An 80-year-old man presented with abdominal discomfort, constipation, malaise, loss of appetite and weight loss of 6 months duration. On local examination, there was a hyperpigmented lesion (17×13 mm) (figure 1) on the sole of the right heel which was asymmetrical, had irregular borders and colour variegation. It had central ulceration. Also, there were satellite lesions around it. On systemic examination, there was hepatomegaly. The striking finding was a bunch of matted lymph nodes in the right inguinal region (figure 2).
On digital rectal examination, there were impacted faecoliths. Abdominal ultrasonography revealed hepatomegaly with a small hypoechoic lesion (7×7 mm). There was a conglomerate lymph node mass (85×48 mm) along right ilial vessels causing elevation of iliac vessels anterolaterally and compression of the large bowel (figure 3).
On fine needle aspiration cytology of inguinal mass, black watery material was aspirated. Cytology showed dispersed malignant cells with marked nuclear pleomorphism and prominent nucleoli with abundant cytoplasm-containing pigment, confirming the diagnosis of metastatic deposits of melanoma (figure 4). There was no evidence of metastasis in the lungs or bones.
The case illustrates acral lentiginous malignant melanoma in the right sole with lymphatic metastasis in the right inguinal and pelvic lymph nodes associated with haematogenous spread in the liver (AJCC stage 4). Unfortunately, the patient came for the first time to the hospital with metastasis.