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Table of Contents 
CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 6  |  Page : 606-608
Malignant melanoma clinically masquerading vascular tumor: A diagnostic dilemma


Department of Dermatology, Medical College and Hospital, Kolkata, Kolkata, West Bengal, India

Date of Web Publication5-Nov-2015

Correspondence Address:
Indrashis Podder
Department of Dermatology, Medical College and Hospital, Kolkata, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.169137

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   Abstract 

Malignant melanoma is an invasive neoplasm of the skin, whose incidence is reported to be rising among Indians. We hereby present a unique case of unilateral, multiple, asymptomatic, pigmented, nodular lesions over the lower limb; resembling vascular tumor, revealing itself as malignant melanoma only on histopathology. To the best of our knowledge, such a unique presentation of malignant melanoma has not yet been reported from the Indian subcontinent.


Keywords: Malignant melanoma, unilateral, vascular tumor


How to cite this article:
Pradhan S, Sancheti K, Podder I, Gharami RC. Malignant melanoma clinically masquerading vascular tumor: A diagnostic dilemma. Indian J Dermatol 2015;60:606-8

How to cite this URL:
Pradhan S, Sancheti K, Podder I, Gharami RC. Malignant melanoma clinically masquerading vascular tumor: A diagnostic dilemma. Indian J Dermatol [serial online] 2015 [cited 2020 Nov 27];60:606-8. Available from: https://www.e-ijd.org/text.asp?2015/60/6/606/169137

What was known?
Malignant melanoma is a rare melanocytic tumor, which is uncommon in these parts of the world.



   Introduction Top


Melanoma is a malignant tumor arising from melanocytes; often invasive in nature. Although traditionally malignant melanoma has been considered a tumor of the Caucasians, recently, an increasing incidence is being noted in India. [1] Because of its rarity, its presentation often presents a baffling picture. We present here a case of malignant melanoma, resembling a vascular tumor; the first of its kind from the Indian subcontinent.


   Case Report Top


A 40-year-old gentleman presented to us with multiple asymptomatic, pigmented, nodular lesions, resembling cluster of grapes, distributed over the medial aspect of right lower limb. Initially, there was a single nodular lesion, which rapidly increased in size over the next 3 months; gradually new nodules arose in the vicinity which coalesced with each other to form a plaque. He also complained of heaviness due to a mass in his right groin. His past medical and surgical history including drug history were unremarkable. Fever or other constitutional symptoms were absent except for the presence of significant weight loss and occasional episodes of bleeding from the lesions when subjected to trivial trauma; he also complained of occasional breathlessness and two episodes of bloody expectoration following cough.

On dermatological examination, multiple dome-shaped nodular lesions were found on the distal part of right lower limb; ranging from 2-3 mm in diameter to plaque of 5 cm × 7 cm with bosselated surface; formed by the coalescence of individual nodules [Figure 1]. The color varied from light to dark mottled brown with some lesions showing atrophy and superficial ulceration. On palpation, they were firm, nontender nodules with the smooth, glossy surface, with woody hard induration of the underlying skin. A few lesions were ulcerated, which exuded blood on touching. General survey was normal except for the presence of pallor and a palpable mass in the right inguinal region sized about 7 cm × 3 cm which was hard and immobile [Figure 2]. Routine hematologic and biochemical investigations were within normal limits except for the presence of anemia (Hb - 8.4g/dl) and an elevated erythrocyte sedimentation rate (55 mm/h). The patient was referred to the Department of General Medicine to evaluate his respiratory complaint and rule out any other evidence of systemic metastasis.
Figure 1: (a and b) Multiple brownish dome-shaped nodular lesions with a bosselated surface, right lower limb

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Figure 2: Right inguinal lymphadenopathy

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On histopathological examination (HPE), sections showed a proliferative growth centered in the upper dermis with marked thinning of the epidermis [Figure 3]. Tumor cells were arranged in nests with focal infiltration of adnexa [Figure 4]. The cells were polygonal with hyperchromatic nuclei, perinuclear halo, and prominent nucleoli; also inclusion bodies were found with conspicuous mitotic activity [Figure 5]. Melanin pigment was frequently seen. Separate cell nests of tumor cells and tumor emboli were identified. These HPE features suggested the diagnosis of malignant melanoma. We referred the patient to the Department of Oncology for chemotherapy or radiation.
Figure 3: Proliferative growth in the upper dermis with marked thinning of epidermis (H and E, ×40)

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Figure 4: Lobulated mass showing closely packed pigmented cells (H and E, ×100)

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Figure 5: The mass showing clustered polygonal cells with hyperchromatic nuclei and perinuclear halo (H and E, ×400)

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   Discussion Top


Melanoma is a malignant tumor arising from melanocytes. Clark et al. divided malignant melanoma into three main subsets, [2] by using a combination of clinical and pathological features; the superficial spreading melanoma, the nodular melanoma, and the lentigo maligna melanoma. Reed et al. added a fourth group, the acral lentiginous or palmoplantar malignant melanoma. [3] The National Institutes of Health consensus conference on the diagnosis of melanoma has suggested the use of the asymmetry, border irregularity, color variegation, diameter >6 mm checklist for the detection of melanocytic lesions. Risk factors for the development of melanoma may be divided into three categories: Phenotypic manifestations of gene/environment interactions, environmental factor, and genetic factors. [4],[5] These factors may also determine subtypes and anatomic localization of melanoma. The histological diagnosis of melanoma is based on the assessment of a constellation of findings, including both architectural and cytological features. Cytological atypia, nuclear enlargement, nuclear pleomorphism, hyperchromasia of nuclei, nucleolar variability, and the presence of mitoses especially deep in the dermis, is considered necessary for a diagnosis of melanoma. There is a lack of maturation of nests of melanocytes with a descent into the dermis. Pagetoid spread of large solitary epidermal melanocytes is usually considered diagnostic of melanoma. In our case, the histopathology is consistent with findings of melanoma.

However, clinically our case resembled Kaposi sarcoma, hemangioendothelioma, angiosarcoma, etc. Kaposi sarcoma is multifocal, endothelial proliferation predominantly involving the skin and other organs and associated with the formation of vascular channels and proliferation of the spindle-shaped cell. Clinically, skin lesions vary from small violaceous papules to large plaques to ulcerated nodules. Initially, the upper body is involved, often along skin lines in a pityriasis rosea-like pattern and at sites of local trauma. Lesions develop on the face, in particular, the nose, and on oral mucosal surfaces, including the gums and hard palate. [6] During tumor progression the color changes to brownish and the skin overlying the tumor becomes hyperkeratotic and, in particular on the lower extremities, may ulcerate. [7],[8],[9] Surrounding the tumor there is frequently a pitting edema which may evolve into fibrosis. On HPE, tumor lobules are composed of bland, spindle-shaped cells with poorly defined, pink cytoplasm along with extensive vascular proliferation at all levels of the dermis. Our case seemed clinically similar, but histopathology clinched it as melanoma.

Retiform hemangioendothelioma presents mainly in young adults, with no sex predilection, as a slowly growing, asymptomatic, dermal, and subcutaneous plaque or nodule. Histology reveals arborizing, thin-walled, narrow, vascular channels with a striking resemblance to the rete testis. Angiosarcoma is a malignant vascular tumors arising from both vascular and lymphatic endothelium. [10],[11] Dusky blue or red nodules develop and grow rapidly, and fresh, discrete nodules appear nearby. In some cases, hemorrhagic blisters are a prominent feature. As the tumors grow, the edema may increase, and older lesions may ulcerate. On histology vascular channels infiltrate the normal structures in a disorganized fashion along with the characteristic "dissection of collagen." In our case, none of the histological features of hemangioendothelioma or angiosarcoma was present.

There have been reports of rare disseminated malignant melanoma presenting as multiple asymptomatic, nodular lesions on the trunk, extremities, and the face [12] and a rare sporotrichoid pattern of malignant melanoma. [13] However, our case is unique as it is malignant melanoma mimicking closely mimicking a vascular tumor; where the final diagnosis could only be reached on HPE. Very few reports have depicted an unilateral distribution of malignant melanoma; [14],[15] in our case also the lesions are unilateral; distributed only over the right lower limb; this has further added to the uniqueness of our case.

Malignant melanoma is itself a rare disease in our set-up, further the unilateral distribution and clinical resemblance to vascular tumors has made our case even more unique; all these features prompted the current case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Johnson TM, Chang A, Redman B, Rees R, Bradford C, Riba M, et al. Management of melanoma with a multidisciplinary melanoma clinic model. J Am Acad Dermatol 2000;42 (5 Pt 1):820-6.  Back to cited text no. 1
    
2.
Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res 1969;29:705-27.  Back to cited text no. 2
    
3.
Reed RJ, Ichinose H, Clark WH Jr, Mihm MC Jr. Common and uncommon melanocytic nevi and borderline melanomas. Semin Oncol 1975;2:119-47.  Back to cited text no. 3
    
4.
Usher-Smith JA, Emery J, Kassianos AP, Walter FM. Risk prediction models for melanoma: A systematic review. Cancer Epidemiol Biomarkers Prev 2014;23:1450-63.  Back to cited text no. 4
    
5.
Gandini S, Sera F, Cattaruzza MS, Pasquini P, Picconi O, Boyle P, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005;41:45-60.  Back to cited text no. 5
    
6.
Porras B, Costner M, Friedman-Kien AE, Cockerell CJ. Update on cutaneous manifestations of HIV infection. Med Clin North Am 1998;82:1033-80, v.  Back to cited text no. 6
    
7.
Vieira J, Frank E, Spira TJ, Landesman SH. Acquired immune deficiency in Haitians: Opportunistic infections in previously healthy Haitian immigrants. N Engl J Med 1983;308:125-9.  Back to cited text no. 7
    
8.
Templeton AC. Kaposi′s sarcoma. Pathol Annu 1981;16(Pt 2):315-36.  Back to cited text no. 8
    
9.
Tappero JW, Conant MA, Wolfe SF, Berger TG. Kaposi′s sarcoma. Epidemiology, pathogenesis, histology, clinical spectrum, staging criteria and therapy. J Am Acad Dermatol 1993;28:371-95.  Back to cited text no. 9
    
10.
Mark RJ, Poen JC, Tran LM, Fu YS, Juillard GF. Angiosarcoma. A report of 67 patients and a review of the literature. Cancer 1996;77:2400-6.  Back to cited text no. 10
    
11.
Bardwil JM, Mocega EE, Butler JJ, Russin DJ. Angiosarcomas of the head and neck region. Am J Surg 1968;116:548-53.  Back to cited text no. 11
    
12.
Verma KK, D′Souza P, Sirka CS, Raman RS, Rathi SK. Disseminated malignant melanoma. Indian J Dermatol Venereol Leprol 1999;65:230-1.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Rawal RC, Mangla K. Sporotrichoid pattern of malignant melanoma. Indian J Dermatol Venereol Leprol 2008;74:70-1.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
14.
Ariel IM. Disseminated melanoma with unique unilateral distribution. Cancer 1975;36:2143-6.  Back to cited text no. 14
    
15.
Misago N, Takahashi M, Kohda H. Unilateral dysplastic nevi associated with malignant melanoma. J Dermatol 1991;18:649-53.  Back to cited text no. 15
    

What is new?
A rare report of malignant melanoma from the Indian subcontinent region, which clinically resembled a vascular tumor; histopathological examination clinched the final diagnosis


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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