Regional ganglionar metastasis 24 years after surgical resection of a malignant melanoma

A 40-year-old woman, with type I skin, came to the Dermatology Clinic after noticing a tumor in the armpit. The physical examination revealed a hard, stretched-shaped tumoral node with a diameter of 30 mm, located in the left armpit. It moved on the superficial and deeper layers. In addition, the scar of a large graft was found in the homolateral supraclavicular region, where a malignant melanoma had been excised 24 years earlier. At that time, the primary tumoral lesion had the characteristics of an extensive superficial melanoma with an infiltrating core with vertical growth. The pathologic study of the tumor confirmed the diagnosis of a malignant melanoma with a Clark level II and a 1.17 mm Breslow thickness. Surgery had a margin of 3 cm. At present, the patient is in excellent condition and laboratory tests are normal. Immunologic tests performed showed a slight increase in CD4+, CD45A+, DR+ lymphocytes, CD16+, CD56+, NK cells, and a marked increase in tumor necrosis factor-α (TNF-α) and γ-interferon (IFN-γ) levels (Table 1). Imaging studies (chest X-rays, abdominal ultrasound, bone scintigraphy) did not show any abnormal signs. Computerized tomography confirmed the ganglionic mass, without any other abnormalities. Tc-99m methoxy-isobutyl-isonitrile (MIBI) scintigraphy was performed, showing a focally increased concentration of radiomarker in the left armpit, indicating a thick adenopathic conglomerate (Fig. 1). No other areas of abnormal uptake were observed, not even in the original area of the primary tumor. The surgical exploration of the axillar contents confirmed the presence of adenopathies. Pathology studies showed metastatic invasion of intensely melanin-pigmented and pleomorphic cells, with atypical mitosis.