- Email: [email protected]
Dermoscopic features of amelanotic melanoma
P2809
P2811
Multiple epidermotropic cutaneous melanoma metastases Marisol Contreras, Virgen de la Victoria University Hospital, Ma´laga, Spain; Alfred Kopf, MD, NYU Langone Medical Center, New York, NY, United States; David Cohen, MD, MPH, NYU Langone Medical Center, New York, NY, United States; David Polsky, MD, PhD, NYU Langone Medical Center, New York, NY, United States; Vitaly Terushkin, NYU Langone Medical Center, New York, NY, United States
Malignant melanoma arising as a Marjolin ulcer Mary Guo, MD, MSN, MS, Saint Louis University Hospital, Department of Dermatology, Saint Louis, MO, United States; Enrique Herrera, Virgen de la Victoria University Hospital, Ma´laga, Spain; Matilde Mendiola, Virgen de la Victoria University Hospital, Ma´laga, Spain; Norberto Lopez, Virgen de la Victoria University Hospital, Ma´laga, Spain; Rosa Castillo, Virgen de la Victoria University Hospital, Ma´laga, Spain
Introduction: Epidermotropic metastases of malignant melanoma are very rare and there are few published cases. The presence or absence of junctional activity has always been considered to be the histologic feature to distinguish primary and metastatic lesions, but in many cases there are overlapping features that make them difficult to differentiate. Therapeutic management will be different in the case of a primary malignant melanoma and a metastatic lesion of melanoma. Case report: A 41-year-old man consulted for a pigmented lesion of 2 years’ evolution and 3cm in size located on the left shoulder blade. The lesion has been growing slowly but in the last 3 months has presented with a sudden eruption of more than 300 pigmented lesions. Her sister was operated of a extension superficial melanoma 20 years ago and is currently free of disease. The extension study showed the presence of supraclavicular, mediastinic, and hiliar lymph nodes in the computerized tomography scan. Before referring the patient to the oncology service, we removed the primary lesion and multiple pigmented lesions also suggestive of melanomas. The histopathology study of the larger lesion shows an extension superficial melanoma, Clark level IV and Breslow index 2.5mm. The multiple lesions suggestive of melanomas showed thinning of the epidermis by aggregates of atypical melanocytes within the dermis and melanocytes sometimes in the vascular lumen in the upper part of the dermis. They were diagnosed as metastases of malignant melanoma.
A 61-year-old white woman with a history of diabetes, hypertension, and chronic venous stasis presented to her podiatrist with a nonhealing ulcer on the left medial ankle for 5 months. The ulcer base was biopsied and showed malignant melanoma, nodular type, Breslow depth 3.7mm, Clark level IV with ulceration. Patient was referred to our facility for treatment. On physical examiantion, she had a 1.0- 3 0.9cm crusted red papule on her left medial ankle and changes of lipodermatosclerosis. There was left inguinal lymphadenopathy. Further work-up revealed multiple nonhemorrhagic lesions on brain MRI. Full body PET/CT showed lymphadenopathy in the left lower extremity, abdomen, and pelvis consistent with metastatic melanoma. The patient’s disease progressed in spite of interleukin-2 immunotherapy. She passed away a few months after the diagnosis of melanoma. A Marjolin ulcer is a cutaneous malignancy occurring in the setting of chronic ulcers, sinuses, or longstanding scars of various etiologies. These malignancies include squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas arising as Marjolin ulcers pose diagnostic and treatment challenges. Review of the literature identified eight cases of malignant melanoma arising at sites of chronic ulceration. Seven of the eight cases involved ulcers of the foot and five patients had metastases at diagnosis. This highlights the aggressive nature of melanoma arising as a Marjolin ulcer. Delay of diagnosis often accounts for thicker Breslow depth and poor prognosis.
Discussion: The development of multiple primary cutaneous malignant melanomas in a single individual is an unusual but recognized phenomenon. It is only in the case of familial melanoma that the rate of multiple primary melanomas becomes disproportionately higher. There are a variety of criteria in the literature on how to distinguish multiple primary melanomas from cutaneous metastases of melanoma. It is important to learn components of the patient history that can aid in the correct diagnosis, to describe histologic characteristics of primary and metastatic malignant melanoma lesions, and to emphasize the need to distinguish between primary and malignant processes relative to therapy. To clarify this problem, Kornberg et al tried to further define the histologic differences between primary and epidermotropic malignant melanomas, even though there vas a significant overlapping of the histologic features.
Commercial support: None identified.
Commercial support: None identified.
P2810 Pigmented mammary Paget disease mimicking cutaneous melanoma Teresa Meyer, Virgen de la Victoria University Hospital, Ma´laga, Spain; Blanca Moyano, Virgen de la Victoria University Hospital, Ma´laga, Spain; Enrique Herrera, Virgen de la Victoria University Hospital, Ma´laga, Spain; Enrique Herrera-Acosta, Virgen de la Victoria Univeristy Hospital, Ma´laga, Spain; Maria Angustias Gallardo, Virgen de la Victoria University Hospital, Ma´laga, Spain Introduction: Paget disease of the breast nipple and areola complex represents a cutaneous manifestation of an underlying breast malignancy. The typical clinical presentation is that of an itching, excoriated nipple with associated erythema and nipple drainage. Pigmented mammary Paget disease is a rare clinicopathologic variant of mammary Paget disease that may clinically, dermoscopically, and histopathologically mimic malignant melanoma. Case report: We report a case of a 55-year-old Spanish woman who was referred to our department regarding a 3-year history of asymptomatic progressively enlarging pigmented lesion on her left mammary nipple and areola. Physical examination revealed a 4.5 3 3cm, dark brown, well defined plaque involving 80% of the areola; the nipple had disappeared. On dermoscopy, the lighter portion of the lesion corresponded to a whitish-pink area with irregular linear vessels resembling an area of regression, whereas the darker portion was characterized by dark brown diffuse pigmentation with irregular black dots and small grey-white structures. There was no palpable breast masses, and no supraclavicular or axillary lymphadenopathy. Suspecting a melanocytic lesion, we decided to take a punch biopsy specimen of the pigmented area. Histologic evaluation integrated with immunohistochemical staining showed pigmented mammary Paget disease, therapeutic excision was performed, showing an in situ ductal breast carcinoma. Discussion: Paget disease of the breast usually presents as an erythematous patch, typically eczematous in appearance. The pigmented variant is rare. Dermoscopic results that showed a nonspecific pattern with irregularly diffuse pigmentation and regression like structures suggesting a diagnosis of melanoma have been previously reported. This case shows that the diagnosis of pigmented mammary Paget disease cannot be determined by clinical examination and dermoscopy alone. Detailed pathologic evaluation, including immunohistochemical staining, is essential for making the correct diagnosis. Commercial support: None identified.
MARCH 2010
P2812 Dermoscopic features of amelanotic melanoma Luis Dehesa, MD, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Las Palmas, Spain; Joel Crockett, MD, Saint Louis University, School of Medicine, Saint Louis, MO, United States; Nicole Burkemper, MD, Saint Louis University, Dept of Dermatology, Saint Louis, MO, United States; Scott Fosko, MD, Saint Louis University, Dept of Dermatology, Saint Louis, MO, United States Dermoscopy is an in vivo technique that enables the clinician to visualize hundreds of different features in pigmented and nonpigmented skin lesions. It is useful to be able to recognize specific features that are indicative of early melanoma, but it can still be very difficult. That is the case of amelanotic melanoma. We present three cases of amelanotic melanoma in which the dermoscopy helped us strongly to suspect the diagnosis. In our opinion, it is very important to perform a thorough examination of the lesions in order to find the diagnostic clue. The presence of some globules grouped in the periphery of the amelanotic tumor was the clue in our three patients. Commercial support: None identified.
J AM ACAD DERMATOL
AB101
P2811
Multiple epidermotropic cutaneous melanoma metastases Marisol Contreras, Virgen de la Victoria University Hospital, Ma´laga, Spain; Alfred Kopf, MD, NYU Langone Medical Center, New York, NY, United States; David Cohen, MD, MPH, NYU Langone Medical Center, New York, NY, United States; David Polsky, MD, PhD, NYU Langone Medical Center, New York, NY, United States; Vitaly Terushkin, NYU Langone Medical Center, New York, NY, United States
Malignant melanoma arising as a Marjolin ulcer Mary Guo, MD, MSN, MS, Saint Louis University Hospital, Department of Dermatology, Saint Louis, MO, United States; Enrique Herrera, Virgen de la Victoria University Hospital, Ma´laga, Spain; Matilde Mendiola, Virgen de la Victoria University Hospital, Ma´laga, Spain; Norberto Lopez, Virgen de la Victoria University Hospital, Ma´laga, Spain; Rosa Castillo, Virgen de la Victoria University Hospital, Ma´laga, Spain
Introduction: Epidermotropic metastases of malignant melanoma are very rare and there are few published cases. The presence or absence of junctional activity has always been considered to be the histologic feature to distinguish primary and metastatic lesions, but in many cases there are overlapping features that make them difficult to differentiate. Therapeutic management will be different in the case of a primary malignant melanoma and a metastatic lesion of melanoma. Case report: A 41-year-old man consulted for a pigmented lesion of 2 years’ evolution and 3cm in size located on the left shoulder blade. The lesion has been growing slowly but in the last 3 months has presented with a sudden eruption of more than 300 pigmented lesions. Her sister was operated of a extension superficial melanoma 20 years ago and is currently free of disease. The extension study showed the presence of supraclavicular, mediastinic, and hiliar lymph nodes in the computerized tomography scan. Before referring the patient to the oncology service, we removed the primary lesion and multiple pigmented lesions also suggestive of melanomas. The histopathology study of the larger lesion shows an extension superficial melanoma, Clark level IV and Breslow index 2.5mm. The multiple lesions suggestive of melanomas showed thinning of the epidermis by aggregates of atypical melanocytes within the dermis and melanocytes sometimes in the vascular lumen in the upper part of the dermis. They were diagnosed as metastases of malignant melanoma.
A 61-year-old white woman with a history of diabetes, hypertension, and chronic venous stasis presented to her podiatrist with a nonhealing ulcer on the left medial ankle for 5 months. The ulcer base was biopsied and showed malignant melanoma, nodular type, Breslow depth 3.7mm, Clark level IV with ulceration. Patient was referred to our facility for treatment. On physical examiantion, she had a 1.0- 3 0.9cm crusted red papule on her left medial ankle and changes of lipodermatosclerosis. There was left inguinal lymphadenopathy. Further work-up revealed multiple nonhemorrhagic lesions on brain MRI. Full body PET/CT showed lymphadenopathy in the left lower extremity, abdomen, and pelvis consistent with metastatic melanoma. The patient’s disease progressed in spite of interleukin-2 immunotherapy. She passed away a few months after the diagnosis of melanoma. A Marjolin ulcer is a cutaneous malignancy occurring in the setting of chronic ulcers, sinuses, or longstanding scars of various etiologies. These malignancies include squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas arising as Marjolin ulcers pose diagnostic and treatment challenges. Review of the literature identified eight cases of malignant melanoma arising at sites of chronic ulceration. Seven of the eight cases involved ulcers of the foot and five patients had metastases at diagnosis. This highlights the aggressive nature of melanoma arising as a Marjolin ulcer. Delay of diagnosis often accounts for thicker Breslow depth and poor prognosis.
Discussion: The development of multiple primary cutaneous malignant melanomas in a single individual is an unusual but recognized phenomenon. It is only in the case of familial melanoma that the rate of multiple primary melanomas becomes disproportionately higher. There are a variety of criteria in the literature on how to distinguish multiple primary melanomas from cutaneous metastases of melanoma. It is important to learn components of the patient history that can aid in the correct diagnosis, to describe histologic characteristics of primary and metastatic malignant melanoma lesions, and to emphasize the need to distinguish between primary and malignant processes relative to therapy. To clarify this problem, Kornberg et al tried to further define the histologic differences between primary and epidermotropic malignant melanomas, even though there vas a significant overlapping of the histologic features.
Commercial support: None identified.
Commercial support: None identified.
P2810 Pigmented mammary Paget disease mimicking cutaneous melanoma Teresa Meyer, Virgen de la Victoria University Hospital, Ma´laga, Spain; Blanca Moyano, Virgen de la Victoria University Hospital, Ma´laga, Spain; Enrique Herrera, Virgen de la Victoria University Hospital, Ma´laga, Spain; Enrique Herrera-Acosta, Virgen de la Victoria Univeristy Hospital, Ma´laga, Spain; Maria Angustias Gallardo, Virgen de la Victoria University Hospital, Ma´laga, Spain Introduction: Paget disease of the breast nipple and areola complex represents a cutaneous manifestation of an underlying breast malignancy. The typical clinical presentation is that of an itching, excoriated nipple with associated erythema and nipple drainage. Pigmented mammary Paget disease is a rare clinicopathologic variant of mammary Paget disease that may clinically, dermoscopically, and histopathologically mimic malignant melanoma. Case report: We report a case of a 55-year-old Spanish woman who was referred to our department regarding a 3-year history of asymptomatic progressively enlarging pigmented lesion on her left mammary nipple and areola. Physical examination revealed a 4.5 3 3cm, dark brown, well defined plaque involving 80% of the areola; the nipple had disappeared. On dermoscopy, the lighter portion of the lesion corresponded to a whitish-pink area with irregular linear vessels resembling an area of regression, whereas the darker portion was characterized by dark brown diffuse pigmentation with irregular black dots and small grey-white structures. There was no palpable breast masses, and no supraclavicular or axillary lymphadenopathy. Suspecting a melanocytic lesion, we decided to take a punch biopsy specimen of the pigmented area. Histologic evaluation integrated with immunohistochemical staining showed pigmented mammary Paget disease, therapeutic excision was performed, showing an in situ ductal breast carcinoma. Discussion: Paget disease of the breast usually presents as an erythematous patch, typically eczematous in appearance. The pigmented variant is rare. Dermoscopic results that showed a nonspecific pattern with irregularly diffuse pigmentation and regression like structures suggesting a diagnosis of melanoma have been previously reported. This case shows that the diagnosis of pigmented mammary Paget disease cannot be determined by clinical examination and dermoscopy alone. Detailed pathologic evaluation, including immunohistochemical staining, is essential for making the correct diagnosis. Commercial support: None identified.
MARCH 2010
P2812 Dermoscopic features of amelanotic melanoma Luis Dehesa, MD, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Las Palmas, Spain; Joel Crockett, MD, Saint Louis University, School of Medicine, Saint Louis, MO, United States; Nicole Burkemper, MD, Saint Louis University, Dept of Dermatology, Saint Louis, MO, United States; Scott Fosko, MD, Saint Louis University, Dept of Dermatology, Saint Louis, MO, United States Dermoscopy is an in vivo technique that enables the clinician to visualize hundreds of different features in pigmented and nonpigmented skin lesions. It is useful to be able to recognize specific features that are indicative of early melanoma, but it can still be very difficult. That is the case of amelanotic melanoma. We present three cases of amelanotic melanoma in which the dermoscopy helped us strongly to suspect the diagnosis. In our opinion, it is very important to perform a thorough examination of the lesions in order to find the diagnostic clue. The presence of some globules grouped in the periphery of the amelanotic tumor was the clue in our three patients. Commercial support: None identified.
J AM ACAD DERMATOL
AB101