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August 2009
By Kirkland Lau, DO, and Stephen M. Schleicher, MD
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CASE:
A 77-year-old man has a 1.7-cm nodule on his right lower back. The lesion has been present for several years and has been steadily increasing in size. He denies associated pruritus or pain, but bleeding episodes have become more frequent. He gives a history of multiple sunburns, which were especially frequent when he served in the Army. The patient has no personal or family history of skin cancer. Examination reveals a somewhat friable erythematous mass with blackish pigmentation of the borders. Inguinal and axillary lymph nodes are nonpalpable.
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The patient has malignant melanoma. On histologic examination, radial and vertical growth phases were both present. The greatest thickness was 3.45 mm and the Clark level of invasion was III (tumor involving most of the upper dermis). Ulceration was present, and the precursor lesion was likely a dermal nevus. Lymphovascular invasion was not identified. A wide surgical excision was performed, and a sentinel lymph node was biopsied from the right axilla. Melanoma was not identified in the lymph node. Blood work and chest x-ray were also normal. All subsequent follow-up examinations have been unremarkable.
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Dr. Lau is director of the DermDx Centers for Dermatology in Reading, Pennsylvania. Dr. Schleicher is director of DermDOX Center in Hazleton, Pennsylvania, a clinical instructor of dermatology at the Philadelphia College of Osteopathic Medicine and Kings College in Wilkes-Barre, Pennsylvania, and an associate professor of medicine at the Commonwealth Medical School in Scranton, Pennsylvania. He is also a member of the EMERGENCY MEDICINE editorial board.
Emerg Med 41(8):15-16, 2009
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