The Case StudyThe Discovery

"Hannah, do you mind if I step into the bathroom to get something?" Hannah's husband, Joe, exclaimed. "I'm just stepping out of the shower, so yes, you can come in," said Hannah as she slid the glass shower door open. "I'll just be a second," said Joe as the bathroom door swung open. "Hey, I never noticed that mole on your back." "Oh, that tiny thing," said Hannah. "I've had that for a couple of years now." "Well, it doesn't look so tiny to me," said Joe. "I think you should get that checked out." "I guess I probably should," said Hannah. "You know my aunt had skin cancer."

At the Dermatologist

History:

Hannah Jones, a married, 48-year-old avid long-distance runner previously in good health, presented to her dermatologist during which a suspicious-looking mole was noticed on the upper left portion of her back. She reported that she has had that mole for a couple of years but thinks that it may have gotten larger over the past two years. Hannah reported that she has noticed itchiness around this mole over the past few weeks. She had multiple other moles on her back, arms, and legs, none of which looked suspicious.

Upon further questioning, Hannah reported that her aunt died in her late forties of skin cancer, but he knew no other details about her illness. Hannah is a teacher who spends most of the week indoors. On weekends, however, she typically goes for a 5-mile run and spends much of her weekend and summer afternoons gardening. She has a light complexion and blonde hair and reports that she sunburns easily but uses protective sunscreen only sporadically.

Physical Examination

Head, neck, thorax, and abdominal exams were normal, apart from a hard, enlarged, non-tender mass felt in the left axillary region. In addition, a 1.6 x 2.8 cm mole was noted on the left posterior thoracic region. The lesion had an appearance suggestive of melanoma. It was surgically excised with 3 mm margins using a local anesthetic and sent to the pathology laboratory for histologic analysis.

Pathology Report

The pathology report gave the following description of the tissue sample:

"Diagnosis: Superficial spreading melanoma with vertical level V invasion. Coalescent nests of neoplastic cells were noted in the papillary and reticular dermis and in the subcutaneous layer. In addition, large, pink-stained cells with pleomorphic nuclei were found spreading radially through the epidermal layer. Proliferating lymphocytic cells are noted in the dermis surrounding the malignant cells."

Follow-Up

Hannah is told that she has malignant melanoma and that it may have already metastasized. She is advised that she may need additional surgery to verify that the tumor has metastasized.

 

1. Explain how the appearance of a malignant melanoma differs from that of a normal mole, or Nevis, on gross inspection and why it was important to surgically excise and examine this mole.
2. Describe the differences in stages I through IV in melanoma and why it is useful to determine the level of invasion of this lesion.
3. Describe the layer of the integument involved in malignant melanoma and to which tissues of the body the cancer could spread.
4. Why does Hannah's physician think that her cancer has already metastasized?