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Figure 1. A 3.2 cm mass on the plantar surface of the foot. |
A 79-year-old African-American male, South Pacific World War II Veteran presented to the office with a lesion on his left foot. His wife had noticed the lesion for about a year, but the patient did not see a physician previously because the lesion was asymptomatic. He denied that the lesion had itched or spontaneously bled in the past. One month prior to his visit, however, he began to have some pain in the area and saw his primary physician who performed a biopsy. The pathology report was suggestive of malignant melanoma. The patient then presented for a second opinion. Family history was negative for melanoma and the patient noted no past personal history of melanoma. He suggested possible atomic radiation exposure at the close of World War II.
On exam, there is a 3.2-cm diameter black mass on the medial plantar surface of his left foot (Figure 1). It was firm, non-tender to palpation, and non-fluctuant. There was no appreciable core, and no obvious bleeding papillary tips. No palpable adenopathy was noted in the inguinal canal or popliteal fossa. No other atypical cutaneous lesions were noted. The patient was referred to a plastic surgeon. Wide excision and skin grafting was performed; the foot was spared. The pathology report on this procedure disclosed malignant melanoma, Clark's Level IV, tumor thickness 4.35 mm. Left femoral lymph nodes, along with surrounding skin on the left foot were also resected, and were negative for metastatic lesions. Metastatic workup was negative, and systemic Interferon was declined. The patient recovered at a nursing facility and is currently being followed by his primary care physician.
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Figure 1. A 3.2 cm mass on the plantar surface of the foot. |
Malignant melanoma is uncommon on the foot and in the African American patient population1. When melanoma occurs in pigmented patient populations, it usually tends to occur in non-sun exposed areas, such as the plantar surface of the foot, as well as anogenital and choroidal locations. In such cases, the histologic subtype tends to be acral lentiginous melanoma2. The current case was interesting in that the patient was of African American heritage, and the location of the lesion was on the plantar surface.
A recent retrospective study3 of 60 patients with foot and ankle area melanoma disclosed that the most common location was on the plantar aspect of the foot. Five-year survival was shorter in patients with plantar or subungal lesions than with lesions located in other areas of the ankle or foot. A recent retrospective study4, however, discloses that 113 patients with acral lentigionous melanoma compared similarly in outcome to patients with superficial spreading melanoma out to five years.
Bennett5 retrospectively reviewed the tumor registry of a 650-bed teaching hospital in Connecticut, as well as the Connecticut tumor registry for a nine-year period from July 1980 to July 1989. Patient age, race, gender, diagnosis, and delay of definitive therapy were recorded. Tumor location, size, staging, follow up, recurrence, and disease free interval were recorded. Delay in diagnosis occurred in 68% of cases from the hospital and 16% from the tumor registry. Plantar warts were one of the more common diagnostic errors in the groups with initially incorrect diagnosis. Regardless of stage, melanoma of the foot had a worse prognosis than melanoma of the thigh or lower leg. This finding is correlated by Barnes et al 6 who found that location of melanoma on the plantar aspect of the foot was an independent variable associated with a less favorable outcome.
In essence, it is important when examining patients to not neglect the plantar surface and periungual areas, and to be suspicious of lesions in these locations. Lesions that may give an initial clinical impression of plantar warts need to be watched, and biopsy should be performed for lesions which fail to respond to appropriate treatment.
References
1. Di schino M, Bobin P, et al. Malignant melanoma among ethnic Melanesian population of New Caledonia. Med Trop Mar. 1989; 49(2): 139-44.
2. Muchmore JH, Mizuguchi RS, Lee C. Malignant melanoma in American black females: an unusual distribution of primary sites. J Am Coll Surg. 1996; 183(5); 457-65.
3. Fortin PT, Freiberg A, Rees R, et al. Malignant melanoma of the foot and ankle. J of Bone and Joint Surgery. 1995; 77(9): 1396-403.
4. Breuninger H, Kohler C, Drepper H, et al. Is acrolentigionous melanoma more malignant than superficial spreading melanoma at a high risk site? A matched pair comparison between 113 ALM and SSM within the scope of multicenter study. Hautzart. 1994; 45(8): 529-31.
5. Bennett DR, Wasson D, Macarthur JD, et al. The effect of misdiagnosis and delay in diagnosis on clinical out come in melanomas of the foot. J Am Coll Surg. 1994; 179(3):279-84.
6. Barnes BC, Seigler HF, Saxby TS, et al. Melanoma of the foot. J Bone Joint Surgery. 1994; 76(6): 892-8.
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