Short synacthen tests (SST) are frequently used for assessing adrenocorticotropin hormone (ACTH) deficiency. We present the case of a 53-year-old man receiving immunotherapy for metastatic melanoma, who subsequently developed immune checkpoint inhibitor (ICI) induced hypothyroidism and was investigated for the presence of ICI-induced hypocortisolaemia on different occasions. Despite two reassuring SSTs, he subsequently developed clinical and biochemical evidence of ACTH deficiency. The ACTH on local measurement was not conclusively in keeping with ICI related ACTH deficiency but when repeated using an alternative assay, confirmed the diagnosis. The case illustrates the evolution of ACTH deficiency and exposes the potential pitfalls of screening strategies. Two important lessons may be gleaned from this case: i) SSTs can be normal in early cases of secondary adrenal insufficiency e.g. hypophysitis due to adrenal reserve. ii) When there is mismatch between the clinical and biochemical presentation, the ACTH should be repeated using a different assay.

Background: Patients with melanoma have been found to be at greater risk of adverse outcomes including mortality after contacting COVID-19. Management of postsurgical complications presented additional challenges by potentially increasing exposure to COVID-19 through repeated inpatient admissions to hospital during the pandemic. We report four cases for which skin flaps, lymph ligation and split-thickness skin graft (STSG) were successfully used in the treatment of complications in the trunk and extremities after wide local excision (WLE). This study details the operative experience in management of postsurgical complications for melanoma in the trunk and extremities during a 6-month period at the height of the COVID-19 pandemic Case presentation: We present 4 cases detailing management of complications that occurred after wide local excisions performed for melanoma during Feb. to Oct.-2020. Case 1: a 90-year-old man who experienced wound dehiscence and necrosis on the shoulder after non- radical excision for an aggressive melanoma, underwent the side-to-side closure after ellipse formed WLE with modified tangent-to-circle method. Case 2: an 80-year-old man who had undergone excision for melanoma in his left upper arm, histopathology did not show radically. Two weeks after the excision, he underwent a WLE and direct reconstruction with double rotation skin flap. Case 3: a 55-year-old man that experienced a large wound dehiscence on his back due to WLE. He underwent an advanced double skin flap operation. Case 4: a 36-year-old woman who had a lymphorrhea and graft necrosis after WLE and STSG on the right lower leg. A combination of micro lymph ligation and re- STSG was performed. One month after the operation, all wounds had healed. There was no clinical evidence of tumor recurrence after eight months post procedure. Conclusions: Severe complications (e.g., large wound dehiscence, necrosis or lymphorrhea) following wide local excision of melanoma are infrequent but must be swiftly and appropriately managed, especially during the COVID-19 pandemic to decrease the likelihood of COVID-19 infection and impaired oncology outcomes from delaying systemic cancer therapy due to the complications in primary interventions.