ABSTRACT
Giant melanomas of the peripheral limbs are a rare surgical entity, with fewer than six cases reported in published literature. Previous case reports primarily described attempts at surgical cures utilizing a multidisciplinary approach. We believe this is the first report addressing the complexities of tumor complications specifically from the perspective of acute care surgery. The surgical procedure in this case aimed exclusively at arresting bleeding rather than oncological cure. The role of surgery in addressing complications in palliative care of large tumors is significant. It enhances patient comfort and assists in establishing management guidelines for rare tumors, such as giant peripheral melanoma.
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Keywords: Acute care surgery; Hemorrhage; Hospice and palliative care nursing; Melanoma; Palliative care; Case reports
INTRODUCTION
Giant melanomas of the peripheral limbs are an extremely rare clinical phenomenon, with fewer than six cases described in the existing literature. Approximately 19% of all melanomas occur in the arm [
1]. In rare cases, melanomas can reach enormous sizes, presenting significant challenges for both patients and healthcare providers. This case report explores the complexities involved in diagnosing, managing, and treating gigantic peripheral melanomas, as well as the management of complications associated with these large tumors in acute care settings.
CASE REPORT
Ethics statement
The patient provided informed consent for publication of the research details and clinical images before death, understanding that the surgical goal was strictly hemostasis, not oncological cure.
Patient information
A 94-year-old woman residing in a care home in Saskatchewan, Canada, presented to the emergency department with bleeding from a skin lesion on her left forearm. She had previously been diagnosed with stage IV melanoma and was receiving palliative treatment.
Clinical findings
Local examination revealed a large lesion on her left forearm (
Fig. 1). The lesion was so extensive that the patient was unable to elevate her left arm. Additionally, her left limb had become nonfunctional due to motor nerve involvement by the tumor (
Fig. 2). Active bleeding was noted from the base of the wound (
Fig. 3). Blood loss from this lesion had previously necessitated a blood transfusion. After detailed discussions with the patient and her family, the decision was made to operate solely to control bleeding.
Under general anesthesia, surgical access to the lesion base was obtained, and bleeding was successfully controlled using surgical sutures (
Fig. 4). A LigaSure bipolar device (Medtronic) was employed to excise the superficial portion of the tumor. Subsequently, the lesion base was oversewn using figure-of-eight sutures with 2-0 Vicryl (Ethicon). A pressure dressing was applied to the wound to maintain hemostasis. supplemented by an upper limb tourniquet, which was removed after 30 minutes.
The patient experienced an uneventful postoperative recovery and was discharged back to the care home. At a surgical follow-up 2 weeks later, the wound was found to have healed without evidence of further bleeding (
Fig. 5).
DISCUSSION
Gigantic melanomas, defined as melanomas exceeding 10 cm in diameter, present rare and formidable challenges in surgical oncology. These lesions involve unique diagnostic, therapeutic, and palliative complexities requiring a multidisciplinary approach [
2].
Diagnosing gigantic melanomas often involves delayed patient presentations, as evidenced by our 94-year-old female patient with a bleeding forearm lesion. Delayed diagnoses frequently result in advanced disease stages, complicating management. Standard diagnostic procedures include dermatoscopy, biopsy, and imaging modalities such as magnetic resonance imaging, computed tomography, and positron emission tomography scans to evaluate disease extent [
2]. For melanomas mimicking other conditions, including sarcomatoid melanomas, histological and immunohistochemical analyses are crucial. Immunohistochemical staining for S100 and SOX10 is especially important in giant sarcomatoid melanomas [
3].
Management of gigantic melanomas entails substantial complexity. Surgical resection remains the primary therapeutic option. Given their size and location, these tumors often require extensive reconstructive procedures. Honeyman and Wilson [
4], in the case of a 57-year-old woman with a 14×7×12-cm melanoma, performed wide local excision followed by a split-thickness skin graft. They highlighted the necessity of wide excision margins and diligent follow-up due to high recurrence and metastatic risk. Torresetti et al. [
5] emphasized targeted therapy's role in managing BRAF-mutant melanomas, underscoring significant therapeutic responses achievable even in advanced stages. In a patient with a 19×16-cm sarcomatoid melanoma, they performed wide excision and immediate reconstruction with a dermal substitute.
Advanced gigantic melanoma cases may require systemic treatments such as immunotherapy or targeted therapies. BRAF and MEK inhibitors have significantly improved patient outcomes in BRAF-mutant melanoma cases. A case report involving sarcomatoid melanoma demonstrated the effectiveness of combined BRAF/MEK inhibitor therapy, achieving complete response without adverse events [
6]. Genetic testing in melanoma management is emphasized, given that targeted therapies substantially improve clinical outcomes and patient quality of life [
7].
For inoperable cases or those with extensive metastatic disease, palliative care is integral to patient management, focusing on symptom relief and quality of life. In our patient, surgical intervention primarily aimed at achieving hemostasis and relieving discomfort [
8]. Essential aspects of comprehensive palliative care include adequate pain management, controlling bleeding through surgical hemostasis, and providing psychological support.
A multidisciplinary approach involving oncologists, surgeons, radiologists, and palliative care specialists is now considered foundational for comprehensive care. This team-based approach is vital for formulating thorough treatment plans addressing tumor and patient well-being. The complexity of gigantic melanomas typically necessitates multidisciplinary input to optimize outcomes and manage complications effectively [
9]. Our patient died a few months later in a palliative care home, experiencing no further episodes of tumoral bleeding.
Literature on gigantic melanomas of the peripheral limbs remains sparse, with fewer than six cases documented, including our report. Published studies provide valuable insights into management strategies and outcomes for these rare tumors [
10,
11].
A multidisciplinary approach remains central, while complications from these extensive tumors may become a focus for acute care surgeons, as demonstrated by this case. Surgical intervention targeted bleeding control and hemostasis without pursuing oncological remission.
In conclusion, we present a unique case of giant peripheral melanoma managed surgically to control tumor-associated bleeding. To our knowledge, this is the first report addressing gigantic peripheral melanoma management in an acute care setting. Ongoing research and documentation of such rare cases are crucial for developing evidence-based guidelines, thereby improving patient care and managing complications associated with large tumors.
ARTICLE INFORMATION
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Author contributions
Conceptualization: YP; Methodology: MS; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
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Conflicts of interest
The authors have no conflicts of interest to declare.
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Funding
The authors received no financial support for this study.
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Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.Giant peripheral melanoma, 11 cm wide.
Fig. 2.Giant melanoma with left hand immobility due to motor nerve involvement.
Fig. 3.Active bleeding noted at the base of the tumor (arrow).
Fig. 4.Surgical tumor excision to arrest bleeding. (A) Surgical arrest of bleeding. (B) Tumor mobilization.
Fig. 5.Two-week postoperative follow-up showing hemostasis.
REFERENCES
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