- Email: [email protected]
Hair repigmentation in melanoma
Case Report
Hair repigmentation in melanoma Martin Inzinger, Cesare Massone, Edith Arzberger, Rainer Hofmann-Wellenhof Lancet 2013; 382: 1224 Department of Dermatology, Medical University of Graz, Austria (M Inzinger MD, C Massone MD, E Arzberger MD, R Hofmann-Wellenhof MD) Correspondence to: Dr Martin Inzinger, Department of Dermatology, Medical University of Graz, Auenbrugger Platz 8, A-8036 Graz, Austria martin.inzinger@ medunigraz.at
See Online for appendix
A
A 91-year-old woman came to our clinic with a dark nodule on the back of her scalp, which she had first noticed 4 days earlier. She had also noticed progressive repigmentation of otherwise completely white hair at the same site (figure). The repigmentation started with a few strands of reddish hair about 10 years ago. Within a few years, the colour of the repigmented hair changed again from reddish to dark black, and finally to light brown. Interestingly, the patient never had reddish, black, or light brown hair before. Her natural hair colour as a young adult was light blonde. Examination of the patient’s scalp showed a coarse black nodule measuring 8 mm in diameter and several satellite lesions (figure). A patch of pigmented hair around the nodule was surrounded by mainly white hair. Histological investigation of the excised nodule showed a melanoma with a tumour thickness of 3·5 mm. Atypical melanocytes were seen in all layers of the epidermis including sheets and nests extending down to the deep dermis and invading the hair follicles (appendix). Masson-Fontana staining revealed dendritic melanocytes in the hair bulbs (appendix) and melanin deposit in the shaft of the normal skin hair follicles around the lesion (appendix). We speculated that the melanoma might have activated hair follicle melanocytes via paracrine secretion of mediators. This possibility is supported by the fact that several neural and immune networks and mediators can activate the receptor tyrosine kinase KIT and activate melanogenesis within the hair bulb.1 Another possible explanation is that hair repigmentation in melanoma areas may have resulted from melanin produced by malignant melanocytes. A similar case of unusual hair repigmentation in lentigo maligna has been reported.2 B
Figure: Hair repigmentation in melanoma (A) Light brown hair repigmentation. (B) 8 mm melanoma with satellite lesions seen on scalp.
1224
The melanoma was excised and the bare area covered with a split-thickness skin graft. 10 months later, the patient developed a local recurrence and one lymph node metastasis. Resection of both lesions was then done. In February, 2013, the patient began receiving curative radiotherapy. She had no signs of further recurrence when last seen in June, 2013. Melanoma is an important public health problem, with increasing prevalence rates throughout the world.3 Current incidence rates are from less than 10 per 100 000 to 20 per 100 000 in Europe, 20–30 per 100 000 in the USA, and 50–60 per 100 000 in Australia.4 Although melanoma constitutes 10% of all detected skin cancers, it accounts for 90% of deaths associated with cutaneous tumours.3,4 Excision at a very early stage is the only means of reducing mortality.3,5 5-year and 10-year survival rates for stage IA disease (according to the grading of the American Joint Committee on Cancer) are 97% and 93%, respectively.3,5 In our experience screening investigations are of utmost importance for early detection of the lesions. Melanomas on the scalp or neck are frequently concealed by hair and an early diagnosis is often challenging. In our patient, the melanoma was already in stage IIIB (AJCC 2009) which is associated with a 5-year survival rate of 57%. This case shows that a slow-growing melanoma on the scalp was indicated by progressive repigmentation of the hair. Timely observation of this sign would have permitted identification of the condition at an earlier stage. We believe that observation of spontaneous hair repigmentation in white-haired individuals should be viewed as a sign that allows for immediate examination to exclude a melanoma on the scalp. Contributors MI looked after the patient and wrote the manuscript. CM did the histology and prepared figures. EA looked after the patient and provided the dermatoscopic image. RH-W looked after the patient and edited the manuscript. Written consent to publish was obtained. References 1 Blume-Peytavi U, Tosti A, Whiting DA, Trüeb R. Hair Growth and Disorders. Berlin: Springer-Verlag, 2008. 2 Dummer R. Clinical picture: hair repigmentation in lentigo maligna. Lancet 2001; 357: 598. 3 Gershenwald JE, Ross MI. Sentinel-lymph-node biopsy for cutaneous melanoma. N Engl J Med 2011; 364: 1738–45. 4 Garbe C, Peris K, Hauschild A, et al. Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline– Update 2012. Eur J Cancer 2012; 48: 2375–90. 5 Argenziano G, Cerroni L, Zalaudek I, et al. Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol 2012; 67: 54–59.
www.thelancet.com Vol 382 October 5, 2013
Hair repigmentation in melanoma Martin Inzinger, Cesare Massone, Edith Arzberger, Rainer Hofmann-Wellenhof Lancet 2013; 382: 1224 Department of Dermatology, Medical University of Graz, Austria (M Inzinger MD, C Massone MD, E Arzberger MD, R Hofmann-Wellenhof MD) Correspondence to: Dr Martin Inzinger, Department of Dermatology, Medical University of Graz, Auenbrugger Platz 8, A-8036 Graz, Austria martin.inzinger@ medunigraz.at
See Online for appendix
A
A 91-year-old woman came to our clinic with a dark nodule on the back of her scalp, which she had first noticed 4 days earlier. She had also noticed progressive repigmentation of otherwise completely white hair at the same site (figure). The repigmentation started with a few strands of reddish hair about 10 years ago. Within a few years, the colour of the repigmented hair changed again from reddish to dark black, and finally to light brown. Interestingly, the patient never had reddish, black, or light brown hair before. Her natural hair colour as a young adult was light blonde. Examination of the patient’s scalp showed a coarse black nodule measuring 8 mm in diameter and several satellite lesions (figure). A patch of pigmented hair around the nodule was surrounded by mainly white hair. Histological investigation of the excised nodule showed a melanoma with a tumour thickness of 3·5 mm. Atypical melanocytes were seen in all layers of the epidermis including sheets and nests extending down to the deep dermis and invading the hair follicles (appendix). Masson-Fontana staining revealed dendritic melanocytes in the hair bulbs (appendix) and melanin deposit in the shaft of the normal skin hair follicles around the lesion (appendix). We speculated that the melanoma might have activated hair follicle melanocytes via paracrine secretion of mediators. This possibility is supported by the fact that several neural and immune networks and mediators can activate the receptor tyrosine kinase KIT and activate melanogenesis within the hair bulb.1 Another possible explanation is that hair repigmentation in melanoma areas may have resulted from melanin produced by malignant melanocytes. A similar case of unusual hair repigmentation in lentigo maligna has been reported.2 B
Figure: Hair repigmentation in melanoma (A) Light brown hair repigmentation. (B) 8 mm melanoma with satellite lesions seen on scalp.
1224
The melanoma was excised and the bare area covered with a split-thickness skin graft. 10 months later, the patient developed a local recurrence and one lymph node metastasis. Resection of both lesions was then done. In February, 2013, the patient began receiving curative radiotherapy. She had no signs of further recurrence when last seen in June, 2013. Melanoma is an important public health problem, with increasing prevalence rates throughout the world.3 Current incidence rates are from less than 10 per 100 000 to 20 per 100 000 in Europe, 20–30 per 100 000 in the USA, and 50–60 per 100 000 in Australia.4 Although melanoma constitutes 10% of all detected skin cancers, it accounts for 90% of deaths associated with cutaneous tumours.3,4 Excision at a very early stage is the only means of reducing mortality.3,5 5-year and 10-year survival rates for stage IA disease (according to the grading of the American Joint Committee on Cancer) are 97% and 93%, respectively.3,5 In our experience screening investigations are of utmost importance for early detection of the lesions. Melanomas on the scalp or neck are frequently concealed by hair and an early diagnosis is often challenging. In our patient, the melanoma was already in stage IIIB (AJCC 2009) which is associated with a 5-year survival rate of 57%. This case shows that a slow-growing melanoma on the scalp was indicated by progressive repigmentation of the hair. Timely observation of this sign would have permitted identification of the condition at an earlier stage. We believe that observation of spontaneous hair repigmentation in white-haired individuals should be viewed as a sign that allows for immediate examination to exclude a melanoma on the scalp. Contributors MI looked after the patient and wrote the manuscript. CM did the histology and prepared figures. EA looked after the patient and provided the dermatoscopic image. RH-W looked after the patient and edited the manuscript. Written consent to publish was obtained. References 1 Blume-Peytavi U, Tosti A, Whiting DA, Trüeb R. Hair Growth and Disorders. Berlin: Springer-Verlag, 2008. 2 Dummer R. Clinical picture: hair repigmentation in lentigo maligna. Lancet 2001; 357: 598. 3 Gershenwald JE, Ross MI. Sentinel-lymph-node biopsy for cutaneous melanoma. N Engl J Med 2011; 364: 1738–45. 4 Garbe C, Peris K, Hauschild A, et al. Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline– Update 2012. Eur J Cancer 2012; 48: 2375–90. 5 Argenziano G, Cerroni L, Zalaudek I, et al. Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol 2012; 67: 54–59.
www.thelancet.com Vol 382 October 5, 2013