Scholarly article on topic 'Primary melanoma in rare locations: Clinical and dermatoscopic features'

Primary melanoma in rare locations: Clinical and dermatoscopic features Academic research paper on "Clinical medicine"

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Indian J Dermatol Venereol Leprol
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Academic research paper on topic "Primary melanoma in rare locations: Clinical and dermatoscopic features"

for low molecular weight cytokeratins (CK7, CAM 5.2), CEA, epithelial membrane antigen and S100 (inconstant).131 The nuclei stain positively for ER and variably, PR, indicating its close histogenesis with that of mucinous breast carcinoma'3 and in our case, both were positive. However, an in situ component of the tumor may stain for CK5/6, p63, calponin and SMA on the myoepithelial cells and this may attest to the tumor being primary and not metastatic mucinous breast carcinoma.[5] In our case, p63 was negative but SMA was positive, indicating the presence of myoepithelial cells, thus, signifying a primary tumor rather than a metastatic one. GI carcinomas show CK20 positivity while PMCS is CK20 negative, but CK7 positive.!1'3! GI carcinomas produce non-sulfated, neutral or sulfated mucins and not sialomucin, which is found in PMCS.'2] Metastatic colonic carcinomas may show dirty necrosis.'31

Psammoma body formation is an active process where collagen fibers and membrane bound vesicles are laid down in concentric circles inside the papillary cores which are subsequently calcified.'61 Interestingly, papillary formations were absent in the present case. However, hyaline globules, which are the putative precursors of psammoma bodies'61 were present inside a few of the glandular lumina.

We found only one previous report of psammoma bodies in PMCS.'7

Debarshi Saha, Urmila N. Khadilkar, Radha R. Pai, Ashwani Kumar

Department of Pathology, Kasturba Medical College (Manipal University), Mangalore, Karnataka, India

Address for correspondence: Dr. Debarshi Saha, Department of Pathology, Kasturba Medical College, Light House Hill Road, Mangalore - 575 001, Karnataka, India.



1. Lennox B, Pearse AGE, Richards HGH. Mucin secreting tumors of the skin. With special reference to the so-called mixed salivary tumor of the skin and its relation to hidradenoma. Journal of Pathology and Bacteriology. 1952; 64:865-880.

2. Martinez SR, Young SE. Primary mucinous carcinoma of skin: A review. Internet J Oncol 2005;2 (2) DOI: 10.5580/13e7.

3. Calonje E, Brenn T, Lazar A, McKee PH. McKee's Pathology of the Skin with Clinical Correlation. 4th ed., Vol. 2. Philadelphia: Elsevier Saunders; 2012. p.1566-8.

4. Kazakov DV, Suster S, LeBoit PE, Calonje E, Bisceglia M, Kutzner H, et al. Mucinous carcinoma of the skin, primary, and secondary: A clinicopathologic study of 63 cases with emphasis

on the morphologic spectrum of primary cutaneous forms: Homologies with mucinous lesions in the breast. Am J Surg Pathol 2005;29:764-82.

5. Qureshi HS, Salama ME, Chitale D, Bansal I, Ma CK, Raju U, et al. Primary cutaneous mucinous carcinoma: Presence of myoepithelial cells as a clue to the cutaneous origin. Am J Dermatopathol 2004;26:353-8.

6. Das DK. Psammoma body: A product of dystrophic calcification or of a biologically active process that aims at limiting the growth and spread of tumor? Diagn Cytopathol 2009;37:534-41.

7. Kalebi A, Hale M. Primary mucinous carcinoma of the skin: Usefulness of p63 in excluding metastasis and first report of psammoma bodies. Am J Dermatopathol 2008;30:510.

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Primary melanoma in rare locations: Clinical and dermatoscopic features

We present two histopathologically proven cases of melanoma in rare locations, documented both clinically and by means of dermatoscopy. Dermatoscopy was performed with the use of a standard, non-polarized hand-held dermatoscope (Dermatoscope Delta 20; Heine, Herrsching, Germany; Handyscope Fotofinder Systems) and videodermatoscope (Medicam 500 Fotofinder Dermoscope).

Case 1

A 41-year-old male farmer and long-time smoker had a mucosal melanoma on the upper lip and palate. Its onset was evident as a brownish macule on the upper lip. It spread rapidly approximately one year prior to evaluation after which a small, pinkish nodule appeared, growing over the next 2 months. The brownish macules enlarged rapidly and extended on to parts of the upper lip, vermillion and palate, as well as the buccal mucosa. The nodule located on the central part of the upper lip was excised and biopsy confirmed the presence of an ulcerated melanoma (Breslow 4.4 mm). Further evaluation with chest X-ray, sonogram of the

abdomen and basic biochemical parameters revealed no abnormalities. Later, the melanoma also spread to the skin of the upper part of the vermillion edge (April, 2011) [Figure 1a]. Dermoscopy was performed on this lesion at various stages of its clinical course. On the first dermatoscopy (January, 2010) of the brownish, mucosal macules, a typical multi-component pattern was observed, including a homogeneous and partly ring-like pattern [Figure 1b]. In the course of several months, a blue-veil sign appeared, with disorganized dermatoscopic structures. One year later, a multi-component pattern was described, demonstrating pseudo-reticular, homogenous and non-specific patterns. In addition, within the vermillion edge, the granular-annular pattern was noted. The hair follicles were accentuated by annular rings surrounding the follicular ostium [Figure 1c]. Because of the mucosal progression and metastases to the submandibular lymph nodes with distant metastases to lungs and liver, the patient underwent lymph node dissection of the submandibular region. He also received adjuvant chemotherapy with dacarbazine (DTIC), cisplatin (CDDP) and paclitaxel. The patient died 24 months after recognition of the initial melanoma because of advanced metastatic disease.

Case 2

A 42-year-old woman was diagnosed with primary melanoma on the left auricle. She presented with a

Figure 1: (a) Melanoma (thickness Breslow 4.4 mm) involving the upper lip, vermillion edge and the skin above the upper lip. A whitish post-surgical scar is seen at the center. (b) Dermatoscopic appearance of the melanoma of the upper lip and vermillion in January, 2010: A typical multi-component pattern was observed, including a homogeneous and partly ring-like pattern. According to classification of the mucosal changes by Blum et al.[1] 3 patterns of pigmented lines were noted: Reticular and parallel lines, a pattern of dots, and circles. (c) Dermatoscopic appearance of the mucosal part of the upper lip in March, 2011: Partially arranged multiple dots and a blue pseudo-veil sign are noted

slowly enlarging asymptomatic patch of two years duration. Clinically, the lesion was 1.0 X 0.7 cm in size, with asymmetric, irregular borders and colors. This patch covered the posterior part of the helix of the ear, being brownish-blackish and oval-shaped [Figure 2a]. On dermatoscopy, the multi-component pattern consisted of pigmented reticular structures, an atypical inverse network, the "island sign" with its irregular focal of the pigmented network, and whitish-bluish, homogenous structures. [Figure 2b]. The patient underwent partial excision of the auricle with a satisfactory cosmetic result and clear surgical margins. Histopathology later confirmed the presence of lentigo maligna. The patient remains without any signs of local reccurrence after 16 months of follow-up.

According to the results of a multicenter study by the International Dermoscopy Society, mucosal pigmented lesions located on lips were characterized by the occurrence of dermatoscopic patterns such as: structureless, lines, circles, dots and rarely globules or clods.[1] Overall, the most common detectable colors of the lesions on lips were brown, grey and red with black, white and purple colors being not very commonly detectable.[1] Comparing studies of Blum et al.[1] to Lin et al.[2] there are some differences in terminology of the mucosal changes. With regard to patterns, structureless was also referred to as homogenous pattern, globules/clods correspond to dotted-globular pattern, lines to finger-print, circles to ring-like pattern, and fish-scale to hyphal pattern.[1,2]

Figure 2: (a) Lentigo maligna of the left auricle (helix). The lesion is 1.0 x 0.7 cm, with asymmetric, irregular borders and colors. (b) On dermatoscopy, a multi-component pattern with the presence of an atypical reticular with homogenous patterns is evident. The lesion shows multiple (6) colors, including light brown, brown, black, reddish, grayish and whitish. An inverse network, the 'island sign' with its irregular foci, pigmented networks, dotted vessels distributed peripherally and whitish-bluish structureless zones was observed

The most common patterns in mucosal melanoma of lips were structureless (100%), lines (54%) especially reticular (27%) and parallel (9%).[1] According to Blum et al. only the presence of structureless zones was significantly associated with malignant lesions.[1] Structureless patterns were found in all malignant lesions but only in 53.2% of benign lesions.[1] Dots were detectable in 28.6% of the malignant mucosal lesions and in 7.9% of the benign lesions.[1] According to Blum et al. multiple colors are a better clue to malignant lesions than multiple patterns.111 Lin et al. stated that mucosal melanomas mainly presented with the multicomponent and homogeneous patterns.121 In the differential diagnosis of benign melanosis of the lip, three major dermatoscopic patterns were identified: a "structureless" pattern with a blue hue, a "parallel pattern", often found in clinically typical melanocytic macules of the lips and the "reticular-like" pattern associated with melanosis, rather rarely occurring on the lips.[3] If a benign lesion was structureless, its color was usually brown but did not include blue, gray, or white.[1] The significant difference between benign and malignant lesions included not only the occurrence of blue, gray and white colors, but their number as well.[1]

According to Stante et al. a recognition of early signs of lentigo maligna on dermatoscopy, before the lesion is associated with the ABCD signs of melanoma, is a clue to early diagnosis.141 The early dermatoscopic indicators of lentigo maligna are asymmetrical pigmented follicular openings, slate-grey short streaks and rhomboidal structures.13,41 Classic dermatoscopic features of extra-facial melanoma (an atypical pigment network, irregularly distributed dots, globules, streaks and pseudo-pods) and dermatoscopic criteria of vertical growth (ulceration, black structureless areas) have rarely been observed in cases of lentigo maligna.151 In the case of lentigo maligna of the auricle presented above, a large number of colors, an atypical pigment network and a number of black, structureless areas were also noted. Furthermore, the features typical for melanoma in situ such as those described previously by Seidnari et al., were all seen in the present case.[6]

Grazyna Kaminska-Winciorek1, Jacek Calik2, Jerzy Wydmanski13, Robert A Schwartz4,

Rafal CzajkowskF

1Dermato-Oncology Unit, The Center for Cancer Prevention and

Treatment, Katowice, 2Department of Oncology, Lower Silesian Oncology Center, Wroclaw, 3Department of Conventional and

Intraoperative Radiotherapy, Maria Sktodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland, "Dermatology, Preventive Medicine and Pathology, Rutgers New Jersey Medical School, Rutgers University, Newark, New Jersey, USA, 5Department of Dermatology, Sexually Transmitted Diseases and Immunodermatology, Ludwik Rydygier Medical College in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland

Address for correspondence: Dr. Grazyna Kaminska-Winciorek, Dermato-Oncology Unit, The Center for Cancer Prevention and Treatment, 16 Fliegera Street, 40-060 Katowice, Poland.



1. Blum A, Simionescu O, Argenziano G, Braun R, Cabo H, Eichhorn A, et al. Dermoscopy of pigmented lesions of the mucosa and the mucocutaneous junction: Results of a multicenter study by the International Dermoscopy Society (IDS). Arch Dermatol 2011;147:1181-7.

2. Lin J, Koga H, Takata M, Saida T. Dermoscopy of pigmented lesions on mucocutaneous junction and mucous membrane. Br J Dermatol 2009;161:1255-61.

3. Mannone F, De Giorgi V, Cattaneo A, Massi D, De Magnis A, Carli P. Dermoscopic features of mucosal melanosis. Dermatol Surg 2004;30:1118-23.

4. Stante M, Giorgi V, Stanganelli I, Alfaioli B, Carli P. Dermoscopy for early detection of facial lentigo maligna. Br J Dermatol 2005;152:361-4.

5. Pralong P, Bathelier E, Dalle S, Poulalhon N, Debarbieux S, Thomas L. Dermoscopy of lentigo maligna melanoma: Report of 125 cases. Br J Dermatol 2012;167:280-7.

6. Seidenari S, Bassoli S, Borsari S, Ferrari C, Giusti F, Ponti G, et al. Variegated dermoscopy of in situ melanoma. Dermatology 2012;224:262-70.

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Dermoscopy in tungiasis

A 24-year-old Chilean male complained of a painful white papule with a brownish central area on the lateral aspect of his left foot [Figure 1]. He noticed it immediately after returning from a 1-week trip to Paraguay. On dermoscopic examination, we observed a round lesion with a dark central pore, an incomplete radiated crown and a pigmented peripheral ring, arranged from the inner to outer aspect [Figure 2]. Additionally, blue-black blotches and whitish oval structures linked together forming chain like structures were noted [Figure 2]. A clinical diagnosis of tungiasis

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