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 Clark’s 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.