Delayed Metastatic Polypoid Nodular Melanoma Diagnosis During COVID-19 Pandemic, Successful Treatment With Surgery and Nivolumab

December 2021 | Volume 20 | Issue 12 | Case Reports | 6071 | Copyright © December 2021


Published online November 10, 2021

Stefan Bradu MD PhDa,b,c, Daniel Siegel MDa,b, Jameson Loyal MDa,c, Andrea Leaf MDd, Alana Kurtti BSa,e, Usha Alapati MDa,c, Jared Jagdeo MD MSa,c

aDermatology Service, VA New York Harbor Healthcare System, Brooklyn, NY
bDepartment of Dermatology, Ronald O. Perelman NYU Grossman School of Medicine, New York, NY
cDepartment of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY
dDepartment of Oncology, VA New York Harbor Healthcare System, Brooklyn, NY
eRutgers Robert Wood Johnson Medical School, Piscataway, NJ

Abstract
Patients with polypoid (pedunculated) melanoma have the poorest 5-year survival rate compared with all other variants of nodular melanoma, presenting with increased thickness, incidence of metastasis, and rates of ulceration. There are few published reports regarding the pathogenesis and treatment of polypoid melanomas. We report the successful treatment of a rapidly developing red nodular polypoid melanoma with metastasis using surgery followed by anti-PD-1 antibody nivolumab in a SARS-CoV-2-positive patient who delayed seeking care due to the COVID-19 pandemic.

J Drugs Dermatol. 2021;20(12): doi:10.36849/JDD.6071

INTRODUCTION

Among the major subtypes of melanoma, nodular melanoma is associated with the poorest prognosis.1 Nodular melanoma can be further subdivided into distinct variants, among which the polypoid (pedunculated) tumor has the poorest 5-year survival rate.1,2 Polypoid melanomas are characterized by an aggressive vertical growth phase and have been associated with early metastases through invasion of blood and lymphatic vessels at the tumor’s periphery.3 Clinically, the polypoid variant has a cauliflower-shaped appearance, with the bulk of the lesion located above the epidermis.1 Compared to other variants of nodular melanoma, polypoid melanoma is associated with younger age at presentation, increased thickness, more frequent ulceration, and higher probability of occult metastasis.1

Although surgical excision is the cornerstone of melanoma management, treatment of polypoid melanoma is complicated by several negative prognostic factors, including early metastasis.4 Nivolumab, an anti-programmed-death-1 (PD-1) antibody, was approved for the treatment of unresectable or metastatic melanoma in 2014, but its role in the treatment of polypoid melanoma with metastasis is unclear.5,6 We report the successful treatment of a rapidly developing red nodular polypoid melanoma with metastasis using surgery followed by nivolumab in a SARS-CoV-2-positive patient who delayed seeking care due to the COVID-19 pandemic.

CASE

We report the case of a 74-year-old man with rapid development of a forearm polypoid melanoma and metastasis concomitant with SARS-CoV-2 infection. An asymptomatic flat “sun spot” on the left forearm was noted by the patient approximately 6 months before diagnosis. It developed into an elevated 3.5 cm x 2.5 cm reddish skin nodule in the two months following SARS-CoV-2 infection. The patient had positive SARS-CoV-2 virus nasopharyngeal swabs and antibodies, in addition to multiple comorbidities including chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, and atrial fibrillation. The patient delayed seeking care for the forearm tumor due to COVID-19, despite noticing the fast enlargement of the lesion into a large, bleeding nodule (Figure 1).