![]() For patients with a PS of <2 (ie, able to go about their normal daily activities but who tire on exertion), systemic palliative oncological treatment can be considered. In stage IV melanoma, a poor prognostic score is associated with poor performance status (PS) high lactate dehydrogenase (LDH) low albumin and involvement of multiple organs, such as brain and liver. The natural history of these lesions was that they spontaneously appeared as a bruise with a central subcutaneous nodule ( figure 1), and the bruise then regressed, leaving only a non-tender subcutaneous nodule which persisted ( figure 2). On examination, there were five lesions: one on the right shoulder one on the medial right clavicle and three on the abdomen. The only medication the patient used was paracetamol. The patient had attended all follow-up appointments, the most recent of which was 6 weeks prior to presentation. ![]() A sentinel lymph node biopsy was negative. There was probable perineural invasion and invasion into the reticular dermis (Clark level 4), but no lymphovascular or microsatellite metastases were identified, and the mitotic index was 5 per mm 2. This had presented on the superior helix of the left ear and had a Breslow thickness of 1.3 mm. His medical history was significant for stage Ib (T2a, N0, M0) cutaneous melanoma 30 months previously, which had been excised with clear margins. ![]() A 46-year-old Caucasian man presented with a 4-week history of bruising and subcutaneous nodules, 2 weeks of progressive back and bilateral hip pain, and one stone of weight loss over a period of 1 month. ![]()
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