|Year : 2000 | Volume
| Issue : 1 | Page : 37-38
Acral lentiginous melanoma
S Khandpur, BSN Reddy
Source of Support: None, Conflict of Interest: None
A 45-year-old man with acral lentiginous melanoma (AJCC Stage IV) of the left sole and lymph node metastasis is described. Three cycles of palliative combination chemotherapy administered to him resulted in the decrease of inguinal lump, however, the lesion over sole showed no variation.
Keywords: Melanoma, Acral lentiginous
|How to cite this article:|
Khandpur S, Reddy B. Acral lentiginous melanoma. Indian J Dermatol Venereol Leprol 2000;66:37-8
| Introduction|| |
Acral lentiginous melanoma (ALM) is the fourth clinicopathologic variant of malignant melanoma recognized and introduced by Reed in 1975.  It occurs commonly over the volar surface of hands and feet, subungual areas, fingers and toes. ALM probably represents the commonest expression of melanoma in blacks and constitutes only 10% of all melanomas on white skin. It is characterized by a lentiginous (radial) growth phase that evolves over months to years to a dermal (vertical) invasive stage.
We report a case of ALM Stage (AJCC staging) over sole in a 45-year-old man. As far as ascertained, we could not come across any documentation of ALM from India, although superficial spreading' and nodular melanomas  have been reported.
| Case Report|| |
A 45-year-old man presented with a brownish black ulcerated growth over the left sole and a lump in the left groin. It started 3 years back as a dark coloured asymptomatic patch with regular border that gradually increased in size with blurring of the margin. A soft swelling appeared within the lesion over the next 3-4 months that broke down causing pain while walking. It was followed 2 years later by an asymptomatic lump over left groin that slowly increased in size, became painful and ruptured discharging pus and necrotic slough. No history of anorexia, weight loss, cough, haemoptysis, seizures, bone pains, urinary or bowel complaints was present. His personal and family history were not contributory.
Dermatologic examination revealed a brownish black plaque over the left sole 6X5 cm. in size, with irregular blurred margin and ulceration over lateral aspect. [Figure - 1] Left inguinal region showed enlarged lymph nodes that were tender, hard, matted and fixed to underlying tissues with ulceration of overlying skin discharging pus and necrotic material. In addition, left external iliac lymph nodes were also palpable. Rest of the mucocutaneous and systemic examination revealed no abnormality.
Routine laboratory investigations including haematological, biochemical and radiological (X-Ray chest, skull, foot, CT scan of head, USG abdomen) were within normal limits. FNAC from left inguinal lymph nodes was consistent with metastatic melanoma. Histopathology of the lesion over foot revealed hyperkeratosis, acanthosis, elongation of rete ridges, junctional activity with descending atypical melanocytes in epitheloid pattern throughout the dermis and ascent of atypical cells in the epidermis suggesting epitheloid type of malignant melanoma.
The patient was diagnosed as a case of ALM Stage IV (AICC staging) and put on palliative chemotherapy consisting of dacarbazine (400mg. I/V daily on Day I-Day 7), adriamycin (60mg I/V on Day I), levamisole (50mg three times daily X 3 days alternate week) and interferon a- 2b (9X10 6sub I.U. I/M alternate day X 3 weeks). Following 3 cycles each monthly, the lesion over sole showed no change but a perceptive decrease in the inguinal swelling was noted.
| Discussion|| |
Melanomas of acral lentiginous type show distinct clinical and histologic features that are characteristically different from the other commoner variants. Our patient represented a classic case of this relatively new variant characterized clinically by a large macular lentiginous pigmented area around an invasive raised tumour. Histopathologically the lesion exhibited a lentiginous radial growth component, a vertical phase of atypical melanocytes in epitheloid pattern, psoriasiform epidermal hyperplasia and a good host response with focal areas of regression.
The hidden location of lesions, especially over plantar surface contributes to poor prognosis by allowing initial lesion to go undetected until the phase of vertical growth occurs.  Our patient showed distant metastasis to external iliac lymph nodes with poor prognosis due to its initial benign asymptomatic appearance and insiduous progress to the invasive and metastatic stage. Early detection of the lesion in the asymptomatic radial growth phase is therefore critical for better prognosis.
In stage I with involvement of sole, wide excision with 3 cm. margin down to deep fascia repaired by split thickness grafting suffices. Occasionally partial amputation of distal foot with regional lymph node dissection is needed with larger lesions and regional lymph node metastasis. With widespread metastasis, treatment is palliative in the form of chemotherapy with short remissions. Our patient in Stage IV ALM was therefore subjected to combination chemotherapy with no change in the primary lesion, though regression in the size of regional lymph nodes was appreciated at the end of 3 cycles.
| References|| |
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[Figure - 1]