Case Report Dermatology 1992;185:140-142
Dermatology Service and Dcrmatopathology Unit, Massachusetts General Hospital, Harvard Medical School, Boston. Mass., USA
Key Words Melanoma Leukoderma Vitiligo Giant congenital nevus Congenital nevi
Leukoderma In Association with Giant Congenital Nevi: Report of Two Cases
Abstract Two patients are presented in whom giant congenital nevi were associated with hypopigmentation. One patient has had no associated melanoma. The second patient developed hypopigmentation years before a melanoma was excised, and increased hypopigmentation was noted years later without evidence of mel anoma recurrence. While the mechanism for the development of the hypopig mentation noted in these two patients is uncertain, an immunologically medi ated systemic process may be responsible.
Introduction
Case Reports
Up to 5-20% of patients with melanoma have been reported to develop areas of hypopigmentation producing a vitiligo-like leukoderma [1-3]. Congenital nevi, in con trast to melanoma, have rarely been associated with pig ment loss. Patients with congenital halo nevi in the absence of an associated melanoma have been observed [4-6]. Reported here are two patients with giant congenital nevi associated with leukoderma who have been followed at the Pigmented Lesion Clinic (PLC) at the Massachusetts Gen eral Hospital. The first patient had a giant congenital nevus without an associated melanoma and has developed recent progressive hypopigmentation. The second patient, also with a giant congenital nevus, has had hypopigmentation since childhood. Progression of the preexisting hypopig mentation has occurred 25 years after the removal of a mel anoma arising within the congenital nevus.
Patient 1 is a 49-ycar-old Japanese female who presented to our PLC in January 1982 for evaluation of her giant congenital nevus. On initial examination, she had a giant congenital hairy nevus in a cape like distribution extending around her flank regions bilaterally to the anterior axillary line. In addition, she had multiple 0.5- to 4-cm ‘satel lite’ raised hyperpigmented plaques on her extremities, buttocks, face and vulva consistent clinically with small congenital nevi. The pigmen tation in the giant lesion was variegated, with blue, grey and black in addition to the dominant brown, and was enhanced by Wood’s light examination. There were also multiple areas of hypopigmentation on the dorsal portion of the nevus, most marked in the left suprascapular region. The patient reported that these localized areas had been treated with dry ice during childhood. These areas had some firm feel ing, suggesting the presence of localized scarring. She denied any recent changes in her nevus. Within the nevus, she had 2 firm, nontender subcutaneous nodules in the paraspinal region. She denied a family history of either melanoma or vitiligo. She had had a right axillary node biopsy in 1982 for enlarged lymph nodes which showed inflammation and a fatty, nonnecrotizing granuloma tous infiltration.
V.A.A. is currently a house officer at Newton* Wellesley Hospital. Newton. Mass.. USA. The study was supported in part by the Marion Gardner Jackson Trust. Bank of Boston. Trustee.
Arthur J. Sober. MI) Department of Dermatology Bartlett 410, Massachusetts General Hospital 32 Fruit St.. Boston. MA 02114 (USA)
Received: November 14, 1991 Accepted: February 21, 1992
© 1992 Karger AG. Basel 1018-8665/92/1852-0140 $ 2.75/0
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 2:53:55 PM
V.A. Alberta R. Barnhillh A.J. Sobera
Discussion Approximately 1% of all infants are born with a small congenital melanocytic nevus [8). Giant congenital nevi are much less common. The risk of melanoma developing in a giant congenital nevus has been estimated to be between 6 and 8% [9, 10], Congenital nevi may develop intralesional hypopigmentation and regression [11]. Halo congenital nevi have also been reported [4. 6, 11-13]. In contrast to
the well-documented association between melanoma and vitiligo-like leukoderma [1.7. 14—251. to our knowledge, there has been only one case report of a patient with a small congenital nevus in whom vitiligo-like leukoderma has developed without an associated malignant melanoma [41. Of note, both of our cases exhibited pigmentary loss involv ing the edge of the nevus and the adjacent normal skin (fig. 1.2). These changes were consistent with a partial halo effect. Patient 2 had a melanoma arising within his giant con genital nevus without evidence of recurrence after long term follow-up. The presence of vitiligo-like leukoderma in patients with melanoma has been associated with an improved survival over those patients without such an asso ciated hypopigmentation, even though the majority of these patients have concurrent nodal metastasis [17, 25]. Vitiligo-like leukoderma may precede the diagnosis of mel anoma or follow it making close follow-up of patient 1 important. In the scries of 27 patients with pigment loss and melanoma reported by Nordlund ct al. [25], 5 had preexist ing hypopigmentation prior to the diagnosis of melanoma. Although the patient described in the second case did notice increased hypopigmentation approximately 10 years following the removal of a primary melanoma, he did recall that these areas had been present since childhood. More over. in contrast to the noted association between vitiligolike leukoderma and melanoma recurrence or metastascs. this patient has remained free of recurrence. This patient's hypopigmentation may have no relationship to his mel anoma. The hypopigmentation in the dorsal aspects of the lesion in patient 1 which was secondary to dry ice treatment in childhood was unrelated to the development of cuta neous and perilesional hypopigmentation more than 30 years later. The incidence of classic vitiligo is reported to be 1-2% in the general population [2,3, 22,25] and 1.3% in patients at the time of diagnosis of their primary melanoma [18]. While some investigators report that 5-20% of patients with malignant melanoma develop hypopigmentary changes [2, 25], in our experience melanoma-associated vitiligo-like leukoderma is relatively uncommon. Patients with halo nevi have an increased incidence of vitiligo 112]. An increased incidence of halo nevi has also been observed in patients with true vitiligo [17]. Lerncr and Nordlund [22] report that as many as 50% of patients with vitiligo also have halo nevi and speculate that vitiligo may begin with the development of these lesions. Although there have been very few cases of congenital halo nevi reported [4.6. 11-13], Berger and Voorhees [ 12] describe a patient with a bathing trunk giant congenital nevus in
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The patient was followed at 3-month intervals without change in the nevus until October 1983 when she developed increased tender ness in one of the subcutaneous nodules mentioned above. A biopsy of this area was consistent with a congenital nevus without evidence of atypia. In June 1988, she noted new areas of hypopigmentation. This loss of pigmentation developed away from the nevus on the flexor surfaces of her wrists bilaterally (right > left) as well as on her anterior chest and along the edge of the nevus (fig. I). These areas were normal in texture and showed no evidence of scarring. No histologic evidence of malignant transformation in the nevus was detected. The patient underwent ophthalmologic and gynecologic examinations to exclude a primary melanoma in cither of these areas and to assess ocular fundi for hypopigmentary changes associated with melanoma [7|. These ex aminations were unremarkable. She continues to be followed at 3- to 4-month intervals. Although the areas of hypopigmentation and depigmentation have progressed clinically, no malignant transformation in the nevus has been detected thus far (January 1992). Patient 2 is a 59-year-old white male with a giant congenital nevus and a history of malignant melanoma on the posterior neck diagnosed in February 1965 who presented to our PLC in November 1988. The patient had a giant congenital nevus in a cape-like distribution extend ing down his left arm, up to his occiput and around to his anterior chest with multiple satellite lesions over his arms. legs, right temple and but tocks. The pigmentation was variegated with blue, brown and black. There were also multiple foci of hypopigmentation and depigmenta tion within the nevus, especially in the left shoulder region and along the inferior edge of the nevus (fig. 2). The patient reported that these areas of hypopigmentation had been present for decades, long before the melanoma had developed, but had progressed over the 25 years following its excision. The patient denied any recent changes in his nevus. A 2-cm subcutaneous nodule in the left upper extremity was also noted. Given the patient's past history of melanoma arising in a nodular lesion, an cxcisional biopsy was performed, and histology revealed a lipoma. Neither lymphadenopathy nor hcpatosplcnomcgaly were detected. The patient denied a family history of melanoma but did report that his maternal aunt had localized 'hypopigmentation' on her skin. He did not know if she had vitiligo. He has had normal yearly ophthal mologic examinations. The patient has subsequently been followed at 6-month intervals without evidence of additional primary tumors or métastasés. Regres sion of the border and an increase in the areas of hypopigmentation both within and outside of the nevus, however, have been noted dur ing follow-up.
whom a halo developed around the lesion. An immunolo gic mechanism has been postulated for the development of this hypopigmentation based on both the hispathology of the lesions and the association between vitiligo and halo nevi mentioned above. In the study by Berger and Voorhees, as well as in other studies [4, 19,22], a dense lymphohistiocytic infiltrate in the dermis surrounding halo nevi has been observed. The evidence for such an immunologic mechanism for the development of leukoderma in melanoma is based largely on clinical observation, such as following immunostimulation with bacillus Calmette-Guerin [26] or vaccinia virus [27] and the cooccurrence of melanoma-associated
vitiligo-like leukoderma and uveitis [14], poliosis [14], iritis [18] or halo nevi [19], Direct evidence is scarce. The mech anism for the development of the hypopigmentation noted in the two patients in the report is uncertain. Both patients will be monitored closely for evidence of malignant change in their congenital nevi as well as in other areas. It is crucial to examine patients with giant congenital nevi and the associated hypopigmentary phenomenon on a regular basis, given the established association between melanoma and vitiligo-like leukoderma [2,3,7, 14-24] and the association between melanoma and giant congenital nevi [9],
1 Albert DM. Todcs-Taylor N. Wagoner M. Nordlund JJ. Lcrner AB: Vitiligo or halo nevi occurring in two patients with choroid mel anoma. Arch Dermatol 1982:118:34-36. 2 I.erner AB. Cage GW: Melanomas in horses. Yale J Biol Med 1973:46:646-649. 3 Klaus SN. Lcrner AB. Bystryn JC. Moellmann G . Quevedo W. Sober AJ: IX. Malignant mel anoma and vitiligo. J Invest Dermatol 1979: 73(No 5. pt 11):491—494. 4 Brownstein MH. Kazam BB. Hashimoto K: Halo congenital nevus. Arch Dermatol 1977:113:1572-1575. 5 Kopf AW. Bart RS: Tumor conference No 36: A congenital pigmented nevus associated with leukoderma. J Dermatol Surg Oncol 1981:7: 547-549. 6 Langer K. Konrad K: Congenital melanocytie nevi with halo phenomenon: Report of two eases and review of the literature. J Dermatol Surg Oncol 1990:16:377-380. 7 Chang MA. Fournier G. Koh I IK. Sober AJ. Nakagawa H. Fitzpatrick TB. Albert DM: Ocular abnormalities associated with cuta neous melanoma and vitiligo-like leukoderma. Graefe’s Arch Clin Exp Ophthalmol 1986:224: 529-535. 8 Rhodes AR: Neoplasms: Benign neoplasias, hyperplasias, and dysplasias of melanocytes: in Fitzpatrick TB. et al. (cds): Dermatology in General Medicine. McGraw-Hill, ed 3. New York. 1987. p 902. 9 Rhodes AR. Wood WC. Sober AJ. Mihm MC: Non-epidermal origin of melanoma associated with a giant congenital ncvoccllular nevus. Plast Reconstr Surg 1981:62:782-790.
10 Kopf AW. Bart RS. Hennessey P: Congenital melanocytie nevi and malignant melanomas. J Am Acad Dermatol 1979:1:123-130. 11 Ridley CM: Giant halo nevus with spontaneous resolution. Trans St Johns Hosp Dermatol Soc 1974:60:54-58. 12 Berger RS. Voorhces JJ: Multiple congenital giant nevocellular nevi with halos. Arch Der matol 1971:104:515-521. 13 Garcia RL. Gano SE: Halo congenital nevus. Cutis 1979:23:338-339. 14 Sober AJ. Haynes HA: Uveitis, poliosis, hypomelanosis. and alopecia in a patient with malig nant melanoma. Arch Dermatol 1978:114: 439-441. 15 Nordlund JJ: Hypopigmentation. vitiligo, and melanoma. Arch Dermatol 1987:123: 1005-1008. 16 Bystryn JC. Rigel D. Friedman R.I. Kopf A: Prognostic significance of hypopigmentation in malignant melanoma. Arch Dermatol 1987; 123:1053-1055. 17 Koh HK. Sober AJ. Nakagawa 11. Albert DM. Mihm MC. Fitzpatrick TB: Malignant mel anoma and vitiligo-like leukoderma: An elec tron microscopic study. J Am Acad Dermatol 1983:9:696-708. 18 Albert DM. Sober AJ. Fitzpatrick TB: Iritis in patients with cutaneous melanoma and vitiligo. Arch Ophthalmol 1978:96:2081-2084. 19 Mitchell MS. Nordlung JJ. Lcrner AB: Com parison of cell-mediated immunity to mel anoma cells in patients with vitiligo, halo nevi or melanoma. J Invest Dermatol 1980:75: 144-147.
20 Millikan LE. Hook RR. Manning PJ: Gross and ultrastructural studies in a new melanoma model: The Sinclair swine. Yale J Biol Med 1973:46:631-645. 21 Takahashi M. Sober AJ. Mosher DB. Fitzpa trick TB. Farinelli WA: Vitiligo-like leuko derma in patients with metastatic malignant melanoma. Pigment Cell 1979:5:73-87. 22 Lcrner AB. Nordlund JJ: Vitiligo: What is it? Is it important? JAMA 1978;239:1183-1187. 23 Fodor J . Bodrogi 1: Vitiligo and malignant mel anoma. Neoplasma 1975:22:445—448. 24 L.erner AB. Nordlund JJ: Should vitiligo be induced in patients after resection of primary melanoma? Arch Dermatol 1977:113:421. 25 Nordlund JJ. Kirkwood JM. Forget BM. Milton G. Albert DM. Lcrner AB: Vitiligo in patients with metastatic melanoma: A good prognostic sign. J Am Acad Dermatol 1983: 9:689-696. 26 Donaldson RC. Canaan SA. McCIcan RB. Ackerman I.V: Uveitis and vitiligo associated with BCG treatments for malignant mel anoma. Surgery 1974:76:771-778. 27 Burdick KIL Hawk W: Vitiligo in a case of vac cinia virus treated melanoma. Cancer 1964: 17:708-712.
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References
Dermatology Service and Dcrmatopathology Unit, Massachusetts General Hospital, Harvard Medical School, Boston. Mass., USA
Key Words Melanoma Leukoderma Vitiligo Giant congenital nevus Congenital nevi
Leukoderma In Association with Giant Congenital Nevi: Report of Two Cases
Abstract Two patients are presented in whom giant congenital nevi were associated with hypopigmentation. One patient has had no associated melanoma. The second patient developed hypopigmentation years before a melanoma was excised, and increased hypopigmentation was noted years later without evidence of mel anoma recurrence. While the mechanism for the development of the hypopig mentation noted in these two patients is uncertain, an immunologically medi ated systemic process may be responsible.
Introduction
Case Reports
Up to 5-20% of patients with melanoma have been reported to develop areas of hypopigmentation producing a vitiligo-like leukoderma [1-3]. Congenital nevi, in con trast to melanoma, have rarely been associated with pig ment loss. Patients with congenital halo nevi in the absence of an associated melanoma have been observed [4-6]. Reported here are two patients with giant congenital nevi associated with leukoderma who have been followed at the Pigmented Lesion Clinic (PLC) at the Massachusetts Gen eral Hospital. The first patient had a giant congenital nevus without an associated melanoma and has developed recent progressive hypopigmentation. The second patient, also with a giant congenital nevus, has had hypopigmentation since childhood. Progression of the preexisting hypopig mentation has occurred 25 years after the removal of a mel anoma arising within the congenital nevus.
Patient 1 is a 49-ycar-old Japanese female who presented to our PLC in January 1982 for evaluation of her giant congenital nevus. On initial examination, she had a giant congenital hairy nevus in a cape like distribution extending around her flank regions bilaterally to the anterior axillary line. In addition, she had multiple 0.5- to 4-cm ‘satel lite’ raised hyperpigmented plaques on her extremities, buttocks, face and vulva consistent clinically with small congenital nevi. The pigmen tation in the giant lesion was variegated, with blue, grey and black in addition to the dominant brown, and was enhanced by Wood’s light examination. There were also multiple areas of hypopigmentation on the dorsal portion of the nevus, most marked in the left suprascapular region. The patient reported that these localized areas had been treated with dry ice during childhood. These areas had some firm feel ing, suggesting the presence of localized scarring. She denied any recent changes in her nevus. Within the nevus, she had 2 firm, nontender subcutaneous nodules in the paraspinal region. She denied a family history of either melanoma or vitiligo. She had had a right axillary node biopsy in 1982 for enlarged lymph nodes which showed inflammation and a fatty, nonnecrotizing granuloma tous infiltration.
V.A.A. is currently a house officer at Newton* Wellesley Hospital. Newton. Mass.. USA. The study was supported in part by the Marion Gardner Jackson Trust. Bank of Boston. Trustee.
Arthur J. Sober. MI) Department of Dermatology Bartlett 410, Massachusetts General Hospital 32 Fruit St.. Boston. MA 02114 (USA)
Received: November 14, 1991 Accepted: February 21, 1992
© 1992 Karger AG. Basel 1018-8665/92/1852-0140 $ 2.75/0
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 2:53:55 PM
V.A. Alberta R. Barnhillh A.J. Sobera
Discussion Approximately 1% of all infants are born with a small congenital melanocytic nevus [8). Giant congenital nevi are much less common. The risk of melanoma developing in a giant congenital nevus has been estimated to be between 6 and 8% [9, 10], Congenital nevi may develop intralesional hypopigmentation and regression [11]. Halo congenital nevi have also been reported [4. 6, 11-13]. In contrast to
the well-documented association between melanoma and vitiligo-like leukoderma [1.7. 14—251. to our knowledge, there has been only one case report of a patient with a small congenital nevus in whom vitiligo-like leukoderma has developed without an associated malignant melanoma [41. Of note, both of our cases exhibited pigmentary loss involv ing the edge of the nevus and the adjacent normal skin (fig. 1.2). These changes were consistent with a partial halo effect. Patient 2 had a melanoma arising within his giant con genital nevus without evidence of recurrence after long term follow-up. The presence of vitiligo-like leukoderma in patients with melanoma has been associated with an improved survival over those patients without such an asso ciated hypopigmentation, even though the majority of these patients have concurrent nodal metastasis [17, 25]. Vitiligo-like leukoderma may precede the diagnosis of mel anoma or follow it making close follow-up of patient 1 important. In the scries of 27 patients with pigment loss and melanoma reported by Nordlund ct al. [25], 5 had preexist ing hypopigmentation prior to the diagnosis of melanoma. Although the patient described in the second case did notice increased hypopigmentation approximately 10 years following the removal of a primary melanoma, he did recall that these areas had been present since childhood. More over. in contrast to the noted association between vitiligolike leukoderma and melanoma recurrence or metastascs. this patient has remained free of recurrence. This patient's hypopigmentation may have no relationship to his mel anoma. The hypopigmentation in the dorsal aspects of the lesion in patient 1 which was secondary to dry ice treatment in childhood was unrelated to the development of cuta neous and perilesional hypopigmentation more than 30 years later. The incidence of classic vitiligo is reported to be 1-2% in the general population [2,3, 22,25] and 1.3% in patients at the time of diagnosis of their primary melanoma [18]. While some investigators report that 5-20% of patients with malignant melanoma develop hypopigmentary changes [2, 25], in our experience melanoma-associated vitiligo-like leukoderma is relatively uncommon. Patients with halo nevi have an increased incidence of vitiligo 112]. An increased incidence of halo nevi has also been observed in patients with true vitiligo [17]. Lerncr and Nordlund [22] report that as many as 50% of patients with vitiligo also have halo nevi and speculate that vitiligo may begin with the development of these lesions. Although there have been very few cases of congenital halo nevi reported [4.6. 11-13], Berger and Voorhees [ 12] describe a patient with a bathing trunk giant congenital nevus in
141
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The patient was followed at 3-month intervals without change in the nevus until October 1983 when she developed increased tender ness in one of the subcutaneous nodules mentioned above. A biopsy of this area was consistent with a congenital nevus without evidence of atypia. In June 1988, she noted new areas of hypopigmentation. This loss of pigmentation developed away from the nevus on the flexor surfaces of her wrists bilaterally (right > left) as well as on her anterior chest and along the edge of the nevus (fig. I). These areas were normal in texture and showed no evidence of scarring. No histologic evidence of malignant transformation in the nevus was detected. The patient underwent ophthalmologic and gynecologic examinations to exclude a primary melanoma in cither of these areas and to assess ocular fundi for hypopigmentary changes associated with melanoma [7|. These ex aminations were unremarkable. She continues to be followed at 3- to 4-month intervals. Although the areas of hypopigmentation and depigmentation have progressed clinically, no malignant transformation in the nevus has been detected thus far (January 1992). Patient 2 is a 59-year-old white male with a giant congenital nevus and a history of malignant melanoma on the posterior neck diagnosed in February 1965 who presented to our PLC in November 1988. The patient had a giant congenital nevus in a cape-like distribution extend ing down his left arm, up to his occiput and around to his anterior chest with multiple satellite lesions over his arms. legs, right temple and but tocks. The pigmentation was variegated with blue, brown and black. There were also multiple foci of hypopigmentation and depigmenta tion within the nevus, especially in the left shoulder region and along the inferior edge of the nevus (fig. 2). The patient reported that these areas of hypopigmentation had been present for decades, long before the melanoma had developed, but had progressed over the 25 years following its excision. The patient denied any recent changes in his nevus. A 2-cm subcutaneous nodule in the left upper extremity was also noted. Given the patient's past history of melanoma arising in a nodular lesion, an cxcisional biopsy was performed, and histology revealed a lipoma. Neither lymphadenopathy nor hcpatosplcnomcgaly were detected. The patient denied a family history of melanoma but did report that his maternal aunt had localized 'hypopigmentation' on her skin. He did not know if she had vitiligo. He has had normal yearly ophthal mologic examinations. The patient has subsequently been followed at 6-month intervals without evidence of additional primary tumors or métastasés. Regres sion of the border and an increase in the areas of hypopigmentation both within and outside of the nevus, however, have been noted dur ing follow-up.
whom a halo developed around the lesion. An immunolo gic mechanism has been postulated for the development of this hypopigmentation based on both the hispathology of the lesions and the association between vitiligo and halo nevi mentioned above. In the study by Berger and Voorhees, as well as in other studies [4, 19,22], a dense lymphohistiocytic infiltrate in the dermis surrounding halo nevi has been observed. The evidence for such an immunologic mechanism for the development of leukoderma in melanoma is based largely on clinical observation, such as following immunostimulation with bacillus Calmette-Guerin [26] or vaccinia virus [27] and the cooccurrence of melanoma-associated
vitiligo-like leukoderma and uveitis [14], poliosis [14], iritis [18] or halo nevi [19], Direct evidence is scarce. The mech anism for the development of the hypopigmentation noted in the two patients in the report is uncertain. Both patients will be monitored closely for evidence of malignant change in their congenital nevi as well as in other areas. It is crucial to examine patients with giant congenital nevi and the associated hypopigmentary phenomenon on a regular basis, given the established association between melanoma and vitiligo-like leukoderma [2,3,7, 14-24] and the association between melanoma and giant congenital nevi [9],
1 Albert DM. Todcs-Taylor N. Wagoner M. Nordlund JJ. Lcrner AB: Vitiligo or halo nevi occurring in two patients with choroid mel anoma. Arch Dermatol 1982:118:34-36. 2 I.erner AB. Cage GW: Melanomas in horses. Yale J Biol Med 1973:46:646-649. 3 Klaus SN. Lcrner AB. Bystryn JC. Moellmann G . Quevedo W. Sober AJ: IX. Malignant mel anoma and vitiligo. J Invest Dermatol 1979: 73(No 5. pt 11):491—494. 4 Brownstein MH. Kazam BB. Hashimoto K: Halo congenital nevus. Arch Dermatol 1977:113:1572-1575. 5 Kopf AW. Bart RS: Tumor conference No 36: A congenital pigmented nevus associated with leukoderma. J Dermatol Surg Oncol 1981:7: 547-549. 6 Langer K. Konrad K: Congenital melanocytie nevi with halo phenomenon: Report of two eases and review of the literature. J Dermatol Surg Oncol 1990:16:377-380. 7 Chang MA. Fournier G. Koh I IK. Sober AJ. Nakagawa H. Fitzpatrick TB. Albert DM: Ocular abnormalities associated with cuta neous melanoma and vitiligo-like leukoderma. Graefe’s Arch Clin Exp Ophthalmol 1986:224: 529-535. 8 Rhodes AR: Neoplasms: Benign neoplasias, hyperplasias, and dysplasias of melanocytes: in Fitzpatrick TB. et al. (cds): Dermatology in General Medicine. McGraw-Hill, ed 3. New York. 1987. p 902. 9 Rhodes AR. Wood WC. Sober AJ. Mihm MC: Non-epidermal origin of melanoma associated with a giant congenital ncvoccllular nevus. Plast Reconstr Surg 1981:62:782-790.
10 Kopf AW. Bart RS. Hennessey P: Congenital melanocytie nevi and malignant melanomas. J Am Acad Dermatol 1979:1:123-130. 11 Ridley CM: Giant halo nevus with spontaneous resolution. Trans St Johns Hosp Dermatol Soc 1974:60:54-58. 12 Berger RS. Voorhces JJ: Multiple congenital giant nevocellular nevi with halos. Arch Der matol 1971:104:515-521. 13 Garcia RL. Gano SE: Halo congenital nevus. Cutis 1979:23:338-339. 14 Sober AJ. Haynes HA: Uveitis, poliosis, hypomelanosis. and alopecia in a patient with malig nant melanoma. Arch Dermatol 1978:114: 439-441. 15 Nordlund JJ: Hypopigmentation. vitiligo, and melanoma. Arch Dermatol 1987:123: 1005-1008. 16 Bystryn JC. Rigel D. Friedman R.I. Kopf A: Prognostic significance of hypopigmentation in malignant melanoma. Arch Dermatol 1987; 123:1053-1055. 17 Koh HK. Sober AJ. Nakagawa 11. Albert DM. Mihm MC. Fitzpatrick TB: Malignant mel anoma and vitiligo-like leukoderma: An elec tron microscopic study. J Am Acad Dermatol 1983:9:696-708. 18 Albert DM. Sober AJ. Fitzpatrick TB: Iritis in patients with cutaneous melanoma and vitiligo. Arch Ophthalmol 1978:96:2081-2084. 19 Mitchell MS. Nordlung JJ. Lcrner AB: Com parison of cell-mediated immunity to mel anoma cells in patients with vitiligo, halo nevi or melanoma. J Invest Dermatol 1980:75: 144-147.
20 Millikan LE. Hook RR. Manning PJ: Gross and ultrastructural studies in a new melanoma model: The Sinclair swine. Yale J Biol Med 1973:46:631-645. 21 Takahashi M. Sober AJ. Mosher DB. Fitzpa trick TB. Farinelli WA: Vitiligo-like leuko derma in patients with metastatic malignant melanoma. Pigment Cell 1979:5:73-87. 22 Lcrner AB. Nordlund JJ: Vitiligo: What is it? Is it important? JAMA 1978;239:1183-1187. 23 Fodor J . Bodrogi 1: Vitiligo and malignant mel anoma. Neoplasma 1975:22:445—448. 24 L.erner AB. Nordlund JJ: Should vitiligo be induced in patients after resection of primary melanoma? Arch Dermatol 1977:113:421. 25 Nordlund JJ. Kirkwood JM. Forget BM. Milton G. Albert DM. Lcrner AB: Vitiligo in patients with metastatic melanoma: A good prognostic sign. J Am Acad Dermatol 1983: 9:689-696. 26 Donaldson RC. Canaan SA. McCIcan RB. Ackerman I.V: Uveitis and vitiligo associated with BCG treatments for malignant mel anoma. Surgery 1974:76:771-778. 27 Burdick KIL Hawk W: Vitiligo in a case of vac cinia virus treated melanoma. Cancer 1964: 17:708-712.
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References
![[Tissular expansion in giant congenital nevi treatment].](/assets/img/hold.png)
