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Unusual presentation of cutaneous metastatic malignant melanoma
I I II I
Unusual presentation of cutaneous metastatic malignant melanoma Stephanie Marschall, MD, a Sophia Welykyj, MD, b Roberto Gradini, N1D, e and Ana Eng, M D c Chicago and Maywood, Illinois This report describes an unusual presentation of cutaneous metastases suspected to have occurred through lymphatic spread in a patient with malignant melanoma. Punctate papular skin lesions correlated histologically with small tumor foci in the papillary dermis. (J AM ACAD DERMATOL 1991 ;24:648-50.) The skin and subcutaneous tissue are among the most common sites involved in metastatic melanoma. Metastases may originate through lymphatic spread, although the most common route is hematogenous. ~ Cutaneous metastases usually involve either the dermis a n d / o r the subcutaneous fat, although rarely atypical melanocytes are found within the epidermis and the upper part of the d e r mis (epidermatotropic metastatic malignant melanoma). 2,3 The designation of regional cutaneous metastases as local satellite or in-transit is based on the distance from the primary melanoma site. 2 This report describes an unusual presentation of multiple punctate in-transit cutaneous metastases in a patient with malignant melanoma. CASE REPORT
A 38-year-old white man had 3-month history of a posterior neck mass. Physical examination revealed an 8 • i0 mm pigmented lesion on the left occipital aspect of the scalp and a 1 cm left occipital lymph node. An excisional biopsy of the pigmented lesion and a fine needle aspirate of the enlarged lymph node were done. Histologic evaluation revealed a malignant melanoma, Clark level IV, 2 mm in maximum thickness. Abnormal cells suggestive of metastatic melanoma were seen in a fine needle aspirate of the enlarged lymph node. Routine laboratory studies, whole-body computed tomography, and bone scan were negative for metastatic disease. The patient had a wide excision of the scalp lesion and a left modified radical neck dissection. No residual melanoma was in the scalp tissue. Two retroauricular lymph nodes, 11 of 15 upper jugular nodes, 10 of 15 midFrom the Department of Dermatology, University of l llinois, Chicago, a and the Section of Dermatology,~ and the Department of Pathology,e Loyola University, Stritch School of Medicine, Maywood.
Reprints not available. 16/'4/19837 648
Fig. 1. Multiple 1 to 2 mm, reddish brown papules of metastatic malignant melanoma on left shoulder and left anterior aspect of chest. die jugular nodes, and all seven lower jugular nodes were positive for metastatic melanoma. During week 9 of interferon-~ treatment, the patient noticed multiple punctate, dark lesions on the left shoulder, chest, and abdomen. Examination at that time revealed approximately 50 reddish brown papules, 1 to 2 mm, on the left shoulder, on the left anterior aspect of the chest, and in the midabdominal region below the xiphoid
Volume 24
Number 4 April 1991
Metastatic malignant melanoma 649
Fig. 2. Atypical melanocytes with pleomorphic nuclei in papillary dermis with compression of epidermis. (Hematoxylin-eosin stain; •
Fig. 3. Malignant melanocytes in lymphatic vessel. Immunoperoxidase stain for factor VIII-related antigen. Blood vessels are positive (black arrows);lymphatics are negative (white arrows). (Peroxidase-antiperoxidase technique; •
process (Fig. 1). Five lesions were excised for biopsy. All specimens revealed atypical melanocytes with pleomorphic nuclei in the papillary dermis with compression of the epidermis (Fig. 2). The tumor cells stained for S-100 protein. Extension of the tumor cells to the reticular dermis and invasion of endothelial-lined spaces were demonstrated in some areas. Immunoperoxidase stain for factor VIII-related antigen positively stained the dermal blood vessels, whereas the lymphatics remained unstained (Fig. 3). This confirmed the presence of metastases within the lymphatic vessels only. Serial sections failed to reveal the tumor cells within the epidermis.
Interferon-3, was discontinued, and the patient was referred for other adjuvant therapy. DISCUSSION This case is an example of metastatic malignant melanoma with multiple punctate, in-transit, cutaneous metastases. Local metastases from malignant melanoma occur in two basic forms. The first, local satellites, occur at the scar or graft site of the primary excision or within 5 cm of them. 4'5 This must be distin-
Journal of the American Academy of Dermatology
650 Marschall et al.
guished from local recurrences from residual tumor. The second, in-transit metastases, occur beyond 5 cm from the primary site and proximal to the regional lymph nodes. 4, 6 Each form m a y manifest epidermatotropism. 7 Cutaneous metastases result from either lymphatic or vascular spread; the most common route is hematogenic. Lymphatic metastases are usually restricted to one side of the body in one anatomic location, but rarely lesions may cross the midline. Cutaneous and subcutaneous metastases that arise solely from lymphatic spread are believed to be uncommon more than 5 cm from the primary site. 1 However, the separate designation of in-transit metastases evolved because of the belief that the lesions resulted from neoplastic cells being trapped in lymph vessels. 4 These may occur in the line of the lymph channels or, in the case of regional node dissemination, they m a y be seen distal to the site of the resected lymph nodes. 8 Our patient's cutaneous metastases occurred in an area greater than 5 cm from the primary site in the line of lymph channels draining the primary melanoma and distal to the site of regional node drainage because of the previous node dissection. Connections exist between the deep cervical system lymphatics, the system responsible for draining the patient's primary lesion, and the axillary lymphatics, which also communicate with the mammary system. 9 This explains the anatomic location of the
metastatic lesions in our patient and classification of them as in-transit, thus supporting the belief that they resulted from neoplastic ceils trapped in lymph vessels. The rapid appearance of multiple smalI Iesions in the anatomic areas outlined, in addition to the observation of tumor cells within the lymph vessels, suggest that cells were carried to these sites by lymphatics with establishment of dermal metastases. REFERENCES
1. Das Gupta T, Brasfield R. Metastatic melanoma: a clinicopathologic study. Cancer 1964;17:1323-39. 2. AckermanAB, Su WPD. The histologyof cutaneous malignant melanoma. In: Kopf AW, Bart RS, Rodriquez-Sains RS, et al. Malignant melanoma. New York: Masson Publishing Co, 1979. 3. KatoT, DemitsuT, Tomita Y, et al. New primary malignant melanoma, epidermotropismand Indian-filearrangement of metastatic tumor cells in a easewith in-transit metastases of an aeral type of malignant melanoma. Dermatologica 1986;173:95-1013. 4. RosesDF, Harris MN, Ackerman AB. Diagnosisand management ofcutaneous malignant melanoma. Maj Probl Clin Surg 1983;27:223-61. 5. Friedman FJ, Rigel DS. The clinical features of malignant melanoma. Dermatol Clin 1985;3:271-83. 6. Roses DF, Harris MN, Rigel D, et al. Local and in-transit metastasesfollowingdefinitiveexcisionof primary cutaneous malignant melanoma. Ann Surg 1983;198:65-9. 7. Warner TFCS, Gilberty EF, Ramirez G. Epidermotropism in melanoma. J Cutan Pathol 1980;7:50-4. 8. McGovernVJ. Malignant melanoma: clinical and histological diagnosis. New York: John Wiley & Sons, 1976. 9. Basmajian JV. Grant's method of anatomy. 9th ed. Baltimore: Williams & Wilkins, 1975.
Unusual presentation of cutaneous metastatic malignant melanoma Stephanie Marschall, MD, a Sophia Welykyj, MD, b Roberto Gradini, N1D, e and Ana Eng, M D c Chicago and Maywood, Illinois This report describes an unusual presentation of cutaneous metastases suspected to have occurred through lymphatic spread in a patient with malignant melanoma. Punctate papular skin lesions correlated histologically with small tumor foci in the papillary dermis. (J AM ACAD DERMATOL 1991 ;24:648-50.) The skin and subcutaneous tissue are among the most common sites involved in metastatic melanoma. Metastases may originate through lymphatic spread, although the most common route is hematogenous. ~ Cutaneous metastases usually involve either the dermis a n d / o r the subcutaneous fat, although rarely atypical melanocytes are found within the epidermis and the upper part of the d e r mis (epidermatotropic metastatic malignant melanoma). 2,3 The designation of regional cutaneous metastases as local satellite or in-transit is based on the distance from the primary melanoma site. 2 This report describes an unusual presentation of multiple punctate in-transit cutaneous metastases in a patient with malignant melanoma. CASE REPORT
A 38-year-old white man had 3-month history of a posterior neck mass. Physical examination revealed an 8 • i0 mm pigmented lesion on the left occipital aspect of the scalp and a 1 cm left occipital lymph node. An excisional biopsy of the pigmented lesion and a fine needle aspirate of the enlarged lymph node were done. Histologic evaluation revealed a malignant melanoma, Clark level IV, 2 mm in maximum thickness. Abnormal cells suggestive of metastatic melanoma were seen in a fine needle aspirate of the enlarged lymph node. Routine laboratory studies, whole-body computed tomography, and bone scan were negative for metastatic disease. The patient had a wide excision of the scalp lesion and a left modified radical neck dissection. No residual melanoma was in the scalp tissue. Two retroauricular lymph nodes, 11 of 15 upper jugular nodes, 10 of 15 midFrom the Department of Dermatology, University of l llinois, Chicago, a and the Section of Dermatology,~ and the Department of Pathology,e Loyola University, Stritch School of Medicine, Maywood.
Reprints not available. 16/'4/19837 648
Fig. 1. Multiple 1 to 2 mm, reddish brown papules of metastatic malignant melanoma on left shoulder and left anterior aspect of chest. die jugular nodes, and all seven lower jugular nodes were positive for metastatic melanoma. During week 9 of interferon-~ treatment, the patient noticed multiple punctate, dark lesions on the left shoulder, chest, and abdomen. Examination at that time revealed approximately 50 reddish brown papules, 1 to 2 mm, on the left shoulder, on the left anterior aspect of the chest, and in the midabdominal region below the xiphoid
Volume 24
Number 4 April 1991
Metastatic malignant melanoma 649
Fig. 2. Atypical melanocytes with pleomorphic nuclei in papillary dermis with compression of epidermis. (Hematoxylin-eosin stain; •
Fig. 3. Malignant melanocytes in lymphatic vessel. Immunoperoxidase stain for factor VIII-related antigen. Blood vessels are positive (black arrows);lymphatics are negative (white arrows). (Peroxidase-antiperoxidase technique; •
process (Fig. 1). Five lesions were excised for biopsy. All specimens revealed atypical melanocytes with pleomorphic nuclei in the papillary dermis with compression of the epidermis (Fig. 2). The tumor cells stained for S-100 protein. Extension of the tumor cells to the reticular dermis and invasion of endothelial-lined spaces were demonstrated in some areas. Immunoperoxidase stain for factor VIII-related antigen positively stained the dermal blood vessels, whereas the lymphatics remained unstained (Fig. 3). This confirmed the presence of metastases within the lymphatic vessels only. Serial sections failed to reveal the tumor cells within the epidermis.
Interferon-3, was discontinued, and the patient was referred for other adjuvant therapy. DISCUSSION This case is an example of metastatic malignant melanoma with multiple punctate, in-transit, cutaneous metastases. Local metastases from malignant melanoma occur in two basic forms. The first, local satellites, occur at the scar or graft site of the primary excision or within 5 cm of them. 4'5 This must be distin-
Journal of the American Academy of Dermatology
650 Marschall et al.
guished from local recurrences from residual tumor. The second, in-transit metastases, occur beyond 5 cm from the primary site and proximal to the regional lymph nodes. 4, 6 Each form m a y manifest epidermatotropism. 7 Cutaneous metastases result from either lymphatic or vascular spread; the most common route is hematogenic. Lymphatic metastases are usually restricted to one side of the body in one anatomic location, but rarely lesions may cross the midline. Cutaneous and subcutaneous metastases that arise solely from lymphatic spread are believed to be uncommon more than 5 cm from the primary site. 1 However, the separate designation of in-transit metastases evolved because of the belief that the lesions resulted from neoplastic cells being trapped in lymph vessels. 4 These may occur in the line of the lymph channels or, in the case of regional node dissemination, they m a y be seen distal to the site of the resected lymph nodes. 8 Our patient's cutaneous metastases occurred in an area greater than 5 cm from the primary site in the line of lymph channels draining the primary melanoma and distal to the site of regional node drainage because of the previous node dissection. Connections exist between the deep cervical system lymphatics, the system responsible for draining the patient's primary lesion, and the axillary lymphatics, which also communicate with the mammary system. 9 This explains the anatomic location of the
metastatic lesions in our patient and classification of them as in-transit, thus supporting the belief that they resulted from neoplastic ceils trapped in lymph vessels. The rapid appearance of multiple smalI Iesions in the anatomic areas outlined, in addition to the observation of tumor cells within the lymph vessels, suggest that cells were carried to these sites by lymphatics with establishment of dermal metastases. REFERENCES
1. Das Gupta T, Brasfield R. Metastatic melanoma: a clinicopathologic study. Cancer 1964;17:1323-39. 2. AckermanAB, Su WPD. The histologyof cutaneous malignant melanoma. In: Kopf AW, Bart RS, Rodriquez-Sains RS, et al. Malignant melanoma. New York: Masson Publishing Co, 1979. 3. KatoT, DemitsuT, Tomita Y, et al. New primary malignant melanoma, epidermotropismand Indian-filearrangement of metastatic tumor cells in a easewith in-transit metastases of an aeral type of malignant melanoma. Dermatologica 1986;173:95-1013. 4. RosesDF, Harris MN, Ackerman AB. Diagnosisand management ofcutaneous malignant melanoma. Maj Probl Clin Surg 1983;27:223-61. 5. Friedman FJ, Rigel DS. The clinical features of malignant melanoma. Dermatol Clin 1985;3:271-83. 6. Roses DF, Harris MN, Rigel D, et al. Local and in-transit metastasesfollowingdefinitiveexcisionof primary cutaneous malignant melanoma. Ann Surg 1983;198:65-9. 7. Warner TFCS, Gilberty EF, Ramirez G. Epidermotropism in melanoma. J Cutan Pathol 1980;7:50-4. 8. McGovernVJ. Malignant melanoma: clinical and histological diagnosis. New York: John Wiley & Sons, 1976. 9. Basmajian JV. Grant's method of anatomy. 9th ed. Baltimore: Williams & Wilkins, 1975.