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Cutaneous recurrence in melanoma: A case series of 19 patients
P6065
P6623
Completely regressed primary cutaneous melanoma presenting with nodal metastasis: A case with sequential photographic evidence Alok Mishra, Northampton General Hospital, Northampton, United Kingdom; Antonia Barbieri, Northampton General Hospital, Northampton, United Kingdom; John F. Nottingham, Northampton General Hospital, Northampton, United Kingdom; Paola De Mozzi, University Hospitals of Leicester, Leicester, United Kingdom; Pick N. Woo, Northampton General Hospital, Northampton, United Kingdom We report a case of complete melanoma regression with clinical, pathologic, and sequential photographic evidence. A 51-year old white man presented with a large painless right sided axillary mass which histologically proved to be metastatic malignant melanoma from an unknown primary site. A subsequent thorough skin examination did not show any suspicious lesions, apart from a shallow pale pink scar on the right upper back which lead to a suspicion of regressed melanoma clinically. An excisional biopsy showed features suggestive of a regressed cutaneous melanoma. At this point, upon detailed questioning, the patient vaguely recalled having had a dark mole on that site several years previously. This was confirmed by an old photograph of his back. A definitive diagnosis of metatastatic melanoma secondary to a completely regressed cutaneous melanoma was made. Although partial regression of cutaneous melanoma is relatively common, complete spontaneous regression is rare and its mechanism not fully understood, although immunologic factors seem to play an important role with recognition of melanoma cells and release of inflammatory factors leading to tumor elimination. Regression is only one of the postulated mechanisms of the occurrence of melanoma of unknown primary and its prognostic role remains an area of controversy. We remind physicians of complete spontaneous regression of primary cutaneous melanoma, as a phenomenon that is easily overlooked and often difficult to demonstrate. Patients with metastatic melanoma with unknown primary require a thorough skin, mucosal and eye examination. In metastatic nodal presentation it is important to focus on cutaneous examination, especially around the area drained by the metastatic node(s), and have a high index of suspicion for scarred, depigmented or halo nevuselike lesions.
Dermatoscopy of a second primary melanoma of the vulva Kristian Eichelmann, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Farah Sevilla, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Jorge Ocampo, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Julio Salas, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Osvaldo Vazquez, MD, PhD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Roger Gonzalez, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico Background: Pigmented lesions of the vulva are a great challenge in the everyday practice. Nowadays more dermatologists are confronted with pigmented lesions of the vulva. Dermatoscopy of pigmented vulvar lesions is a new territory where patterns and structures are still being defined. Multiple pigmented lesions of the vulva can mimic melanomas making it of upmost importance to understand the diverse dermatoscopic features related to melanoma.
Commercial support: None identified.
Case report: A 59-year-old Hispanic woman with a history of cervical carcinoma in 1999 with complete clearance after surgery and follow-up by the oncology department presented to our clinic. In 2005 she developed a pigmented lesion that compromised the right mayor labia of her vulva. An ulcerated melanoma with a 0.66-mm Breslow score was diagnosed and treated with a hemivulvectomy plus complete removal of the inguinal lymphatic chain. Six years later during her annual follow-up visit to the oncologist, another pigmented lesion was spotted, this time on the left mayor labium of the vulva. She was referred to our dermatology department where a pigmented lesion meeting dermatoscopic criteria for malignancy was observed. Two punch biopsies were performed where a multicomponent pattern was seen; characterized by atypical parallel network, structureless areas, globular lesions, ring-like structures and milky-red areas. The histopathology revealed an in situ melanoma. The patient underwent a left hemivulvectomy where a superficial spreading melanoma with a 0.44-mm Breslow score was diagnosed. Her follow-up was done by the oncology department. Discussion: Melanoma is the second leading skin cancer affecting the vulva, only after squamous cell carcinoma. The most frequent subtypes of vulvar melanomas are the nodular and amelanotic types. There are only a few vulvar superficial spreading melanomas reported in the literature. This may be so because of the age of presentation and the infrequent visits to the OBGYN. In this case a metastatic melanoma was ruled out based on the clinical and histopathological findings. Also, a synchronic melanoma was unlikely because of the 6-year period free of disease between both lesions. The best likely diagnosis is a second primary melanoma of the vulva. Unfortunately the patient became unreachable and we could not investigate more on the subject. A multicomponent pattern in a pigmented vulvar lesion in dermatoscopy should always alert the clinician. Commercial support: None identified.
P6289
P6819 Cutaneous recurrence in melanoma: A case series of 19 patients Virginia Alldredge, Tulane University School of Medicine, New Orleans, LA, United States; Frances Collichio, MD, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Nancy E. Thomas, MD, PhD, Nancy E. Thomas, Chapel Hill, NC, United States Background: Nearly half (44.8%) of patients with advanced melanoma will present with metastases to skin or subcutaneous tissue during the disease course. This subtype of recurrence signifies a more favorable prognosis with unique treatment options compared with metastases to other sites. Preclinical detection of early metastatic disease may significantly increase 10-year survival after recurrence in these patients. Various phenotypes of cutaneous recurrence in melanoma have been documented in case reports with identification of metastatic disease often following a period of misdiagnosis. Objective: To describe and photographically document cases of cutaneous metastasis in melanoma presenting to a single institution over 8 months. We also compared phenotype with clinical features and tumor mutation status. Methods: Patients with cutaneous metastasis were approached during clinic visit and consented to study. 19/19 approached patients agreed to participate. Active lesions were photographed and existing photographs were extracted from the medical record. Medical records were reviewed for clinical data. Results: We observed the following phenotypes: subcutaneous nodules, pigmented macules and papules, erythematous patches, and vesiculobullous lesions. Lesions occurred both singularly and clustered. Subcutaneous nodules, without pigment change or erythema were the most commonly observed phenotype, representing 53% of cases. Pigment was observed in a variety of lesions, and frequency of pigment change was similar in BRAF mutant versus wild-type participants. Two (10.5%) cases were best described as an inflammatory phenotype. The majority of cases were symptomatic (26% pruritic, 32% tender). Most were identifiable on PET scan as FDGavid lesions or skin thickening.
Diagnostic accuracy of smartphone application in evaluating pigmented skin lesions Joel Wolf, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Jacqueline Moreau, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Laura Ferris, MD, PhD, Univeristy of Pittsburgh, Department of Dermatology, Pittsburgh, PA, United States; Oleg Akilov, MD, University of Pittsburgh, Department of Dermatology, Pittsburgh, PA, United States Background: Several smartphone applications claim to aid patients in evaluating if a skin lesion is benign or malignant based on evaluation of a photograph. These applications are not subject to regulatory oversight. However, there is a risk that the public may substitute the read out of such an application for the advice of a physician. Objective: To determine the sensitivity and specificity of 4 smartphone applications for classifying melanoma as a concerning lesion on a set of photographs of previously biopsied pigmented skin lesions for which the histologic diagnosis is known. Methods: We evaluated 4 smartphone applications on a set of existing images of previously biopsied pigmented skin lesions from our medical records (18 in situ melanomas, 45 invasive melanomas, and 171 benign lesions). A result of atypical, melanoma, high risk, or problematic was considered to be positive and all other readings were considered negative. Images were cropped to remove any identifiable features or names. Lesions of questionable malignant potential such as high grade dysplastic nevi, spitz nevi, and atypical melanocytic proliferations were excluded. Applications 1, 2, and 3 use automated analysis algorithms and return results in real time, and application 4 sends the image to a board-certified dermatologist who renders an evaluation within 24 hours. Results: The 4 applications we tested accepted between 84.6% and 98.4% of the images presented as evaluable. Application 1 had a sensitivity of 6.8% and a specificity of 93.7%, application 2 had a sensitivity of 69.0% and a specificity of 37.0%. Application 3 had a sensitivity of 70.0% and a specificity of 39.3%. The sensitivity and specificity of application 4 were 98.1% and 30.5%, respectively.
Discussion: Our findings suggest that melanoma metastasized to the skin and subcutaneous tissue presents with varied phenotype and symptoms. Knowledge of such presentations allows for noninvasive diagnosis of recurrent or progressive melanoma. As treatment options for advanced melanoma become available, early diagnosis of metastatic disease is essential.
Conclusion: These findings show that applications available directly to patients to help them to determine if a skin lesion is malignant vary widely in their accuracy. The application which gave the assessment of a board-certified dermatologist had the highest sensitivity, missing only one out of 54 melanomas. Dermatologists should be aware that patients using these applications may be falsely reassured that a melanoma is benign. Although further studies are needed, for patients unable to receive in-person consultation from a dermatologist, applying the ease of smartphone use to store and forward teledermatology may provide a more accurate diagnosis for a single suspicious lesion than an automated application.
Commercial support: None identified.
Commercial support: None identified.
APRIL 2013
J AM ACAD DERMATOL
AB151
P6623
Completely regressed primary cutaneous melanoma presenting with nodal metastasis: A case with sequential photographic evidence Alok Mishra, Northampton General Hospital, Northampton, United Kingdom; Antonia Barbieri, Northampton General Hospital, Northampton, United Kingdom; John F. Nottingham, Northampton General Hospital, Northampton, United Kingdom; Paola De Mozzi, University Hospitals of Leicester, Leicester, United Kingdom; Pick N. Woo, Northampton General Hospital, Northampton, United Kingdom We report a case of complete melanoma regression with clinical, pathologic, and sequential photographic evidence. A 51-year old white man presented with a large painless right sided axillary mass which histologically proved to be metastatic malignant melanoma from an unknown primary site. A subsequent thorough skin examination did not show any suspicious lesions, apart from a shallow pale pink scar on the right upper back which lead to a suspicion of regressed melanoma clinically. An excisional biopsy showed features suggestive of a regressed cutaneous melanoma. At this point, upon detailed questioning, the patient vaguely recalled having had a dark mole on that site several years previously. This was confirmed by an old photograph of his back. A definitive diagnosis of metatastatic melanoma secondary to a completely regressed cutaneous melanoma was made. Although partial regression of cutaneous melanoma is relatively common, complete spontaneous regression is rare and its mechanism not fully understood, although immunologic factors seem to play an important role with recognition of melanoma cells and release of inflammatory factors leading to tumor elimination. Regression is only one of the postulated mechanisms of the occurrence of melanoma of unknown primary and its prognostic role remains an area of controversy. We remind physicians of complete spontaneous regression of primary cutaneous melanoma, as a phenomenon that is easily overlooked and often difficult to demonstrate. Patients with metastatic melanoma with unknown primary require a thorough skin, mucosal and eye examination. In metastatic nodal presentation it is important to focus on cutaneous examination, especially around the area drained by the metastatic node(s), and have a high index of suspicion for scarred, depigmented or halo nevuselike lesions.
Dermatoscopy of a second primary melanoma of the vulva Kristian Eichelmann, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Farah Sevilla, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Jorge Ocampo, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Julio Salas, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Osvaldo Vazquez, MD, PhD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico; Roger Gonzalez, MD, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Monterrey, Mexico Background: Pigmented lesions of the vulva are a great challenge in the everyday practice. Nowadays more dermatologists are confronted with pigmented lesions of the vulva. Dermatoscopy of pigmented vulvar lesions is a new territory where patterns and structures are still being defined. Multiple pigmented lesions of the vulva can mimic melanomas making it of upmost importance to understand the diverse dermatoscopic features related to melanoma.
Commercial support: None identified.
Case report: A 59-year-old Hispanic woman with a history of cervical carcinoma in 1999 with complete clearance after surgery and follow-up by the oncology department presented to our clinic. In 2005 she developed a pigmented lesion that compromised the right mayor labia of her vulva. An ulcerated melanoma with a 0.66-mm Breslow score was diagnosed and treated with a hemivulvectomy plus complete removal of the inguinal lymphatic chain. Six years later during her annual follow-up visit to the oncologist, another pigmented lesion was spotted, this time on the left mayor labium of the vulva. She was referred to our dermatology department where a pigmented lesion meeting dermatoscopic criteria for malignancy was observed. Two punch biopsies were performed where a multicomponent pattern was seen; characterized by atypical parallel network, structureless areas, globular lesions, ring-like structures and milky-red areas. The histopathology revealed an in situ melanoma. The patient underwent a left hemivulvectomy where a superficial spreading melanoma with a 0.44-mm Breslow score was diagnosed. Her follow-up was done by the oncology department. Discussion: Melanoma is the second leading skin cancer affecting the vulva, only after squamous cell carcinoma. The most frequent subtypes of vulvar melanomas are the nodular and amelanotic types. There are only a few vulvar superficial spreading melanomas reported in the literature. This may be so because of the age of presentation and the infrequent visits to the OBGYN. In this case a metastatic melanoma was ruled out based on the clinical and histopathological findings. Also, a synchronic melanoma was unlikely because of the 6-year period free of disease between both lesions. The best likely diagnosis is a second primary melanoma of the vulva. Unfortunately the patient became unreachable and we could not investigate more on the subject. A multicomponent pattern in a pigmented vulvar lesion in dermatoscopy should always alert the clinician. Commercial support: None identified.
P6289
P6819 Cutaneous recurrence in melanoma: A case series of 19 patients Virginia Alldredge, Tulane University School of Medicine, New Orleans, LA, United States; Frances Collichio, MD, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Nancy E. Thomas, MD, PhD, Nancy E. Thomas, Chapel Hill, NC, United States Background: Nearly half (44.8%) of patients with advanced melanoma will present with metastases to skin or subcutaneous tissue during the disease course. This subtype of recurrence signifies a more favorable prognosis with unique treatment options compared with metastases to other sites. Preclinical detection of early metastatic disease may significantly increase 10-year survival after recurrence in these patients. Various phenotypes of cutaneous recurrence in melanoma have been documented in case reports with identification of metastatic disease often following a period of misdiagnosis. Objective: To describe and photographically document cases of cutaneous metastasis in melanoma presenting to a single institution over 8 months. We also compared phenotype with clinical features and tumor mutation status. Methods: Patients with cutaneous metastasis were approached during clinic visit and consented to study. 19/19 approached patients agreed to participate. Active lesions were photographed and existing photographs were extracted from the medical record. Medical records were reviewed for clinical data. Results: We observed the following phenotypes: subcutaneous nodules, pigmented macules and papules, erythematous patches, and vesiculobullous lesions. Lesions occurred both singularly and clustered. Subcutaneous nodules, without pigment change or erythema were the most commonly observed phenotype, representing 53% of cases. Pigment was observed in a variety of lesions, and frequency of pigment change was similar in BRAF mutant versus wild-type participants. Two (10.5%) cases were best described as an inflammatory phenotype. The majority of cases were symptomatic (26% pruritic, 32% tender). Most were identifiable on PET scan as FDGavid lesions or skin thickening.
Diagnostic accuracy of smartphone application in evaluating pigmented skin lesions Joel Wolf, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Jacqueline Moreau, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Laura Ferris, MD, PhD, Univeristy of Pittsburgh, Department of Dermatology, Pittsburgh, PA, United States; Oleg Akilov, MD, University of Pittsburgh, Department of Dermatology, Pittsburgh, PA, United States Background: Several smartphone applications claim to aid patients in evaluating if a skin lesion is benign or malignant based on evaluation of a photograph. These applications are not subject to regulatory oversight. However, there is a risk that the public may substitute the read out of such an application for the advice of a physician. Objective: To determine the sensitivity and specificity of 4 smartphone applications for classifying melanoma as a concerning lesion on a set of photographs of previously biopsied pigmented skin lesions for which the histologic diagnosis is known. Methods: We evaluated 4 smartphone applications on a set of existing images of previously biopsied pigmented skin lesions from our medical records (18 in situ melanomas, 45 invasive melanomas, and 171 benign lesions). A result of atypical, melanoma, high risk, or problematic was considered to be positive and all other readings were considered negative. Images were cropped to remove any identifiable features or names. Lesions of questionable malignant potential such as high grade dysplastic nevi, spitz nevi, and atypical melanocytic proliferations were excluded. Applications 1, 2, and 3 use automated analysis algorithms and return results in real time, and application 4 sends the image to a board-certified dermatologist who renders an evaluation within 24 hours. Results: The 4 applications we tested accepted between 84.6% and 98.4% of the images presented as evaluable. Application 1 had a sensitivity of 6.8% and a specificity of 93.7%, application 2 had a sensitivity of 69.0% and a specificity of 37.0%. Application 3 had a sensitivity of 70.0% and a specificity of 39.3%. The sensitivity and specificity of application 4 were 98.1% and 30.5%, respectively.
Discussion: Our findings suggest that melanoma metastasized to the skin and subcutaneous tissue presents with varied phenotype and symptoms. Knowledge of such presentations allows for noninvasive diagnosis of recurrent or progressive melanoma. As treatment options for advanced melanoma become available, early diagnosis of metastatic disease is essential.
Conclusion: These findings show that applications available directly to patients to help them to determine if a skin lesion is malignant vary widely in their accuracy. The application which gave the assessment of a board-certified dermatologist had the highest sensitivity, missing only one out of 54 melanomas. Dermatologists should be aware that patients using these applications may be falsely reassured that a melanoma is benign. Although further studies are needed, for patients unable to receive in-person consultation from a dermatologist, applying the ease of smartphone use to store and forward teledermatology may provide a more accurate diagnosis for a single suspicious lesion than an automated application.
Commercial support: None identified.
Commercial support: None identified.
APRIL 2013
J AM ACAD DERMATOL
AB151