Mapping the Journey of Melanoma in Limbs: A Case of Delayed Management in Acral Malignant Melanoma - Missed Opportunities in Early Detection, Lymphatic Surveillance, and Surgical Reconstruction

BACKGROUND: Acral malignant melanoma is an aggressive melanoma subtype frequently seen in darker-skinned populations and typically involves the extremities. Early detection and lymphatic staging, including sentinel lymph node biopsy (SLNB), are vital for determining prognosis and guiding treatment. In resource-limited settings, delayed diagnosis and inadequate management remain significant challenges. This case highlights the devastating consequences of missed opportunities for early intervention in acral melanoma and the reconstructive strategies employed in her management. METHODS: We report the case of a 60-year-old female initially treated with a primary big toe amputation for acral malignant melanoma without SLNB or inguinal lymph node dissection (ILND). Over seven years, she developed a fungating mass encasing the femoral neurovascular bundle. Diagnostic evaluation included MRI for tumor assessment, while optimization involved transfusions and nutritional support. Surgical management entailed a modified radical excision with defect reconstruction using a tensor fascia lata (TFL) cutaneous flap. RESULTS: The patient underwent successful tumor resection and limb reconstruction. However, the delay in lymphatic staging and management resulted in advanced disease with significant morbidity. The case underscores the critical role of SLNB, timely ILND, and lymphatic surveillance in reducing metastatic progression. CONCLUSION: This case emphasizes the necessity of early melanoma detection and comprehensive lymphatic surveillance, especially in resource-limited settings. Multidisciplinary management, including surgical and reconstructive strategies, is essential for improving outcomes. Addressing systemic barriers to diagnostic and treatment services can mitigate the impact of advanced melanoma and improve survival rates.