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Hidden in plain sight: umbilical melanoma

Tom Kovitwanichkanont, Shoba Joseph and Leona Yip
Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50490
Published online: 2 March 2020

A 74‐year‐old Caucasian woman was referred for hirsutism over the abdomen and was incidentally found to have a 21 × 25 mm ulcerated nodule over the umbilicus (Box 1). This occurred on the background of a longstanding lesion. Over the previous 6 months, the nodule had become ulcerated and occasionally bled. The remainder of the full skin examination was unremarkable, with no concerning lesions or palpable regional lymphadenopathy. She had no previous malignancy but had a strong family history of colorectal, breast, lung and pharyngeal cancer. Results of investigations to exclude internal malignancies were normal. Following an initial incisional biopsy demonstrating malignant amelanotic melanoma, a subsequent wide local excision confirmed this to be a stage IIIC, extensively ulcerated invasive nodular melanoma of 21 mm thickness and Clark level IV, with a mitotic rate of up to 15/mm2. There was no lymphovascular or perineural invasion. Microsatellites, desmoplasia and regression were not identified. The melanoma was BRAF negative on both immunohistochemical and molecular testing. Sentinel lymph node biopsy showed two metastatic melanoma deposits in the left inguinal sentinel node. Initial staging evaluations showed no evidence of nodal or distant metastases on whole body positron emission tomography–computed tomography (PET–CT) and brain magnetic resonance imaging (MRI). The patient was commenced on adjuvant nivolumab immunotherapy, but 4 months into treatment was confirmed by biopsy to have recurrent left inguinal nodal metastatic disease, and a repeat PET–CT scan showed possible in‐transit metastasis in the abdominal wall. Dissection of the involved ilioinguinal lymph node and ultrasound‐guided removal of the abdominal metastatic deposit were being planned at the time of writing.

  • Tom Kovitwanichkanont1
  • Shoba Joseph1,2
  • Leona Yip3

  • 1 Skin Health Institute, Melbourne, VIC
  • 2 Sinclair Dermatology, Melbourne, VIC
  • 3 Barton Specialist Centre, Canberra, ACT


Acknowledgements: 

We thank Miklos Pohl OAM and Dr Genevieve Bennett for their contributions to patient care.

Competing interests:

No relevant disclosures.

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