TELEDEMATOLOGY READER REPORT1
History
Chief complaint: bleeding skin lesion present for 3 months.
A 56-year-old white female patient with a history of iron deficiency anemia, Hepatitis C, and insulin therapy noticed a lesion near a medical port placed 3 months previously. The lesion grew slowly and started to bleed in the past 2 weeks. The patient visited her primary care doctor with concern about this lesion.
* Prior treatment: The lesion in question was not previously treated.
* Prior biopsy: The lesion in question was not previously biopsied.
* Skin history: A squamous cell carcinoma was excised on the right helix of ear 11 years ago, and basosquamous cell carcinoma was treated on the upper back 4 years ago.
* Significant laboratory findings: none
Image Report
Erythematous, crusted, somewhat pearly nodule was present on the left chest, near a port site used for chemotherapy infusions (Figure 1).
INTERPRETATION OF IMAGES
The findings of a crusted nonhealing lesion with pearliness are most suggestive of basal cell carcinoma. However, the differential diagnosis could include less-common conditions such as amelanotic melanoma and Merkel cell carcinoma. For these reasons, the patient was seen within 72 hours in a rapid access clinic for a biopsy.
RECOMMENDATIONS
The patient's concern prompted the primary care physician to initiate a store-and-forward telehealth visit with dermatologists. After the telehealth visit and virtual examination, an "in-person" examination was recommended for biopsy.
Surgical Recommendation
A saucerization shave biopsy of the lesion was performed to assess the possibility of malignancy.
Diagnosis and Additional Recommendations
Pathological analysis of biopsy confirmed a diagnosis of ulcerated nodular, amelanotic, malignant melanoma. Wide local excision of the lesion was performed, and this showed the melanoma was completely excised. In addition, there were no nodal metastases in a sentinel lymph node biopsy.
CLINICAL PEARL
Amelanotic melanomas account for about 2%-8% of all reported melanomas (Gong et al., 2019; Thomas et al., 2014). These melanomas can be especially hazardous as they represent more than 61% of missed diagnoses (Thomas et al., 2014). In addition, amelanotic melanomas show a higher rate of growth than pigmented melanomas (Liu et al., 2006). The lack of pigment of amelanotic melanomas and varying clinical presentations may lead to a later diagnosis of these lesions and increased Breslow thickness upon diagnosis (Betti et al., 2003; McClain et al., 2012). Late diagnosis of amelanotic melanomas presents with an increased risk to patients, and for this reason, it is important to biopsy lesions of uncertain biologic potential. Patients such as this one reinforce the need for routine self-skin examinations. In addition, patients with a history of skin cancer should be careful to protect themselves against prolonged sun exposure. It is possible that the convenience of a teledermatology consultation was a factor in making the melanoma diagnosis more rapidly and the provision of definitive treatment. Increasing availability of teledermatology through primary care providers offices increases rural access to specialty care and can be lifesaving.
REFERENCES