Physical Examination Head, neck, thorax, and abdominal exams were normal, apart from a hard, enlarged, non-tender mass felt in the left axillary region. In addition, a \( 1.6 \times 2.8 \mathrm{~cm} \) mole was noted on the left posterior thoracic region. The lesion had an appearance suggestive of a melanoma. It was surgically excised with 3 mm margins using a local anesthetic and sent to the pathology laboratory for histologic analysis. Pathology Report The pathology report gave the following description of the tissue sample: "Diagnosis: Superficial spreading melanoma with vertical level \( V \) invasion. Coalescent nests of neoplastic cells were noted in the papillary and reticular dermis and in the subcutaneous layer. In addition, large, pink-stained cells with pleomorphic nuclei were found spreading radially through the epidermal layer. Proliferating lymphocytic cells are noted in the dermis surrounding the malignant cells." Follow-Up Hannah is told that she has malignant melanoma and that it may have already metastasized. She is advised that she may need additional surgery to verify that this tumor has metastasized.

The provided information outlines a clinical case involving a patient named Hannah who has been diagnosed with malignant melanoma. Let's break down the key points and implications of this case step by step. ### Known Conditions 1. **Physical Examination Findings:** - Normal head, neck, thorax, and abdominal exams. - A hard, enlarged, non-tender mass in the left axillary region. - A mole on the left posterior thoracic region measuring \( 1.6 \times 2.8 \, \text{cm} \) with characteristics suggestive of melanoma. 2. **Pathology Report Findings:** - Diagnosis: Superficial spreading melanoma with vertical level \( V \) invasion. - Presence of neoplastic cells in the papillary and reticular dermis and subcutaneous layer. - Large, pink-stained cells with pleomorphic nuclei spreading radially through the epidermis. - Proliferating lymphocytic cells in the dermis surrounding malignant cells. 3. **Follow-Up Recommendations:** - Hannah has been informed of the malignant melanoma diagnosis and the possibility of metastasis. - Additional surgery may be required to confirm metastasis. ### Step-by-Step Analysis 1. **Understanding Melanoma:** - Melanoma is a type of skin cancer that arises from melanocytes, the cells that produce pigment in the skin. - The "superficial spreading" type is the most common form of melanoma and is characterized by horizontal growth before it invades deeper layers. 2. **Vertical Level \( V \) Invasion:** - The vertical level of invasion indicates that the melanoma has penetrated deeply into the skin layers, which is associated with a higher risk of metastasis. - Level \( V \) signifies that the melanoma has invaded the subcutaneous tissue, which is concerning for potential spread to other parts of the body. 3. **Histological Findings:** - The presence of neoplastic cells in various skin layers suggests aggressive behavior of the melanoma. - The description of pleomorphic nuclei indicates that the cancer cells are abnormal and may be rapidly dividing. - The presence of lymphocytic cells suggests an immune response to the tumor, which can be a positive sign, but it also indicates that the body is recognizing the malignancy. 4. **Implications of Metastasis:** - The enlarged mass in the axillary region could represent a lymph node that has been affected by the melanoma. - If metastasis is confirmed, it may require more extensive treatment, including possible lymph node dissection and systemic therapies. 5. **Next Steps:** - Additional imaging studies (e.g., CT scans, PET scans) may be necessary to assess for distant metastasis. - Surgical excision of the primary melanoma with clear margins is crucial. - Follow-up with an oncologist for potential adjuvant therapy (e.g., immunotherapy, targeted therapy) may be indicated based on the stage of the disease. ### Conclusion Hannah's case of malignant melanoma is serious due to the vertical invasion and potential for metastasis. Close monitoring and further surgical intervention are essential to manage her condition effectively. It is important for her to discuss all available treatment options with her healthcare team to ensure the best possible outcome.