lesion was performed to establish and confirm a diagnosis. The differential diagnosis at that time included malignant melanoma, porocarcinoma, and neuropathic ulceration. The biopsy showed ulcerated malignant melanoma in the vertical growth phase extending to the epidermal and dermal margins (Figs. 3 and 4). Melanocytes were predominately epithelioid in morphology and exhibited enlarged, hyperchromatic, atypical nuclei with variability in size and shape, and prominent nucleoli. The tumor extended to the deep margin of the biopsy and measured at least 2.38 mm in thickness. Five mitoses per square millimeter were present. No areas of regression were identified and lymphoid infiltration of the tumor was focal and sparse. Angiolymphatic and
into the dermis with no evidence of maturation or dispersion (H&E 3 100). perineural infiltration were not identified, nor was a precursor nevus apparent. The melanoma was staged at T3b, and a wide local excision with sentinel lymph node biopsy was performed by surgical oncology. Two sentinel nodes were removed, and both showed single cells and scattered nests of atypical melanocytes throughout the node, consistent with metastatic melanoma. A completion node dissection was negative for further disease, and a positron emission tomography scan failed to show clear evidence of further malignancy. His lymph node dissection was complicated by Klebsiella wound infection, which resolved with antibiotic therapy. Ten months after his original diagnosis, he is alive and well with no apparent disease. He chose not to pursue adjuvant interferon therapy.
Figure 2. Closer view of melanoma at presentation.
Note the vascular-appearing papules with tissue stranding throughout and subtle brown pigmentation at the periphery of the lesion, suggestive of melanoma.
296
Figure 4. Nests of atypical melanocytes (H&E 3
200).
May/June 2014 Vol 104 No 3 Journal of the American Podiatric Medical Association
Discussion It is important to maintain a high index of suspicion for malignancy in the setting of atypical or nonhealing foot ulcerations, as delay in diagnosis can lead to later stage of diagnosis and worse outcome.2 Kong et al4 suggest that melanoma of the foot should be suspected if: 1) an ulcer looks atypical; 2) there is no evidence of neuropathy or ischemia upon examination; 3) an ulcer is nonhealing despite strict adherence to treatment; 4) an ulcer is in an unusual anatomic site; 5) an ulcer is painful; or 6) there is pigmentation noted in the ulcer. In our patient, the ulcer had an atypical appearance, was nonhealing and painful, and there was pigmentation at the border of the ulceration. These are reasons for concern and should raise consideration of early biopsy. Initially, malignant melanoma grows in a radial fashion within the epidermis, but over time progresses to a vertical growth phase where the malignant cells invade the dermis and develop the potential for metastasis. Our patient’s melanoma measured at least 2.38 mm deep, was ulcerated, and had a high dermal mitotic rate, putting him at significant risk for metastatic disease. In addition, his sentinel nodes were involved. Sentinel node status is the single most important prognostic factor for survival in melanoma. Our patient was unaware of a previous melanocytic lesion in this site, so it is likely that his melanoma had arisen de novo. It is important to note that approximately 50% or more of malignant melanomas will arise de novo, so a clinician cannot exclude malignancy based on the absence of a preexisting melanocytic lesion.7,8
Conclusions Given the distinct prognostic differences between ulcerations secondary to trauma or venous disease
and malignant melanoma, clinicians should have a high index of suspicion when dealing with atypical ulcers. Our case demonstrates the importance of early diagnosis. Although our patient was aware of the lesion for only 2 or 3 months, he presented with advanced disease. A low threshold for biopsy of these atypical ulcerations is important so that timely referrals and treatments can be implemented given the increased mortality rate associated with acral melanomas. Our case report signifies the importance of considering melanoma on the differential diagnosis of lesions on the lower extremities, especially the plantar foot. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. HABIF, THOMAS P: ‘‘Nevi and Malignant Melanoma,’’ in Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 5th Ed, Elsevier Inc, 2010. Available at: http:// www.mdconsult.com. Accessed October 15, 2011. 2. ALBRESKI D, SLOAN SB: Melanoma of the feet: misdiagnosed and misunderstood. Clin Dermatol 27: 556, 2009. 3. TORRES T, ROSMANINHO A, CAETANO M, ET AL: Malignant melanoma diagnosed as a diabetic foot ulcer. Diabet Med 27: 1302, 2010. 4. KONG MF, JOGIA R, JACKSON S, ET AL: When to biopsy a foot ulcer? Seven cases of malignant melanoma presenting as foot ulcers. Pract Diab Int 25: 5, 2008. 5. WALSH S, FISHER S, SAGE R: Survival of patients with primary pedal melanoma. J Foot Ankle Surg 42: 193, 2003. 6. METZGER S, ELLWANGER U, STROEBEL W, ET AL: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 8: 181, 1998. 7. ZELENT ME, NEESE DJ, GRAHAM RB: Malignant melanoma masquerading as a decubitus heel ulceration. Wound 18: 25, 2006. 8. CLARK WH, FROM L, BERNARDINO EA, ET AL: The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res 29: 705, 1969.
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Malignant Melanoma Presenting as a Nonhealing Heel Ulceration Jacqueline Nicole Fussell, MD* David Lee Troutman, DPM† Eric Hossler, MD‡ Shilpa Agarwal, MD§ Malignant melanoma is responsible for more than three-fourths of skin cancer deaths in the United States. Melanomas presenting on acral surfaces are frequently misdiagnosed initially, leading to progression of disease and worse prognosis. This case is presented to reinforce the significance of careful physical examination and early biopsy of atypical ulcerations of the foot. (J Am Podiatr Med Assoc 104(3): 295-297, 2014)
Malignant melanoma is a malignancy of melanocytes that currently ranks the fifth most common cancer in men and the sixth most common cancer in women in the United States.1 Although it accounts for only about 4% of all skin cancers, malignant melanoma is responsible for approximately 79% of skin cancer deaths. Malignant melanomas of the foot and ankle are frequently misdiagnosed as ulcerations, tinea pedis, and verrucae, leading to a delay in diagnosis and progression of disease.2 Previous case reports and case series highlight the pitfalls in delayed diagnosis of foot malignant melanoma,3,4 and malignant melanomas in this area tend to have a worse prognosis.5 Acral malignant melanoma may be a diagnostic challenge because the classic criteria of diagnosing pigmented lesions (asymmetry, border irregularities, color variegation, change in diameter) are often not apparent. Misdiagnosis is thought to occur in about 40% of malignant melanomas in acral locations.6 Additionally, plantar surfaces are prone to traumatic injury, leading to hemorrhagic changes that are often absent in other areas of the body, sometimes leading to a confusing clinical picture. *Department of Dermatology, Geisinger Medical Center, Danville, PA. †Department of Podiatry, Geisinger Medical Center, Danville, PA. ‡Departments of Dermatology and Dermatopathology, Geisinger Medical Center, Danville, PA. §George Washington University School of Medicine, Danville, PA. Corresponding author: Jacqueline Nicole Fussell, MD, Department of Dermatology, Geisinger Medical Center, 115 Woodbine Lane, Danville, PA 17822-5206. (E-mail: jnfussell@ geisinger.edu)
Biopsy of acral sites is challenging because of an elevated risk of complications including pain, scarring, and infection, especially in the setting of common comorbidities such as diabetes and venous insufficiency. We report a case of malignant melanoma that was misdiagnosed as a traumatic ulcer.
Case Report A 74-year-old male presented to Geisinger Medical Center with a chief complaint of a nonhealing wound on the left heel. He noted the area 2 months prior, and attributed the ulcer to stepping on something. His wife felt that his shoes rubbed his heel the wrong way, causing the wound. He had presented to his primary care physician 2 weeks earlier; radiographs were taken at that time and showed no evidence of a foreign body or osteomyelitis. Treatment consisted of daily application of topical antibacterial cream and Epsom salt soaks. The patient had a history of congestive heart failure, coronary artery disease with bypass repair in 2001, sleep apnea, and basal cell carcinoma of the face. He also had a family history of nonmelanoma skin cancer. Upon examination, the patient was a well-appearing, healthy male in no acute distress, and was comfortable and cooperative. The pedal pulses were palpable and strong, and there were no signs of gross foot deformity. There was a 1.0 3 1.2cm superficial wound noted to the plantar aspect of the left heel (Fig. 1). The wound was irregularly shaped with a dark grayish-purple base (Fig. 2). The lesion was mildly tender with palpation. The patient
Journal of the American Podiatric Medical Association Vol 104 No 3 May/June 2014
295
Figure 1. Photograph showing melanoma on heel at
presentation.
Figure 3. Nests of atypical melanocytes extending
was seen in conjunction with the Geisinger Medical Center Department of Dermatology, and a scoop shave biopsy of the lesion was performed to establish and confirm a diagnosis. The differential diagnosis at that time included malignant melanoma, porocarcinoma, and neuropathic ulceration. The biopsy showed ulcerated malignant melanoma in the vertical growth phase extending to the epidermal and dermal margins (Figs. 3 and 4). Melanocytes were predominately epithelioid in morphology and exhibited enlarged, hyperchromatic, atypical nuclei with variability in size and shape, and prominent nucleoli. The tumor extended to the deep margin of the biopsy and measured at least 2.38 mm in thickness. Five mitoses per square millimeter were present. No areas of regression were identified and lymphoid infiltration of the tumor was focal and sparse. Angiolymphatic and
into the dermis with no evidence of maturation or dispersion (H&E 3 100). perineural infiltration were not identified, nor was a precursor nevus apparent. The melanoma was staged at T3b, and a wide local excision with sentinel lymph node biopsy was performed by surgical oncology. Two sentinel nodes were removed, and both showed single cells and scattered nests of atypical melanocytes throughout the node, consistent with metastatic melanoma. A completion node dissection was negative for further disease, and a positron emission tomography scan failed to show clear evidence of further malignancy. His lymph node dissection was complicated by Klebsiella wound infection, which resolved with antibiotic therapy. Ten months after his original diagnosis, he is alive and well with no apparent disease. He chose not to pursue adjuvant interferon therapy.
Figure 2. Closer view of melanoma at presentation.
Note the vascular-appearing papules with tissue stranding throughout and subtle brown pigmentation at the periphery of the lesion, suggestive of melanoma.
296
Figure 4. Nests of atypical melanocytes (H&E 3
200).
May/June 2014 Vol 104 No 3 Journal of the American Podiatric Medical Association
Discussion It is important to maintain a high index of suspicion for malignancy in the setting of atypical or nonhealing foot ulcerations, as delay in diagnosis can lead to later stage of diagnosis and worse outcome.2 Kong et al4 suggest that melanoma of the foot should be suspected if: 1) an ulcer looks atypical; 2) there is no evidence of neuropathy or ischemia upon examination; 3) an ulcer is nonhealing despite strict adherence to treatment; 4) an ulcer is in an unusual anatomic site; 5) an ulcer is painful; or 6) there is pigmentation noted in the ulcer. In our patient, the ulcer had an atypical appearance, was nonhealing and painful, and there was pigmentation at the border of the ulceration. These are reasons for concern and should raise consideration of early biopsy. Initially, malignant melanoma grows in a radial fashion within the epidermis, but over time progresses to a vertical growth phase where the malignant cells invade the dermis and develop the potential for metastasis. Our patient’s melanoma measured at least 2.38 mm deep, was ulcerated, and had a high dermal mitotic rate, putting him at significant risk for metastatic disease. In addition, his sentinel nodes were involved. Sentinel node status is the single most important prognostic factor for survival in melanoma. Our patient was unaware of a previous melanocytic lesion in this site, so it is likely that his melanoma had arisen de novo. It is important to note that approximately 50% or more of malignant melanomas will arise de novo, so a clinician cannot exclude malignancy based on the absence of a preexisting melanocytic lesion.7,8
Conclusions Given the distinct prognostic differences between ulcerations secondary to trauma or venous disease
and malignant melanoma, clinicians should have a high index of suspicion when dealing with atypical ulcers. Our case demonstrates the importance of early diagnosis. Although our patient was aware of the lesion for only 2 or 3 months, he presented with advanced disease. A low threshold for biopsy of these atypical ulcerations is important so that timely referrals and treatments can be implemented given the increased mortality rate associated with acral melanomas. Our case report signifies the importance of considering melanoma on the differential diagnosis of lesions on the lower extremities, especially the plantar foot. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. HABIF, THOMAS P: ‘‘Nevi and Malignant Melanoma,’’ in Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 5th Ed, Elsevier Inc, 2010. Available at: http:// www.mdconsult.com. Accessed October 15, 2011. 2. ALBRESKI D, SLOAN SB: Melanoma of the feet: misdiagnosed and misunderstood. Clin Dermatol 27: 556, 2009. 3. TORRES T, ROSMANINHO A, CAETANO M, ET AL: Malignant melanoma diagnosed as a diabetic foot ulcer. Diabet Med 27: 1302, 2010. 4. KONG MF, JOGIA R, JACKSON S, ET AL: When to biopsy a foot ulcer? Seven cases of malignant melanoma presenting as foot ulcers. Pract Diab Int 25: 5, 2008. 5. WALSH S, FISHER S, SAGE R: Survival of patients with primary pedal melanoma. J Foot Ankle Surg 42: 193, 2003. 6. METZGER S, ELLWANGER U, STROEBEL W, ET AL: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 8: 181, 1998. 7. ZELENT ME, NEESE DJ, GRAHAM RB: Malignant melanoma masquerading as a decubitus heel ulceration. Wound 18: 25, 2006. 8. CLARK WH, FROM L, BERNARDINO EA, ET AL: The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res 29: 705, 1969.
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