Am J Dermatopathol Volume 37, Number 8, August 2015
Letters to the Editor
Monica Townsend, BA Jenna Wald, MD Michael Murphy, MD† Arni Kristjansson, MD† *University of Connecticut School of Medicine, Farmington, CT †Department of Dermatology, University of Connecticut, Health Center, Farmington, CT
REFERENCES 1. Tieche M. Uber benigne Melanome (Cromatophorome) der Haut-“Blaue Naevi.” Virchows Arch Pathol Anat. 1906;186:212. 2. Park YM, Kang H, Cho BK. Plaque-type blue nevus combined with nevus spilus and smooth muscle hyperplasia. Int J Dermatol. 1999; 38:775. 3. Patrizi A, Medri M, Neri I, et al. Becker naevus associated with basal cell carcinoma, melanocytic naevus and smooth muscle hamartoma. J Eur Acad Dermatol Venereol. 2007;21:130. 4. Tzu J, Goldman C, Perry AE, et al. Combined blue nevus-smooth muscle hamartoma: a series of 12 cases. J Cutan Pathol. 2013; 40:879. 5. Happle R. Superimposed segmental manifestation of polygenic skin disorders. J Am Acad Dermatol. 2007:57:690–699. 6. Happle R. What is paradominat inheritance? J Med Genet. 2009:46:648.
Nodular Melanoma Arising in a Large Segmental Speckled Lentiginous Nevus To the Editor: Melanoma has been reported to arise in up to 39 cases of speckled lentiginous nevus (SLN), mostly of small or intermediate size (,20 cm). A few cases of melanoma arose in large segmental SLNs (.20 cm). The most frequent type of melanoma has been the superficial spreading type.1 At least 2 cases of nodular melanoma have been described to arise in SLN.2,3 We describe a 63-year-old man who developed nodular melanoma in a large segmental SLN with local lymph node involvement and a metastatic disease that led to his death. The patient The authors declare no conflicts of interest.
FIGURE 1. SLN with a hyperpigmented large patch and numerous brown macules and papules distributed in a zosterform pattern.
presented initially with acute neurological findings including dysarthria, nystagmus, ataxia, and dysmetria of the 4 limbs. A lumbar puncture revealed atypical unidentified cells in the cerebrospinal fluid, but brain computed tomography (CT) was normal. Magnetic resonance imaging was contraindicated because of an old shrapnel in the brain. A chest, abdomen, and pelvic CT scan revealed an enlarged lymph node 3 cm in diameter in the left axilla. A biopsy from this lymph node demonstrated metastatic melanoma. The patient was referred to our center for further management. The skin examination revealed large segmental SLN that covered his left thorax, upper limb, shoulder, and axilla (Fig. 1). In the left axilla, there was also a pink indurated nodule with
central dark hyperpigmentation (Fig. 2). Positron emission tomography revealed pathological uptake in a lymph node and the overlying skin in the left axilla and in the left proximal femur. Histopathological examination of a skin nodule demonstrated nodular melanoma, with a Breslow thickness of 8 mm (Fig. 3A, B). There was also a junctional and intraepidermal component of melanoma cells as in primary melanoma (Fig. 3C). A few elongated adjacent pigmented rete ridges that could be the remnants of a lentigo were also observed (Fig. 3D). Elective left axillary lymph node dissection revealed a single lymph node with melanoma metastasis. Analysis for a BRAF mutation was negative. A second lumbar puncture did not show atypical
FIGURE 2. A closer look at the SLN reveals a pink nodule with a central dark pigmentation.
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
www.amjdermatopathology.com |
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Am J Dermatopathol Volume 37, Number 8, August 2015
FIGURE 3. A, A biopsy of the nodule in Figure 1 demonstrates a thick nodular melanoma. B, Higher magnification shows typical melanoma cells with ample cytoplasm and atypical nuclei. C, Melanoma cells are present as single units and in nests at the dermoepidermal junction and slightly above it. D, Several adjacent hyperpigmented elongated rete ridges are also present in the melanoma, which could be the remnants of a macular component of a preexisting SLN.
cells, and there were no paraneoplastic antibodies in the serum. A second CT of the brain was also normal, and the Lactate dehydrogenase (LDH) levels were within the reference range. Nevertheless, the patient continued to deteriorate neurologically and physically despite radiation therapy to the brain and femur and administration of intravenous immunoglobulins because of suspected paraneoplastic cerebellar degeneration. He died shortly thereafter. The prevalence of SLN (also known as nevus spilus) is estimated to be between 1.3% and 2.3%. Its diameter ranges from 2 to 10 cm, but some may cover extensive skin areas with segmental or zosteriform distribution.1,4–6 SLN often appears at birth as a lightly colored macule, histologically
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| www.amjdermatopathology.com
described as lentigo simplex or caféau-lait macule. Over a period of months to years, darker pigmented macules and papules develop, which are usually junctional or compound nevi, and occasionally also intradermal nevi, Spitz nevi, and blue nevi.1,4–6 The nodular melanoma in our patient developed in a large segmental SLN, indicating that SLN including the segmental type should be monitored carefully and considered as a potential precursor of melanoma. Hadas Gescheidt-Shoshany, MD Sara Weltfriend, MD Reuven Bergman, MD† *Department of Dermatology, Rambam Medical Center, Haifa, Israel †The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
REFERENCES 1. Ly L, Christie M, Swain S, et al. Melanoma(s) arising in large segmental speckled lentiginous nevi: a case series. J Am Acad Dermatol. 2011; 64:1190–1193. 2. Corradin MT, Zattra E, Fiorentino R, et al. Nevus spilus and melanoma: case report and review of the literature. J Cutan Med Surg. 2010;14:85–89. 3. Grinspan D, Casala A, Abulafia J, et al. Melanoma on dysplastic nevus spilus. Int J Dermatol. 1997;36:499–502. 4. Haenssle HA, Kaune KM, Buhl T, et al. Melanoma arising in segmental nevus spilus: detection by sequential digital dermatoscopy. J Am Acad Dermatol. 2009;61: 337–341. 5. Abecassis S, Spatz A, Cazeneuve C, et al. Melanoma within naevus spilus: 5 cases [in French]. Ann Dermatol Venereol. 2006;133: 323–328. 6. Piana S, Gelli MC, Grenzi L, et al. Multifocal melanoma arising on nevus spilus. Int J Dermatol. 2006;45:1380–1381.
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Monica Townsend, BA Jenna Wald, MD Michael Murphy, MD† Arni Kristjansson, MD† *University of Connecticut School of Medicine, Farmington, CT †Department of Dermatology, University of Connecticut, Health Center, Farmington, CT
REFERENCES 1. Tieche M. Uber benigne Melanome (Cromatophorome) der Haut-“Blaue Naevi.” Virchows Arch Pathol Anat. 1906;186:212. 2. Park YM, Kang H, Cho BK. Plaque-type blue nevus combined with nevus spilus and smooth muscle hyperplasia. Int J Dermatol. 1999; 38:775. 3. Patrizi A, Medri M, Neri I, et al. Becker naevus associated with basal cell carcinoma, melanocytic naevus and smooth muscle hamartoma. J Eur Acad Dermatol Venereol. 2007;21:130. 4. Tzu J, Goldman C, Perry AE, et al. Combined blue nevus-smooth muscle hamartoma: a series of 12 cases. J Cutan Pathol. 2013; 40:879. 5. Happle R. Superimposed segmental manifestation of polygenic skin disorders. J Am Acad Dermatol. 2007:57:690–699. 6. Happle R. What is paradominat inheritance? J Med Genet. 2009:46:648.
Nodular Melanoma Arising in a Large Segmental Speckled Lentiginous Nevus To the Editor: Melanoma has been reported to arise in up to 39 cases of speckled lentiginous nevus (SLN), mostly of small or intermediate size (,20 cm). A few cases of melanoma arose in large segmental SLNs (.20 cm). The most frequent type of melanoma has been the superficial spreading type.1 At least 2 cases of nodular melanoma have been described to arise in SLN.2,3 We describe a 63-year-old man who developed nodular melanoma in a large segmental SLN with local lymph node involvement and a metastatic disease that led to his death. The patient The authors declare no conflicts of interest.
FIGURE 1. SLN with a hyperpigmented large patch and numerous brown macules and papules distributed in a zosterform pattern.
presented initially with acute neurological findings including dysarthria, nystagmus, ataxia, and dysmetria of the 4 limbs. A lumbar puncture revealed atypical unidentified cells in the cerebrospinal fluid, but brain computed tomography (CT) was normal. Magnetic resonance imaging was contraindicated because of an old shrapnel in the brain. A chest, abdomen, and pelvic CT scan revealed an enlarged lymph node 3 cm in diameter in the left axilla. A biopsy from this lymph node demonstrated metastatic melanoma. The patient was referred to our center for further management. The skin examination revealed large segmental SLN that covered his left thorax, upper limb, shoulder, and axilla (Fig. 1). In the left axilla, there was also a pink indurated nodule with
central dark hyperpigmentation (Fig. 2). Positron emission tomography revealed pathological uptake in a lymph node and the overlying skin in the left axilla and in the left proximal femur. Histopathological examination of a skin nodule demonstrated nodular melanoma, with a Breslow thickness of 8 mm (Fig. 3A, B). There was also a junctional and intraepidermal component of melanoma cells as in primary melanoma (Fig. 3C). A few elongated adjacent pigmented rete ridges that could be the remnants of a lentigo were also observed (Fig. 3D). Elective left axillary lymph node dissection revealed a single lymph node with melanoma metastasis. Analysis for a BRAF mutation was negative. A second lumbar puncture did not show atypical
FIGURE 2. A closer look at the SLN reveals a pink nodule with a central dark pigmentation.
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
www.amjdermatopathology.com |
663
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Am J Dermatopathol Volume 37, Number 8, August 2015
FIGURE 3. A, A biopsy of the nodule in Figure 1 demonstrates a thick nodular melanoma. B, Higher magnification shows typical melanoma cells with ample cytoplasm and atypical nuclei. C, Melanoma cells are present as single units and in nests at the dermoepidermal junction and slightly above it. D, Several adjacent hyperpigmented elongated rete ridges are also present in the melanoma, which could be the remnants of a macular component of a preexisting SLN.
cells, and there were no paraneoplastic antibodies in the serum. A second CT of the brain was also normal, and the Lactate dehydrogenase (LDH) levels were within the reference range. Nevertheless, the patient continued to deteriorate neurologically and physically despite radiation therapy to the brain and femur and administration of intravenous immunoglobulins because of suspected paraneoplastic cerebellar degeneration. He died shortly thereafter. The prevalence of SLN (also known as nevus spilus) is estimated to be between 1.3% and 2.3%. Its diameter ranges from 2 to 10 cm, but some may cover extensive skin areas with segmental or zosteriform distribution.1,4–6 SLN often appears at birth as a lightly colored macule, histologically
664
| www.amjdermatopathology.com
described as lentigo simplex or caféau-lait macule. Over a period of months to years, darker pigmented macules and papules develop, which are usually junctional or compound nevi, and occasionally also intradermal nevi, Spitz nevi, and blue nevi.1,4–6 The nodular melanoma in our patient developed in a large segmental SLN, indicating that SLN including the segmental type should be monitored carefully and considered as a potential precursor of melanoma. Hadas Gescheidt-Shoshany, MD Sara Weltfriend, MD Reuven Bergman, MD† *Department of Dermatology, Rambam Medical Center, Haifa, Israel †The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
REFERENCES 1. Ly L, Christie M, Swain S, et al. Melanoma(s) arising in large segmental speckled lentiginous nevi: a case series. J Am Acad Dermatol. 2011; 64:1190–1193. 2. Corradin MT, Zattra E, Fiorentino R, et al. Nevus spilus and melanoma: case report and review of the literature. J Cutan Med Surg. 2010;14:85–89. 3. Grinspan D, Casala A, Abulafia J, et al. Melanoma on dysplastic nevus spilus. Int J Dermatol. 1997;36:499–502. 4. Haenssle HA, Kaune KM, Buhl T, et al. Melanoma arising in segmental nevus spilus: detection by sequential digital dermatoscopy. J Am Acad Dermatol. 2009;61: 337–341. 5. Abecassis S, Spatz A, Cazeneuve C, et al. Melanoma within naevus spilus: 5 cases [in French]. Ann Dermatol Venereol. 2006;133: 323–328. 6. Piana S, Gelli MC, Grenzi L, et al. Multifocal melanoma arising on nevus spilus. Int J Dermatol. 2006;45:1380–1381.
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
