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Oncology

Sudden Development of Indurated Subcutaneous Nodules in a Patient With a Recent Melanoma Surgical Procedure

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Dermatology

Published Online: January 26, 2022

JAMA Dermatology Clinicopathological Challenge

Article Information and Disclosures

Alejandra Sandoval-Clavijo, MD, MSc¹;

Raquel Albero-González, MD, PhD²;

Agustí Toll, MD, PhD¹

Author Affiliations

¹Department of Dermatology, Hospital Clínic, University of Barcelona, Barcelona, Spain
²Department of Pathology, Hospital Clínic, Centre de Diagnostic Biomedic, Barcelona, Spain

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A woman in her 40s with a medical history of multiple sclerosis consulted for the sudden development of 2 adjacent nodules on the left arm. An excision with 1-cm margins of the left arm demonstrated desmoplastic melanoma with a Breslow thickness of 1 mm, and a left axillary sentinel lymph node biopsy (SLNB) had been performed 3 weeks before under general anesthesia. The patient was also being treated with subcutaneous interferon beta 1a for the multiple sclerosis. Physical examination revealed 2 indurated and mobile subcutaneous nodules on the anterior surface of the arm 5 cm distal to the surgical scar, the larger of them measuring 15 mm in diameter (Figure, A) and the smaller of them measuring 4 mm. When the arm was abducted to 90°, the patient denied pain but described a subtle tightness sensation on the arm. An excisional biopsy from the larger lesion was performed (Figure, B-D).

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C. Axillary web syndrome

Associated with the clinical findings, a subtle cord that projected from the largest nodule to the axillary region could be seen in physical examination (Figure, A). An excisional biopsy of the larger lesion showed the presence of dilated and thrombosed vessels in the subcutaneous tissue, with signs of recanalization. Other features present were edema, areas of acute hemorrhage, recent fibrosis, and focal steatonecrosis, without evidence of malignant melanoma (Figure, B). An immunohistochemical study confirmed the lymphatic vascular origin of the lesion, with expression for CD31, ERG and D2-40 (podoplanin) antibodies. Human herpesvirus 8 test results were negative. In this setting, a Sox10 staining was also performed, ruling out a metastasis of melanoma. The medical history of a left axillary SLNB associated with the clinical, pathological, and special staining findings confirmed the diagnosis of axillary web syndrome (AWS).

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Article Information

Corresponding Author: Alejandra Sandoval-Clavijo, MD, MSc, Department of Dermatology, Hospital Clinic, Carrer Villaroel 170, 08036, Barcelona, Spain (dsandoval@clinic.cat).

Published Online: January 26, 2022. doi:10.1001/jamadermatol.2021.5689

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.