Case Presentation
A 60-year-old male veteran of African American and Japanese descent,
presented for concerns of a growing lesion on his left lower abdomen.
The lesion was present for several years, but had been recently
increasing in size, catching on his belt, and bleeding. The patient
denied any personal or family history of skin cancer nor history of
sunburns. Work history included service in the military, with
deployments in Spain, Italy, and France. As a deckhand painting and
cleaning ships, he spent significant time outdoors. Physical exam
revealed a friable dark brown to black exophytic ulcerated tumor growing
atop a broader dark brown plaque measuring 4.0 x 2.0 cm on the left
lower abdomen with background Fitzpatrick V skin type (Figure 1).
Wide local excision and dissection of superficial left inguinal lymph
nodes revealed nodular melanoma with Breslow depth of 5.1 mm and a
Clarkâs level of IV (Figure 2). A BRAF V600E mutation was
detected, and melanoma was confirmed in four lymph nodes. Subsequent
imaging revealed innumerable 1-3 mm nodules in bilateral lungs and a
solitary lesion in the left temporal lobe with TNM staging of T4bN3cM1.
Treatment began with combined RAF and MEK inhibitors, dabrafenib and
trametinib. Within 12 months, pulmonary and brain lesions disappeared,
however progression was noted in T6 vertebra. 15 months after diagnosis,
treatment was changed to combination checkpoint inhibition with
ipilimumab and nivolumab and stereotactic beam radiation therapy (SBRT).
The patient passed away 21 months after initial diagnosis.