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Recurrent lentigo maligna melanoma commingling the tumour nests of a basal cell carcinoma
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, e227ee228
CASE REPORT
Recurrent lentigo maligna melanoma commingling the tumour nests of a basal cell carcinoma Z. Hassan*, F. Ahmad, P. Brackley Department of Plastic Surgery, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, UK Received 19 November 2012; accepted 8 March 2013
KEYWORDS Recurrent lentigo maligna melanoma; Commingling; Basal cell carcinoma
Summary There are various types and combinations of coexisting cutaneous neoplasms which have been documented in the past but are uncommon. In this report we describe a case of basal cell carcinoma (BCC) colonised by recurrent lentigo maligna melanoma. A review of the literature has established the coexistence of lentigo maligna and BCC in six cases. The unusual combination of melanoma and BCC poses a therapeutic and prognostic dilemma. BCC is known to have a favourable outcome whereas melanoma tends to behave in a more aggressive manner leading to a less favourable outcome. There are conflicting views as to whether these lesions should be treated as BCC’s or lentigo maligna melanoma. Our case appears to be unique, in that it was a recurrent lentigo maligna melanoma which was colonising the BCC. We treated our patient with wide local excision and full thickness skin graft and will continue to observe him on an outpatient basis. There needs to be long term follow up of a larger number of patients for us to truly appreciate the biological significance of parasitism of BCC by lentigo maligna melanoma. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The coexistence of lentigo maligna and basal cell carcinoma (BCC) is a very rare occurrence.1e6 Even rarer is the colonisation of malignant melanocyte cells within the
carcinoma nests.3e6 We describe a case of BCC colonised by recurrent lentigo maligna melanoma.
Case report * Corresponding author. Tel.: þ44 (0) 151 426 1600; fax: þ44 (0) 151 430 1855. E-mail address: [email protected] (Z. Hassan).
A 79 year old caucasian male had a lesion on the tip of his nose present for approximately one year and located
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.011
e228
Figure 1 Photo illustrating pigmented lesion on nose with colour variegation. Note previous skin graft superior to this lesion. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
inferiorly to a previous full thickness skin graft. On examination the lesion measured 15 mm 15 mm in diameter, pigmented with colour variegation (Figure 1). A punch biopsy of this lesion was reported as a dysplastic naevus. The patient underwent excision of the lesion at the nasal tip and reconstructed with a full thickness graft. Histological assessment demonstrated a ‘central focus of basal cell carcinoma’ up to 1.4 mm thick. Atypical melanocytes colonised these nests of basal cell carcinoma, confirmed by immunocytochemistry. These appeared to represent coexistence of basal cell carcinoma with recurrent lentigo maligna melanoma. The lesion did not extend to the excision margins’. Five years previously, he attended our department with a 2 year history of lesion on the dorsum of his nose that had increased in size but had not developed any colour or shape change. On examination it was 13 mm 8 mm in diameter, flat with brown/black colour variegation. It was excised and a full thickness skin graft applied. Histology reported it as a completely excised lentigo maligna melanoma, with nests of atypical melanocytes extending down into the dermis without normal maturation.
Discussion A review of the literature has established the coexistence of lentigo maligna and BCC in six cases.1e6 In four case reports lentigo maligna was found to intermingle directly with the BCC.3e6 BCC’s are thought to arise from the follicular outer root sheath epithelium.7 Melanocytes usually reside in the basal epidermal and follicular epithelium, hence the presence of benign melanocytes within BCC is established.8 Melanocytes may become entrapped within tumour nests as a BCC proliferates. Lentigo maligna has been noted to involve follicular epithelium and malignant melanocytes can become incorporated into a BCC by similar mechanisms. The unusual combination of melanoma and BCC poses a therapeutic and prognostic dilemma. BCC has a favourable outcome whereas melanoma may not. The prognosis of
Z. Hassan et al. malignant melanoma can be correlated to its Breslow thickness.9 If we assume that our patient’s melanocytic component of the BCC to be equivalent to an invasive melanoma of similar thickness, then the Breslow thickness would have been 1.4 mm. However, Burkhalter suggested that this lesion should be interpreted as simple colonisation of BCC by lentigo maligna.3 These two explanations lead to different courses of management and prognoses. The extension of melanoma through appendageal structures is not considered invasion and is not included in the Breslow measurement. The other factor in our case was that the lesion was a recurrent lentigo maligna melanoma and not a new melanoma. Surgery is still the treatment of choice but a wide margin is unnecessary. Our case appears to be unique, in that it was a recurrent lentigo maligna melanoma which was colonising the BCC. We treated our patient with wide local excision and full thickness skin graft and will continue to observe him. There needs to be long term follow up of these patients for us to understand the biology of commingled BCC by lentigo maligna melanoma.
Conflict of interest None.
Funding N/A.
Acknowledgments Nil.
References 1. Sina B, Samorodin C. Basal cell carcinoma surrounded by lentigo maligna. Cutis 1989;44:81e2. 2. Hirakawa E, Miki H, Kobayashi S, Nomura Y, Ohmori M. Collision tumor of cutaneous malignant melanoma and basal cell carcinoma. Pathol Res Pract 1998;194:649e53. 3. Burkhalter A, White WL. Malignant melanoma in situ colonizing basal cell carcinoma. A simulator of invasive melanoma. Am J Dermatopathol 1997;19:303e7. 4. Wang H, Benda PM, Piepkorn MW. Parasitism of basal cell carcinoma by lentigo maligna melanoma. J Am Acad Dermatol 2003;48:S92e4. 5. Belisle A, Gautier MS, Ghozali F, Plantier F, Wechsler J. A collision tumor involving basal cell carcinoma and lentigo maligna melanoma. Am J Dermatopathol 2005;27:319e21. 6. Taibjee SM, Gee BC, Sanders DS, Smith A, Carr RA. Lentigo maligna involving the tumour nests and stroma of a nodular basal cell carcinoma. Br J Dermatol 2007;157:184e8. 7. Jimenez FJ, Burchette Jr JL, Grichnik JM, Hitchcock MG. BerEP4 immunoreactivity in normal skin and cutaneous neoplasms. Mod Pathol 1995;8:854e8. 8. Florell SR, Zone JJ, Gerwels JW. Basal cell carcinomas are populated by melanocytes and Langerhans [correction of Langerhan’s] cells. Am J Dermatopathol 2001;23:24e8. 9. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 1970; 172:902e8.
CASE REPORT
Recurrent lentigo maligna melanoma commingling the tumour nests of a basal cell carcinoma Z. Hassan*, F. Ahmad, P. Brackley Department of Plastic Surgery, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, UK Received 19 November 2012; accepted 8 March 2013
KEYWORDS Recurrent lentigo maligna melanoma; Commingling; Basal cell carcinoma
Summary There are various types and combinations of coexisting cutaneous neoplasms which have been documented in the past but are uncommon. In this report we describe a case of basal cell carcinoma (BCC) colonised by recurrent lentigo maligna melanoma. A review of the literature has established the coexistence of lentigo maligna and BCC in six cases. The unusual combination of melanoma and BCC poses a therapeutic and prognostic dilemma. BCC is known to have a favourable outcome whereas melanoma tends to behave in a more aggressive manner leading to a less favourable outcome. There are conflicting views as to whether these lesions should be treated as BCC’s or lentigo maligna melanoma. Our case appears to be unique, in that it was a recurrent lentigo maligna melanoma which was colonising the BCC. We treated our patient with wide local excision and full thickness skin graft and will continue to observe him on an outpatient basis. There needs to be long term follow up of a larger number of patients for us to truly appreciate the biological significance of parasitism of BCC by lentigo maligna melanoma. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The coexistence of lentigo maligna and basal cell carcinoma (BCC) is a very rare occurrence.1e6 Even rarer is the colonisation of malignant melanocyte cells within the
carcinoma nests.3e6 We describe a case of BCC colonised by recurrent lentigo maligna melanoma.
Case report * Corresponding author. Tel.: þ44 (0) 151 426 1600; fax: þ44 (0) 151 430 1855. E-mail address: [email protected] (Z. Hassan).
A 79 year old caucasian male had a lesion on the tip of his nose present for approximately one year and located
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.011
e228
Figure 1 Photo illustrating pigmented lesion on nose with colour variegation. Note previous skin graft superior to this lesion. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
inferiorly to a previous full thickness skin graft. On examination the lesion measured 15 mm 15 mm in diameter, pigmented with colour variegation (Figure 1). A punch biopsy of this lesion was reported as a dysplastic naevus. The patient underwent excision of the lesion at the nasal tip and reconstructed with a full thickness graft. Histological assessment demonstrated a ‘central focus of basal cell carcinoma’ up to 1.4 mm thick. Atypical melanocytes colonised these nests of basal cell carcinoma, confirmed by immunocytochemistry. These appeared to represent coexistence of basal cell carcinoma with recurrent lentigo maligna melanoma. The lesion did not extend to the excision margins’. Five years previously, he attended our department with a 2 year history of lesion on the dorsum of his nose that had increased in size but had not developed any colour or shape change. On examination it was 13 mm 8 mm in diameter, flat with brown/black colour variegation. It was excised and a full thickness skin graft applied. Histology reported it as a completely excised lentigo maligna melanoma, with nests of atypical melanocytes extending down into the dermis without normal maturation.
Discussion A review of the literature has established the coexistence of lentigo maligna and BCC in six cases.1e6 In four case reports lentigo maligna was found to intermingle directly with the BCC.3e6 BCC’s are thought to arise from the follicular outer root sheath epithelium.7 Melanocytes usually reside in the basal epidermal and follicular epithelium, hence the presence of benign melanocytes within BCC is established.8 Melanocytes may become entrapped within tumour nests as a BCC proliferates. Lentigo maligna has been noted to involve follicular epithelium and malignant melanocytes can become incorporated into a BCC by similar mechanisms. The unusual combination of melanoma and BCC poses a therapeutic and prognostic dilemma. BCC has a favourable outcome whereas melanoma may not. The prognosis of
Z. Hassan et al. malignant melanoma can be correlated to its Breslow thickness.9 If we assume that our patient’s melanocytic component of the BCC to be equivalent to an invasive melanoma of similar thickness, then the Breslow thickness would have been 1.4 mm. However, Burkhalter suggested that this lesion should be interpreted as simple colonisation of BCC by lentigo maligna.3 These two explanations lead to different courses of management and prognoses. The extension of melanoma through appendageal structures is not considered invasion and is not included in the Breslow measurement. The other factor in our case was that the lesion was a recurrent lentigo maligna melanoma and not a new melanoma. Surgery is still the treatment of choice but a wide margin is unnecessary. Our case appears to be unique, in that it was a recurrent lentigo maligna melanoma which was colonising the BCC. We treated our patient with wide local excision and full thickness skin graft and will continue to observe him. There needs to be long term follow up of these patients for us to understand the biology of commingled BCC by lentigo maligna melanoma.
Conflict of interest None.
Funding N/A.
Acknowledgments Nil.
References 1. Sina B, Samorodin C. Basal cell carcinoma surrounded by lentigo maligna. Cutis 1989;44:81e2. 2. Hirakawa E, Miki H, Kobayashi S, Nomura Y, Ohmori M. Collision tumor of cutaneous malignant melanoma and basal cell carcinoma. Pathol Res Pract 1998;194:649e53. 3. Burkhalter A, White WL. Malignant melanoma in situ colonizing basal cell carcinoma. A simulator of invasive melanoma. Am J Dermatopathol 1997;19:303e7. 4. Wang H, Benda PM, Piepkorn MW. Parasitism of basal cell carcinoma by lentigo maligna melanoma. J Am Acad Dermatol 2003;48:S92e4. 5. Belisle A, Gautier MS, Ghozali F, Plantier F, Wechsler J. A collision tumor involving basal cell carcinoma and lentigo maligna melanoma. Am J Dermatopathol 2005;27:319e21. 6. Taibjee SM, Gee BC, Sanders DS, Smith A, Carr RA. Lentigo maligna involving the tumour nests and stroma of a nodular basal cell carcinoma. Br J Dermatol 2007;157:184e8. 7. Jimenez FJ, Burchette Jr JL, Grichnik JM, Hitchcock MG. BerEP4 immunoreactivity in normal skin and cutaneous neoplasms. Mod Pathol 1995;8:854e8. 8. Florell SR, Zone JJ, Gerwels JW. Basal cell carcinomas are populated by melanocytes and Langerhans [correction of Langerhan’s] cells. Am J Dermatopathol 2001;23:24e8. 9. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 1970; 172:902e8.