Novel Treatment of In-Transit Metastatic Melanoma With Shave Excision, Electrodesiccation and Curettage, and Topical Imiquimod 5% Cream

May 2021 | Volume 20 | Issue 5 | Case Reports | 555 | Copyright © May 2021


Published online April 28, 2021

Jeffrey A. Globerson DOa, Trevor Nessel MS-IVa, Brandon M. Basehore DOb, Eli R. Saleeby MDc

aBeaumont Health Systems, Department of Dermatology, Farmington Hills Campus, Farmington Hills, MI
bBroward Health Medical Center, Department of Dermatology, Fort Lauderdale, FL
cThe Skin Institute of South Florida, Coral Springs, FL

Abstract
In-transit metastatic melanoma is classified as a regional intralymphatic metastasis of melanoma. Currently, there is no standardized regimen used to treat in-transit metastatic melanoma, and therapy is individualized based on the patient. While many patients undergo surgical procedures, those with surgical contraindications or declination face challenges when attempting to find adequate treatment options. This case report demonstrates the successful treatment of multiple in-transit metastatic melanoma lesions using the combination of shave excision, electrodesiccation and curettage, and topical imiquimod cream. Several months later, examination showed clinical resolution of the original metastatic lesions. This treatment regimen may provide an alternative option for a select group of patients with certain comorbidities and therapeutic contraindications.

J Drugs Dermatol. 20(5):555-557. doi:10.36849/JDD.5675

INTRODUCTION

In-transit metastatic melanoma (ITMM) is defined as metastases of melanocytes within the regional dermal or subcutaneous lymphatics greater than 2 cm from the primary lesion but not further than regional lymph nodes.1 It commonly presents clinically as erythematous papules or nodules of variable size that can display pigment.2 A standardized protocol for treatment of ITMM has yet to be determined and presents a therapeutic challenge. Different therapies are used depending on the anatomic site of malignancy, extent of metastasis, and patient condition. For patients who are not surgical candidates, literature has documented the successful use of alternative treatments, such as topical imiquimod monotherapy or combination therapies.3 We present a case report of a patient with multiple ITMMs treated with shave excision, electrodesiccation and curettage (ED&C), and daily application of topical imiquimod 5% cream for three months. To the best of the authors’ knowledge, this is the first report of using this combination of treatment modalities for ITMM. This case demonstrates that this therapeutic approach may be considered in patients with ITMM who are not candidates for surgical excision.

CASE REPORT

An 89-year-old male was referred to the dermatology clinic in March 2015 for surgical excision of confirmed malignant melanoma (MM) on his chest (Breslow thickness 2.4mm, stage T3a). Examination revealed numerous multicolored papules on his right medial breast and upper chest suspicious for lymphocutaneous ITMM (Figure 1). Biopsy of one such lesion confirmed the diagnosis of MM (stage T1b). There was no palpable evidence of nodal disease. At that time, the patient deferred sentinel lymph node biopsy and underwent positron emission tomography (PET), which detected no evidence of nodal or visceral metastases.

Potential treatment options including surgical excision, systemic therapy, and alternative locally destructive and immunomodulatory modalities were presented to the patient and his caregivers. Given the presence of multiple lesions, the patient’s limited functional status, and the prognosis of his disease, the decision was made to pursue a combination of local surgical and topical treatments. Thirty-three deep shave biopsies were performed with a #15 surgical blade followed by