CASE STUDY ON MALIGNANT MELANOMA

A Case Study in partial fulfilment of the requirements for NSG10

Xavier University – Ateneo de Cagayan

Submitted by:

Kiril Gabriel Caballes

Natasha Sam Cenita

Austin Jay A. Ceniza

Roland Laurence B. Jardiolin

William Jayson

John Carlo Kho

Kei Laguda

Hannah Andrea T. Mercurio

BSN1-NB

Submitted to:

Mrs. Jesusa F Gabule

August 10, 2019

 I. Case Analysis Problem

Chief Complaint:
48-year-old man with suspicious-looking mole on his back.

History:
Max Burnell, a single, 48-year-old avid long-distance runner previously in good
health, presented to his primary physician for a yearly physical examination, during
which a suspicious-looking mole was noticed on the back of his left arm, just proximal
to the elbow. He reported that he has had that mole for several years but thinks that it
may have gotten larger over the past two years. Max reported that he has noticed
itchiness in the area of this mole over the past few weeks. He had multiple other moles
on his back, arms, and legs, none of which looked suspicious. Upon further
questioning, Max reported that his aunt died in her late forties of skin cancer, but he
knew no other details about her illness. Max is a computer programmer who spends
most of the work week in doors. On weekends, however, he typically goes for a 5-mile
run and spends much of his afternoons gardening. He has a light complexion, blonde
hair, and reports that he sunburns easily but uses protective sunscreen only
sporadically.

Physical Examination:
Head, neck, thorax, and abdominal exams were normal, except for a hard,
enlarged, non-tender mass felt in the left axillary region. In addition, a 1.6 x 2.8 cm
mole was noted on the dorsal upper left arm. The lesion had an appearance
suggestive of a melanoma. It was surgically excised with 3 mm margins using a local
anaesthetic and sent to the pathology laboratory for histologic analysis.
 II. Case Analysis Proper

1. How does the appearance of malignant melanoma differ from that of a normal
mole, or Nevis, on gross inspection (i.e. the macroscopic appearance)?

The appearance of malignant melanoma differs from that of a normal mole, or

Nevis, on gross inspection because of different factors. Firstly, melanomas are usually
asymmetrical whereas, a normal mole is symmetrical. Normal moles also have a
smooth border whereas, melanomas have an irregular border. Moreover, melanomas
have different shades of brown and can have a shade of blue to them, whereas, normal
moles have only one shade of brown. Melanomas often tend to bleed and have a red
type halo around them. Moles are smooth in texture, whereas, melanomas are often
uneven and irregular in texture.

References(Q1):
https://www.coursehero.com/file/p3ajsgf/Questions-1-How-does-the-appearance-of-
a-malignant-melanoma-differ-from-that-of/

2. Draw a normal mole and a malignant melanoma, as they might appear on the
skin.

References(Q2):
https://www.reddit.com/r/coolguides/comments/a2whax/abcs_of_melanoma_guide_t
o_differentiating/

3. Why was it important to surgically excise and examine this mole?

It is very important to surgically excise and examine this mole in order to
determine if it were just a normal mole or not. With the fact that Max’s aunt had died
due to skin cancer, it becomes more necessary to assess the said mole since skin
cancer can be hereditary or genetically passed. Moreover, because the type of skin
cancer that his aunt had wasn’t specified, it becomes very important to check on Max
whether the mole that he had either came from his aunt, a different type of skin disease
or if it were just a regular mole. Even if Max doesn’t go out much often and even if he
does use sunscreens, it is still crucial to examine the mole to be able to reduce the
chances of melanoma to develop, a type of skin cancer, by detecting early signs and
possible symptoms of skin cancer. According to the Cleveland Clinic in their website,
“Being proactive about preventing skin cancer is important for your health. This is
especially true if; you have fair skin, you have many moles on your body, or your
immediate family members have many moles, atypical moles, or a history of skin
cancer.”. All these conditions apply to the situation of Max Burnell which makes his
mole examinations significant.

References(Q3):
https://my.clevelandclinic.org/health/articles/12015-regular-mole-checks

4. What do levels I, II, III, IV, and V vertical invasion refer to when describing
melanomas?
The Clark level of invasion was a method devised by Wallace Clark, a
pathologist, revolving around the intention of measuring the depth of penetration of a
melanoma into the skin in accordance to the anatomic layers. It is basically a method
for determining the prognosis of a patient with melanoma. The five levels of vertical
invasion are discussed in detail below:
a. Level 1 Vertical Invasion
The first level of vertical invasion is apparent when atypical melanocytic cells
are localized and confined merely to the outermost layer of the skin, namely the
epidermis. It is noted that the said cells have not yet invaded through the basement
membrane. This level of vertical invasion is also called melanoma in-situ, labeled as
the earliest stage of melanoma.
b. Level 2 Vertical Invasion
The second level of vertical invasion is recognized when the melanoma tumor
has just begun to invade the basement membrane, progressively travelling into the
second major layer of the skin, namely dermis, particularly in the papillary dermis.
c. Level 3 Vertical Invasion
The third level of vertical invasion occurs when the melanoma tumor causes
the expansion of the papillary dermis due to it filling the dermis. However, it is noted
that the melanocytic cells have not yet invaded the reticular dermis, this still being
present only in the skin.
d. Level 4 Vertical Invasion
The fourth level of vertical invasion comes about when the melanoma tumor
has invaded the reticular dermis. It is noted that the melanocytic cells in this level of
vertical invasion is still present only in the skin.
e. Level 5 Vertical Invasion
 The fifth level of vertical invasion transpires when the melanoma tumor has
penetrated into the fat of the skin beneath the dermis, thus invading the
subcutaneous fat layer, extending internally from the epidermis and dermis.

References(Q4):
www.bad.org.uk/shared/get-file.ashx?id=2126&itemtype=document
https://www.medicinenet.com/script/main/art.asp?articlekey=19818
calepima201.pbworks.com/w/file/fetch/.../Melanoma%20with%20answers.docx

5. Why is it useful to determine the level of invasion of this lesion?

It is helpful to be knowledgeable about the level of invasion due to the following

reasons. First, it aids the doctor or physician to decide what kind of therapy, if there's
any that he needs to conduct to the patient after surgery. Second, it also aims to
conclude a prognosis for the patient's immediate recovery. However, if the patient's
melanoma has not been metastasized or cured as soon as possible, the 5-year
patient's survival rate levels are the following:

Level 1 99+%

Level 2 99%

Level 3 95%

Level 4 75%

Level 5 39%

On the contrary, if the patient's melanoma has been metastasized, his survival
rate is as follows: Stage II Melanoma (30%) and Stage III Melanoma (less than 10%).
For the overall conclusion based on the given statistics, the only way to cure a patient
with melanoma is to catch it as early as possible. Clinical staging, biopsy, and
pathologic assessment of the melanoma's tumor are also essential in determining its
specific stage. Unfortunately, studies have found out that therapies for this disease
aren’t too effective but if it has been diagnosed earlier, there is still a chance to fully
cure it. Treating early-stage melanomas that have spread deeper into the skin requires
surgical removal of affected lymph nodes, chemotherapy through pills and/or
injections, radiation therapy to destroy cancer cells and avoid it from spreading
throughout the body, biological therapy to strengthen the patient's immune system,
and lastly targeted therapy for needed drug medications in determining the cancer
cells' vulnerability for immediate recovery.
References(Q5):
https://www.mayoclinic.org/diseases-conditions/melanoma/diagnosis-treatment/drc-
20374888
https://training.seer.cancer.gov/melanoma/abstract-code-stage/staging.html

6. Propose an explanation for why proliferating lymphocytes were noted around the
borders of the lesion.
Lymphocytes are one of several different types of white blood cells which play
an important part of the body’s immune system. It recognizes foreign materials that
have the potential to make the body sick. There are three types of lymphocytes, known
as T cells, B cells, and natural killer cells. T cells are developed in the thymus gland.
These cells are important in immunity because it recognizes antigens and is able to
bind to them. B cells are distinguished from other lymphocytes by a protein on their
surface known as the B-cell receptor. This protein is specialized to recognize and
attach to specific antigens. Natural killer cells are lymphocytes that are known to be
cytotoxic. This means that they have the ability to kill other cells. This includes virally
infected cells, cancerous cells and other types of tumor cells. The presence of
proliferating lymphocytes indicates that the body’s immune system is trying to kill the
cancerous cells around the lesion and prevents it from further metastasizing. Thus,
the proliferative capability of lymphocytes is important in the evaluation of the patient’s
prognosis, especially for Max Burnell whose adult immune system is not as effective
in cancer surveillance role compared to his younger immune system.

References(Q6):
https://link.springer.com/referenceworkentry/10.1007%2F3-540-27806-0_920
https://www.healthline.com/health/lymphocytes#function

7. Why does Max's physician think that his cancer has already metastasized?
A cancer that has already metastasized is one that has already spread to other
sites of the body by metastasis. Max’s physician thinks that his cancer has already
metastasized because the suspicious-looking mole found on his left arm was found to
be a melanoma. It is described to be hard and is located in his left axillary; this is where
regional lymph nodes are located. The large lump in his axillary is found to be a
cancerous enlarged lymph node filled with proliferating cancer cells.

References(Q7):
https://www.britishskinfoundation.org.uk/melanomaskincancer
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2490832/
8. What additional surgical procedures might help Max’s physician determine
whether his cancer has metastasized?
The foreign and unusual mole found in the left arm of Max made his Physician
diagnose him with melanoma that is in the process of metastasizing. Melanoma is a
tumor of melanin-forming cells. It can be any lump or tumor present on the skin, being
affiliated with skin cancer. Max’s Physician can do more inspections on the surface of
the left arm and check if there are more hardened lumps on the skin. The enlarged
lymph node that is diagnosed as a cancerous object should be further examined. If
surgical procedures were of concern, surgical removal and histologic examination of
the left axillary mass would ascertain whether Max's melanoma has metastasized.

References(Q8):
http://oncolex.org/Melanoma/Background/Etiology
https://collegegrad.com/careers/physicians-and-surgeons

9. How do malignant melanomas normally spread to other areas of the body?

According to the American Cancer society, malignant melanoma is a type of
cancer cell that breaks away to all parts of our body. Since melanoma affects our skin
it is more likely to spread faster. It will first spread to our immune system or the lymph
nodes with a 70-75 percent chance of spreading. It will then spread to our blood vessel
which can be resulted in affecting our lungs, bones, heart, thyroid, kidney, liver,
gallbladder, and brain.

References(Q9):
https://www.healthline.com/health/skin-cancer

10. Describe some of the current theories of the etiology of malignant melanoma.
The exposure to sunlight or the exposure to the Ultra-Violet Rays of the sun, to
be specific, is thought to be the main cause of melanoma in the skin. Exposure to
sunlight makes the melanocytes to produce more melanin, making the skin darker.
Other causes could be from of the familial disposition and birthmarks. However,
according to Kari Dolven-Jacobsen MD Ph.D. an Oncologist in Oslo University
Hospital, Norway, he edited in his website that Norwegian Melanoma Group has
recommended not to use Solarium because it will only increase the risk factors of
having Melanoma in the skin. Full agreement has yet to be reached but it was already
given as a warning based on the conclusions of the different studies conducted in the
field. Atypical mole syndrome (AMS) is also one of the etiologies of melanoma. The
National Institute of Health (NIH) defines AMS as the incidence of melanoma in one
or more 1st or 2nd degree family members. It is those moles which meet criteria for
atypical histology. Atypical moles pose an increased risk for developing melanoma.
The greatest risk factor is atypical moles in people from families with one or two family
members who have had melanoma. However, it is still unclear whether isolated moles
themselves can be considered pre-stages for melanoma.

References(Q10):
https://www.skincancer.org/skin-cancer-information/melanoma
https://www.verywellhealth.com/where-and-why-can-melanoma-spread-3010811