Photo Rounds

Dark spots in multiple locations

A 72-year-old woman presented to her family physician (FP) with dark spots that had developed in multiple locations over the previous 3 months. Most of them were raised, but there were no associated symptoms of pain or itching. The patient wondered whether these spots were related to her visits to a local park where ticks had been reported. The FP asked about previous cancers, and the patient indicated that she’d had a melanoma removed from her leg 22 years earlier. On physical exam, there were numerous dark macules, papules, and nodules from the patient’s neck down to her waist. None of the patient’s lymph nodes were palpable.

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Dark spots in multiple locations

The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)

The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

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