Malignant melanoma (MM) is a highly aggressive skin cancer with a pronounced potential for metastasis.¹ Despite representing only approximately 10% of all skin-related malignancies, melanoma accounts for roughly 80% of skin cancer-related mortality.² The global incidence of melanoma, particularly in Europe, has been rising sharply, although mortality rates have declined over the years. In 2020, global deaths attributable to cutaneous melanoma exceeded 55,000 annually, with Europe accounting for approximately 50% of these fatalities.^3,4,5 In 2022, a study by Arnold et al. projected that by 2040, the incidence of melanoma will increase by 50% to 510,000 new cases, resulting in an estimated 96,000 deaths.⁵ Given its substantial disease burden, melanoma prognosis varies markedly by stage at diagnosis. Early detection of the disease is critical, as melanoma confined to the skin is associated with a 5-year survival rate approaching 99%, whereas regional or distant metastatic involvement reduces survival to 75% and 35%, respectively. Thus, early-stage detection is essential to prevent a poorer prognosis.⁶

Nodular malignant melanoma (NMM) is a rare subtype that makes up about 14% of all melanoma cases, characterized by rapid tumour growth.^7,8 Diagnosing is challenging, frequently resulting in presentations at advanced stages of the disease, where management is largely palliative-driven due to delayed detection.

Here, we report the case of a 61-year-old British male who presented with a giant nodular metastatic malignant melanoma manifesting as a large fungating lesion exceeding 10 cm in diameter on the upper posterior thoracic region. As a result of delayed presentation, the patient was diagnosed with stage IV NMM, necessitating a palliative approach to the surgical management and treatment plan. This case report is reported in line with the SCARE checklist.⁹

A 61-year-old man with a past medical history of Type 2 diabetes mellitus (T2DM) on insulin, hypertension (HTN), stroke, decompensated heart failure with severe systolic impairment (Ejection Fraction of 25%–30%), anxiety, and depression presented to the Accident & Emergency Unit (A&E) of the Northumbria Specialist Emergency Care Hospital in Cramlington, Northumberland, United Kingdom. The patient was complaining of a painless lump on the back, first noticed 6 weeks prior to presentation, which had since become bloody, itchy, and malodorous. The odour and the extent of blood loss prompted the patient to seek medical attention. The patient did not complain of any notable constitutional symptoms. There was no significant family or personal history of skin-related malignancies. There was no history of allergies. The patient previously worked as a building worker and was an ex-smoker who stopped a few weeks prior to attending A&E. Occupational exposure to UV radiation and environmental carcinogens has been reported as contributing factors in melanoma development; however, a direct causal relationship cannot be established in this case. He had no history of alcohol intake and lived alone in sheltered accommodation. Clinical examination showed a foul-smelling 10 cm circular pedunculated granulomatous skin lesion on the upper posterior mid-thoracic region, with oozing fresh red blood, necrotic tissue, ulceration, and erythematous outer margins with suspected cellulitis. Despite the size of the lesion, the mobility of the upper limbs, shoulders, and neck was not compromised. Further examination revealed a hard, firm right axillary lymph node measuring approximately 2 × 2 cm, with no enlargement of cervical nodes. At the time, there was no notable neurovascular dysfunction. Full blood count (FBC) showed mild anemia, a hemoglobin (HB) of 118 g/L, a raised C-reactive protein (CRP) of 74 mg/L, and a lactate of 1.1 mmol/L. He was urgently referred under the 2-Week Wait (2WW) pathway to Newcastle Plastic Surgery, followed by the Northumbria NHS Trust Plastics and Safeguarding Team. During this time, the patient was sent home on a one-week course of oral co-amoxiclav.

Throughout clinical follow-ups, the lesion demonstrated rapid growth, predominantly in thickness, and the patient developed a 3 × 3 cm enlarged right axillary lymph node, confirmed by CT. Notably, the patient was severely depressed, a factor that likely contributed to the delayed presentation for medical evaluation.

At initial assessment, the lesion was considered most likely to represent either a fungating squamous cell carcinoma of the upper mid-back or malignant melanoma. However, the lesion morphology and rapid progression increased clinical suspicion for malignant melanoma.

A 4 mm punch biopsy of the 10 × 10 cm exophytic fungating growth, 7 mm thick, was performed and sent for analysis. Immunohistochemistry (IHC) was positive for Melan-A (MC4). Histopathology confirmed NMM of the upper posterior thoracic region. A staging computed tomography (CT) scan showed suspicious lesions in the right axillary lymph node, along with suspected bilateral adrenal and left lung lesions. Biopsy and imaging confirmed metastatic melanoma. Within just over one month of the initial presentation, the lesion exhibited rapid growth, doubling in thickness and measuring 10 × 12 cm in diameter (Figure 1). Excoriations were noted along the right axilla, while the right axillary lymph node had enlarged to 3 × 3 cm from approximately 2 × 2 cm. At this point, the decision to perform a palliative resection of the large mass prior to performing the Fine Needle Aspiration Cytology (FNAC) and Positron Emission Tomography (PET) scan was reached by the MDT. The procedure was planned after careful perioperative optimization. The timeline of key clinical events is summarised in Table 1.

During the perioperative planning, the patient was shown to have poor medication adherence along with several systemic co-morbidities, classifying him as ASA 3 on the American Society of Anesthesiologists (ASA) Physical Status Classification System. This increased his risk during anesthesia and the post-operative (post-op) period.¹⁰ On initial review by the diabetic team, glycated hemoglobin (HbA1c) was 91 mmol/L while the estimated glomerular filtration rate (eGFR) was >90 mL/min/1.73 m². The patient was restarted on Metformin 1 g twice daily along with Lantus 8 units once daily (OD) in the morning. Echocardiography results showed “normal left ventricle size with severe systolic impairment, visual EF 25%–30%. Normal right ventricle size and function. Dilated atria. Trace Mitral Regurgitation and Tricuspid Regurgitation.” The cardiologist had recommended the patient be started on bisoprolol 2.5 mg OD, clopidogrel 75 mg OD, and lisinopril 5 mg OD. He was further transfused with one unit of packed red blood cells (PRBC) in addition to 40–80 mg of furosemide to treat the microcytic anemia (HB 103 g/L). Additionally, the patient received an iron infusion. Once appropriate service referrals to the diabetic, tissue viability, cardiology, and the palliative care team were performed, within two months from the first clinical visit, the patient was perioperatively optimized. In the period leading up to surgery, the wound was cleansed, gently irrigated with sterile saline, and redressed using non-adherent primary dressings according to the recommendations from the tissue viability team. Magnetic Resonance Imaging (MRI) was scheduled to assess the lesion and underlying structure prior to surgery. A large predominantly exophytic mass along the back measuring 10.2 × 10 cm in the coronal plane and up to 4.5 cm in depth was reported. It was confined to the subcutaneous fat and laid within 5 mm of the deep fascia with no evidence of breaching through it. The underlying vertebrae showed normal spinous processes and cord signal. Figure 2 showcases a sagittal T1 MRI image of the 10.2 × 10 cm NMM.

Palliative surgery was scheduled for symptomatic control, including odour, pain, and comfort. Prior to the surgery, clopidogrel was stopped, and the patient was transfused with another unit of PRBC. He was admitted for the surgical excision of the skin lesion and immediate reconstruction with two propeller-plus flaps from the lateral upper back based on the posterior intercostal perforators.¹¹ BRAF proto-oncogene (BRAF) was requested and returned as mutant-positive. The prognosis was deemed to be less than 3 months.

Following the surgical excision of the lesion, on post-operative day 23, PET scan results revealed highly metabolically active (FDG-avid) metastases in bilateral axillary lymph nodes, the left upper abdomen, and both lungs. Low-grade uptake was seen in the left adrenal gland, which was indeterminate but suspicious for malignancy. Uptake was further observed on the left side of the neck. Lymph node biopsy was further consistent with metastatic malignant melanoma. The patient was diagnosed with stage IV metastatic melanoma—T4b N3 M1c.

Throughout the case, the challenges that were encountered included: complex co-morbidities, medication non-adherence, self-neglect, the patient's poor mental and emotional health, and most importantly, the patient's difficulty retaining information. Challenges were overcome through working with various specialties to optimize the patient for surgery, simplifying the medication regimen, engaging the patient's mother in the treatment plan, and further connecting with the patient often to avoid fallout. As the patient was a poor surgical candidate, reconstruction following tumour excision required careful consideration of operative time, anaesthetic tolerance, flap selection, flap viability following the closure of the large defect, and potential postoperative complications.

Surgery was performed under general anaesthesia with the patient in the prone position. Preoperative markings were made, and perforators were identified using a hand-doppler (Figure 3). At induction, the patient received a single prophylactic dose of co-amoxiclav. The patient underwent palliative excision of a large (>10 cm) fungating melanoma of the upper back with immediate reconstruction using two perforator-plus propeller fasciocutaneous flaps harvested from the lateral chest based on two posterior intercostal perforators (Figure 4A). Two drains were inserted. Topical tranexamic acid (2 g) was administered intraoperatively. The lesion was excised with a 15 mm deep margin and lateral margins >3 cm to achieve local tumour clearance. In the context of Stage IV disease, the primary surgical goal was symptomatic palliation rather than oncological cure. Margin selection was guided by the aim of achieving macroscopic clearance for symptom control, in accordance with current melanoma guidelines.^12,13 A topical negative-pressure (TNP) dressing (VAC therapy) was applied at low pressure (50 mmHg) to support wound healing and reduce wound contamination (Figure 4B). Intraoperative perfusion of the perforator-plus flaps was assessed visually and by clinical assessment of capillary refill prior to final inset. Low-pressure TNP at 50 mmHg was selected over the flaps to minimise the risk of adverse pressure effects on the perforator-plus flap perfusion, consistent with the established practice for this flap design.

Postoperative management included hemoglobin monitoring, tinzaparin 3500 IU, and 48 h of intravenous antibiotics followed by 5 days of oral step-down therapy. Initial plans were to remove drains after 48 h if output was <40 mL/24 h. The patient was nursed in the lateral or prone position to avoid pressure on the flaps. Intravenous flucloxacillin was given for 48 h and then stepped down to oral co-amoxiclav for 5 days. Because the drain output remained

>40 mL/24 h, one drain was kept for an additional 24 h.

On postoperative day 2, the patient tolerated oral intake and reported a pain score of 0. The VAC drain contained 80 mL of serosanguineous fluid. On postoperative day 3, the spinal VAC drain was removed. Clopidogrel was restarted on postoperative day 6. No acute postoperative complications occurred. The wound continued to heal with minor tissue sloughing, but there was no erythema or evidence of surgical-site infection.

A referral was subsequently made to the Plastic Surgery team at the Royal Victoria Infirmary (RVI) for right axillary FNA, PET imaging, and consideration of axillary clearance.

Following surgery, systemic therapy was considered, given the tumour was BRAF mutation positive. BRAF/MEK targeted therapy was discussed at the MDT; however, it was not initiated due to the patient's severely impaired cardiac function (EF 25%–30%) and poor performance status. Similarly, immunotherapy was contraindicated given the risk of immune-mediated cardiac toxicity in the context of pre-existing severe systolic impairment. The decision to pursue palliative supportive care alone was reached following MDT consensus, reflecting the patient's overall clinical frailty and limited physiological reserve.¹³ Axillary dissection was discussed as a high-risk procedure with a risk of perioperative death; however, the patient wished to proceed. Four months after excision of the primary melanoma, he underwent right axillary dissection in Newcastle for widespread metastatic disease within the axillary lymph nodes.

The patient was discharged with a TNP dressing in place, and he attended twice-weekly follow-ups at the dressing clinic. Over the subsequent months, the majority of the flaps healed well, with minimal areas of sloughing, which were debrided, cleaned, and sutured using aseptic technique in the clinic. The remainder of the flap continued to heal uneventfully (Figure 5). No signs of infection were observed. Wound care included: cleaning with Prontosan, three layers of Inadine as primary dressings, and Opsite as a secondary dressing.

Following palliative debulking, the patient reported significant symptomatic improvement, with resolution of malodour, cessation of active bleeding, reduction in pain, and substantially reduced dressing burden. These improvements contributed meaningfully to the patient's quality of life and comfort in the remaining months. The patient had continued care under the palliative care team, while wound management continued under the care of the plastics wound clinic for 4 months. Despite these gains, the patient's general condition gradually deteriorated—in keeping with the advanced stage of his disease—and he unfortunately died at home 8 months after the primary surgical procedure.

Malignant melanoma is a subtype of cutaneous skin cancer that is derived from pigment-producing melanocytes that have undergone oncogenic transformation.^1,14 They are characterized by rapid proliferation and high rates of early metastases. NMM can be described as an aggressive skin cancer, which histologically shows vertically proliferating melanocytes involving or sparing the epidermis. Characteristically, lesions tend to present as pedunculated or as a polypoid nodule, while being grey, brown, or black in color.¹⁵ Factors that primarily contribute to this transformation include: excessive exposure to ultraviolet (UV) radiation; aging, geographical location of habitation such as Australia, New Zealand, Europe, etc; genetic vulnerability (personal or family history); occupational exposures to various chemicals and radiation; and phototypes I–III.^{3,5,14,15,16,17} Though prevalent among individuals of lighter skin tones, incidence is markedly lower in the darker-skinned population. However, the disease can still occur.¹⁶ A 2022 study by Olsen et al. revealed the incidence of melanoma in women to be higher than in males up to the age of 50, with the majority of cases anatomically involving the lower extremities.

Whereas men are at a higher risk after the age of 50 and tend to present often with MM involving the trunk.¹⁶ Our reported patient falls into this statistic.

Diagnosis involves visual examination with a dermatoscope, excision biopsy (gold standard), and histopathological analysis.^15,18,19 Adjunctive testing, including IHC and genetic screening (Neurofibromin-1, KIT, NRAS, BRAF), can be performed to accurately diagnose.^15,19 Staging is critical and can predict the prognosis for the patient. As witnessed with our patient, a staging CT and PET scan were performed to understand the extent of disease to tactfully create a treatment plan.^19,20,21 Our reported patient had stage IV (T4b N3 M1c) NMM with distant metastasis to the axilla bilaterally, upper abdomen, and lungs. The disease was quite advanced, and in this case, prognostic factors, including Breslow's thickness, Clark level, Mitotic Rate, and widespread metastases, led to palliative debulking.^19,22 This was chosen as the intervention to relieve the patient of ongoing symptoms related to discomfort and bleeding, while focusing on improving the remaining quality of life.

Treatment is dependent on the stage of the disease. This can include surgical resection, Mohs micrographic surgery in minimally invasive lesions, neoadjuvant therapies such as chemotherapy, hormone therapy, radiation therapy, or a combination of these treatments, with post-operative adjuvant immunotherapy performed to prevent recurrence.^15,19,23

While awareness of the condition, along with improved surveillance programs worldwide, has increased over the years, the diverse combination of variables that play a role in the development of MM is quite challenging to narrow down, as each patient's lifestyle, genetics, and environment they live in contribute to the risk of acquiring the disease. Although systematic discrepancies exist between the incidence between males and females, some studies show promising steps toward finding common variables and risk factors, such as anatomical site of the presenting lesion within males and females, phototypes, geography, sex, or age that help in screening patients.^{2,3,5,15,16,17,24}

Giant MMs are rare in clinical presentation and are scarcely reported in the literature. While reports of giant MMs involving patients presenting with lesions are often found on the trunk followed by the lower extremities, globally reported cases also include: the face (forehead), feet, anterior chest wall, upper limb, hands, breast, shoulder, back, and anorectal presentations.^{25,26,27,28,29,30,31,32,33,34,35,36,37,38} Here, we discuss a giant cutaneous MM that measured above the average size at 10 × 12 cm with a thickness of 61 mm, complicated with widespread metastasis to the axillary lymph nodes, abdomen, and lungs. Many challenging factors played a role in providing suitable management. The delayed presentation with advanced disease resulted in a poor prognosis. The patient had several co-morbidities that were not optimized or treated prior to surgery. Thus, he was deemed a poor surgical candidate at the time, resulting in the postponement of the procedure and further limiting reconstructive options to those compatible with the patient's reduced physiological reserve. Poor medication adherence and alleged misinformation in medication management further complicated optimizing the patient perioperatively. Mental health challenges resulting in self-neglect delayed seeking medical attention. His difficulty in retaining information that was complex required a family member to accompany his visits at a suitable time. Lastly, his lack of knowledge of MM did not allow him to screen prophylactically with a primary care physician. Unfortunately, the patient did not seek medical attention until the profuse hemorrhaging had become severe, and the consequent delay in treatment significantly diminished his prognosis.

Surgical removal and flap reconstruction were performed once effectively optimized by numerous sub-specialties. Immediate reconstruction with two posterior intercostal perforator-plus propeller flaps from the lateral upper back was performed. A major surgical challenge was determining how to achieve a primary closure for the large posterior trunk defect while avoiding the use of alternative devices, such as tissue expanders or microsurgical free tissue transfer, in the context of time sensitivity. The primary objective was to perform the simplest, safest, and most expedient procedure that would promote rapid wound healing, given the patient's deteriorating clinical condition and limited tolerance for a prolonged, complex surgery. The use of a tissue expander was considered unsuitable because of the delay required for staged skin expansion.³⁹

Microsurgical free tissue transfer was deemed inappropriate due to the patient's inability to tolerate prolonged anaesthesia.⁴⁰ Similarly, regional flap reconstruction was considered relatively lengthy with the risk of skin necrosis and technically complex for this medically fragile patient. Skin grafting was not feasible because of the exposed spinal bone and insufficient durability.⁴¹ Prioritizing the minimization of operative time and surgical stress, a local perforator plus flap-based approach was selected.^42,43,44,45 The posterior intercostal perforator plus-based flaps provided rapid, reliable, single-stage reconstruction with well-vascularized tissue, while avoiding increased morbidity and significant operative time associated with microsurgical or staged alternatives in this medically compromised patient.^{11,40,42,43,44,45} This prevented venous congestion of the flaps post-operatively and preserved the viability of the tissue used in repairing a large defect. While limitations such as limited rotation in perforator plus flaps exist, compared to perforator flaps, perforator plus flaps include more than one blood supply from a retained base, securing the future viability of the tissue when repairing large defects.^{42,43,44,45,46,47}

PET scanning was further performed to be meticulous and advise further management. Adjuvant immunotherapy and neoadjuvant therapies were considered however, but dismissed as a result of poor cardiac function after weighing the risks and benefits. Lastly, the patient had a dissection of the axilla to provide comfort in removing obstructing lymph nodes. The patient had no acute complications and received continued care under the wound clinic, safeguarding, and palliative care teams.¹²

In our case, disease management was affected by several factors and challenges; overall, the patient had a timely biopsy with histology confirming NMM. Avid referrals to plastics, CT imaging confirming the stage of the cancer, MDT discussions, which helped speed the communication of the diagnosis to the patient effectively, while finding a suitable surgical palliative treatment at stage IV with advanced metastasis. In a study by Davies et al.⁴⁸ from the Royal Victoria Infirmary, an analysis highlighting the delay in the pathway from MM biopsy to wide local excision was studied, for which the trust standard was a 31-day clock. However, our case was unique as a result of the patient having untreated multiple co-morbidities. This emphasizes the importance of accommodating such patients when establishing trust pathways.

Although screening measures continue to improve, very rarely do patients presenting with lesions of this size seek early medical attention. Patients with similar presentations have common behaviors, such as self-neglect, delaying medical attention, lack of knowledge of the disease, and/or poor mental health, which then result in a poor prognosis. In 2021, Myers & Hyde reported a case of a giant posterior left scapular (17.0 × 17.0 × 6.0 cm) MM with delayed presentation secondary to self-neglect.⁴⁹ Like our case, the patient presented after following ongoing bleeding, but differed in the presentation of additional constitutional symptoms. Early screening and regular yearly whole-body exams for people who are at higher risk may help avoid late-stage cancer and thereby imminent death.

Malignant melanoma is an aggressive skin cancer with a poor prognosis when diagnosed at a late stage. This case highlights the urgent need for therapeutic and surgical strategies targeting stage IV metastatic melanoma in patients with complex comorbidities and metastatic complications. The advocacy of screening programs, self-screening awareness, and knowledge of the condition must be addressed appropriately by healthcare professionals, as melanoma remains the fifth most common cancer on the rise in the UK.⁴⁹ Enhanced screening initiatives targeting high-risk individuals may contribute to earlier detection and improved outcomes. Furthermore, the public must be informed about the potentially fatal consequences of delaying medical attention when cancer is suspected.