On examination, she had an ulcer on the plantar aspect of the lef

On examination, she had an ulcer on the plantar aspect of the left foot over the first and second metatarsal heads. The spherical, nodular ulcer was approximately 2–3cm in size. It appeared superficial with rolled edges and an unhealthy grey hue to the MK-2206 mouse wound

bed. There was no pain evident. (Figure 1.) The unusual appearance of the wound bed, nodular and patchy with a varying depth of pigment radiating peripherally to the centre of the lesion, should have raised a suspicion that the wound may have been sinister in nature. It should be noted that sun exposure is not always a factor in the development of this type of tumour. Initially, this ulceration had been treated as a neuropathic lesion, because the patient did have sensory neuropathy. This had been confirmed by using a 128Hz tuning fork and a 10g weighted monofilament. The lesion had been present DZNeP mouse since mid-December 2008. It had started as an area of

callous which had been pulled off by the patient, leaving an abrasion. The patient’s local surgery had been treating the lesion, which failed to resolve. Eventually, the referral was made to the multidisciplinary diabetes foot clinic. The consultant in charge of the clinic was suspicious when he saw the lesion, and accordingly a biopsy was taken by the podiatrist. The result of the biopsy was a thick acral melanoma. The likelihood of a five-year survival from an acral melanoma

is dependent on ‘Breslow’s thickness’. This recognised histological technique involves taking a wedge or punch biopsy of the suspected area and determining the thickness of the lesion. Less than 1mm thickness will relate to a second 95–100% survival rate. A 1–2mm thickness gives an 80–96% survival rate. A 2.1–4mm thickness will give a 60–75% survival rate. Finally, a thickness of over 4mm will relate to a 50% survival rate. A further histological technique is ‘Clarke’s level’1 which is a staging system of the lesion using five distinct levels. It can be used in conjunction with Breslow’s thickness. However, it does have a lower predictive value and is less reproducible. This technique determines the depth of invasion by the tumour into the tissues. The patient was immediately seen by the consultant dermatologist. He clinically confirmed the diagnosis and referred her to a consultant plastic and hand surgeon. The patient has since had a wide excision of the lesion and has had a split skin graft which has now healed (Figure 2). Currently, the patient is well, since having the surgery, which was carried out in October 2009.

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