Borderline Intermediate Thickness Cutaneous Melanoma Class B: Isn’t it Time for Personalised One Step Surgical Approach as Standard Clinical Behaviour?

We present a 40-year-old female who visited our clinic with a solitary lesion on the posterolateral aspect of the lower left leg (Figure 1a). She noticed a progressive change in the size and shape of the lesion and decided to consult a dermatologist in March 2021. The patient had a history of Hashimoto’s thyroiditis that was well-controlled onlevothyroxine. No other comorbidities were reported and she was otherwise healthy. During the clinical examination a single pigmented patch measuring 2.5 cm in greatest diameter was identified. Morphologically the lesion was asymmetrical with irregular borders and uneven colour. At the centre, an exudative, ulcerated nodule was also noted (Figure1a-f). Clinical and dermatoscopic findings were consistent with the diagnosis of a superficial spreading cutaneous melanoma. Ultrasound diagnostics of the abdominal cavity and retroperitoneal organs showed no signs of tumor spread. Chest radiography was also within normal limits. Laboratory testing showed an elevated uric acid level of 456 μmol/l (reference range 142 - 340 μmol/l), but otherwise all other parameters were normal. Following the recommended American Joint Committee on Cancer (AJCC) guidelines, we performed a primary resection with 0.5 cm margins in all directions. The resected tissue was subsequently sent for histopathological evaluation and confirmed the diagnosis of borderline intermediate thickness malignant melanoma - class B, 4 mm Breslow thickness, Clark IV, (pT4BN0M0) (Figure2a-d). There was high mitotic activity but no spontaneous regression, insignificant lymphocytic stromal reaction and clear resection margins. Post diagnostic workup, including chest and abdominal CT, showed no signs of metastatic dissemination. One week later, the patient was sent to the National Oncology Hospital for re-excision and Sentinel Lymph Node Biopsy (SLNB). The re-excision of additional 2cm from the previous surgical scar was conducted in parallel with removal of the draining sentinel lymph node (Figures 3a & 3d). The closure of the defect after re-excision led to the unfortunate complication of wound dehiscence and failure to close successfully (Figure 3b-c). However, after several sessions of debridement, cleansing, rebandaging and administration of antibiotics, there was visible improvement with subsequent resolution(Figure 3d-f). Since that time, she has been in excellent condition, and no complications have been reported to date.