26 years old. Family history positive for diabetes and vascular disease. No history of cancer nor of melanoma in the family. White skin with clear phototype , rutilo (red hair, lentigo). Height 177 cm; weight 62 kg. , myopia (11 diopters). Silent medical history.
September 2004: removal of a small nevus on the right arm that she had constantly stroked. The pathology report reads: combined nevus (junctional Spitz) major axis of 0.7 cm with disease-free margins. Upon review on 02/2009 Dr reports: Melanoma with superficial diffusion, moderately pigmented, no ulceration, with epithelioid cells, level III , 0,92 mm thick, TIL present, mitosis 1-6 per mm², associated with combined melanic nevus, margins and apexes are disease free.
In December 2008, self-discovery of a lymph node at the right armpit, LDH 297 (v.n. 190-450) resected.
01/2009 : 7x4x3 cm with irregular surface. Massive metastatic melanoma spreading around the lymph node and with large necrotic areas. TIL absent. Furthermore, resection of skin nevus on the left knee: combined warty nevus with disease-free margins. CT scan of 01/2009 and of CT/PET of 01/2009 both revealed spleen involvement of 2.5cm, two subcutaneous lesions of 2cm, one on the left shoulder blade at the level of the infraspinatus muscle on the posterior axillary line, the other on the right shoulder blade at 4cm from the spine .This last one was PET negative.
On 022009 the patient underwent surgical treatment performed by Dr of Milan Cancer Institute (Istituto Nazionale dei Tumori di Milano) attempting to eradicate the disease: radical lymphoadenectomy of the right armpit, splenectomy, resection of both subcutaneous lesions. The pathology report was transmitted only orally so far: evidence of disease in all the areas investigated. Post-op complications included constipation and abdominal pain.
On 02/2009 CT of the abdomen was performed which proved negative for surgical complications or other lesions.
On 02/2009 evidence of a new subcutaneous node of 1.8 x 0.7 cm on the right arm in the anterocubital region. Restaging is scheduled in March; chemotherapy planned for 03/2009 with CVD regimen (Cisplatin 30 mg/mq gg 1-3, Vindesin 2,5 mg/mq g 1, Decarbazina 250 mg/mq gg 1-3) q 21 with re-evaluation after 4 cycles.