Lentigo Maligna Melanoma With Local and Distant Blue Nevus-like Metastases.

Melanoma or melanoma metastases can rarely mimic blue nevi clinically and/or histologically, presenting a diagnostic pitfall for both the clinician and the dermatopathologist. We report a case of an invasive lentigo maligna melanoma with subsequent development of multiple, cutaneous blue nevus-like localized metastases followed by a distant metastasis, heralding widespread systemic metastases.

Sentinel lymph node biopsy in paediatric melanoma. A case series.

The incidence of melanoma in children is uncommon, being particularly rare in children under 10 years-old. However, this disease is increasing by a mean of 2% per year. As in adults, the lymph node status is the most important prognostic factor, crucial to performing the selective sentinel lymph node biopsy (SLNB). We report 3 cases of paediatric patients of 3, 4 and 8 years-old, in which SLNB was performed for malignant melanoma. Paediatric age implies greater technical difficulty to the scintigraphy scan due to poor patient cooperation, with mild sedation required in some cases, and only being able to acquire planar images in other cases. SPECT/CT was only performed in the oldest patient. In our cases, SLNB was useful for selecting the least invasive surgery in order to reduce morbidity.

Correlation of histologic regression in primary melanoma with sentinel node status.

IMPORTANCE: The influence of regression on the status of the sentinel node (SN) is controversial. In many centers, the presence of regression in thin melanomas supports the performance of an SN biopsy. OBJECTIVE: To identify whether regression in primary melanoma has any influence on SN involvement. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of melanomas with a Breslow thickness greater than 0.75 mm and undergoing SN biopsy from January 1, 2003, through December 31, 2010, at Instituto Valenciano de Oncología, which receives melanoma patients from regional hospitals and dermatology practices. Only cases with paraffin blocks or histologic slides representative of the primary tumor and available for review were included in the study. Melanomas from 201 patients met these criteria and constitute the core of this study. EXPOSURES: Sentinel node biopsy in melanoma. MAIN OUTCOMES AND MEASURES: Presence or absence of regression in the primary melanoma, type (early vs late), and extension were correlated with the presence or absence of metastasis in the SNs. In addition, the main clinical and histologic characteristics of the primary melanoma were correlated with the status of SN and the regression features. RESULTS: Regression was found in 52 melanomas (25.9%). Regression did not show a statistically significant association with SN status. When melanomas were subdivided by Breslow thickness into 4 groups, those with regression had a lower frequency of positive SNs in 3 of the 4 groups (≤1.00, 1.01-2.00, and >4.00 mm), although differences did not reach statistical significance in any group. We found no influence by type of regression or its extension on the SN status. Regression was found more frequently in thin melanomas (≤1.00 mm), melanomas located on an axial site, and superficial spreading or lentigo maligna melanoma types (P = .02, P < .001, and P = .03, respectively). CONCLUSIONS AND RELEVANCE: Regression of the primary melanoma is not associated with a higher proportion of positive SNs. These data do not support the practice of performing SN biopsy in thin melanomas with regression in the absence of additional adverse prognostic characteristics.

Cutaneous head and neck melanoma: the old and the new.

The incidence rate of malignant melanoma has shown a rapid worldwide rise in recent years. The staging and management of head and neck melanoma presents some unique challenges. Surgery remains the cornerstone of treatment, while sentinel node biopsy is the most accurate staging modality for regional disease. The complex regional anatomy and lymphovascular drainage of this region may account for the increased biologic aggressiveness and treatment challenges of this disease. Improved understanding of the radiobiology of melanoma has resulted in new adjuvant radiotherapy approaches, yielding improved control rates. The treatment outcomes of metastatic head and neck melanoma remain disappointing but important progress has been made in the understanding of melanoma biology.

Toxicity of combined treatment of adjuvant irradiation and interferon alpha2b in high-risk melanoma patients.

Surgically resected stage III melanoma patients commonly receive adjuvant therapy with interferon (IFN) alpha2b. For those patients with high-risk features of draining node recurrence, radiation therapy can also be considered as a treatment option. The purpose of this retrospective study was to assess the efficacy and radiation-related toxicity of this combined therapy. Eighteen patients receiving adjuvant IFNalpha2b therapy during radiation therapy, or within 1 month of its completion, were reviewed retrospectively and analysed for outcome. Radiation was delivered at 600 cGy dose per fraction, in 16 out of 18 patients, twice a week, and at 200 cGy dose per fraction in two patients five times a week. Total radiation dose and number of fractions were as follows: 30 Gy/5 fr (n=8), 36 Gy/6 fr (n=8) and 50 Gy/25 fr (n=2). The percentage of disease-free patients, with no local recurrence, at 3 years was 88%. In 10 patients, IFNalpha2b was administered concurrently with radiotherapy; in three, within 30 days before or after radiation; and in five, more than 30 days after radiation. All the patients experienced acute skin reactions, grade I on the Radiation Therapy Oncology Group (RTOG) scale. Late radiation-related toxicity was seen in one patient with grade III (RTOG) skin reaction and two with grade IV (RTOG) radiation-induced myelitis. Concurrent use of adjuvant radiotherapy and IFNalpha2b might enhance radiation-induced toxicity, and special care should be taken when the spinal cord is included in the radiation field.

Conventional histology vs. three-dimensional histology in lentigo maligna melanoma.

BACKGROUND: Conventional surgery for lentigo maligna melanoma (LMM) is based on normal histological evaluation. However, such evaluation leaves diagnostic gaps. In contrast, complete three-dimensional (3D) histology of excision margins permits accurate detection of continuously spreading tumour strands like those of LMM. These can be specifically excised in tumour-positive areas with smaller excision margins, and better cosmesis and function. To date there have been no controlled studies of micrographic surgery of LMM. OBJECTIVES: Clinical parameters and surgical strategies influencing the prognosis of patients with LMM were evaluated in a prospective study of melanoma patients in the Department of Dermatology of the University of Tübingen (1980-99). METHODS: The 292 LMMs comprised 7.4% of 3960 primary stage I and II melanomas treated during this period. One hundred and thirty-six patients in this group (46.6%) underwent surgery on the basis of 3D histology. RESULTS: The geometric mean excision margins were significantly smaller in the 3D histology group (P < 0.0001). Patients with micrographic surgery had fewer recurrences. Multivariate analysis of clinical, histological and surgical variables was carried out, and tumour thickness and 3D histology proved to be independent, significant factors for the prognosis of recurrence-free survival (relative risk, RR 2.08, P < 0.0001 and RR 2.11, P = 0.0037, respectively). There were no melanoma-related deaths in the 3D histology group. All 16 melanoma-related deaths were observed among the 156 patients of the conventional histology group (10.3%). CONCLUSIONS: Excision of LMM using 3D histology resulted in a twofold lower probability of recurrence and twofold smaller excision margins. 3D histology is a valuable diagnostic tool and can be used in the management of LMM because of the latter's pattern of continuous tumour spread.

[Trigeminal neuralgia presenting as a deep recurrent desmoplastic neurotropic melanoma of a lentigo maligna]. / Névralgie faciale révélatrice d'une récidive desmoplastique profonde et neurotrope d'un mélanome de Dubreuilh.

INTRODUCTION: Neurotropic melanoma is a particular anatomopathological form corresponding to dermal proliferation of desmoplastic cells of neuroid differentiation. We report a new case of neurotropic melanoma revealed by facial neuralgia. CASE REPORT: A 64 year-old man presented in 1996 with a lentigo maligna on the right cheek treated by complete excision. After 2 years of medical supervision, a pigmented lesion recurred leading to new surgical treatment. The histological examination of the total lesion showed intra-epidermal atypical melanocyte proliferation without dermal invasion. In 1999, right trigeminal neuralgia occurred without associated cutaneous change. Cranial MRI revealed an infiltration of the right trigeminal nerve. Endo-buccal surgery disclosed a black swelling of the trigeminal nerve. Histological examination and immunohistochemistry revealed a desmoplastic melanoma. DISCUSSION: Neurotropic melanoma with nerve invasion by malignant cells presenting as a trigeminal neuralgia is rare. Our case report underlined the depth of the neurotropic melanoma and the initial existence of a lentigo maligna without associated "neurotropic" melanoma.

A conservative surgical approach to the treatment of 'locally invasive' lentigo maligna melanoma of the face.

Lentigo maligna has the potential for malignant change, and is managed in many cases by wide local excision. However, there are clinical situations in which aggressive surgical management is inappropriate or unsuccessful. We present three such cases, in which a more conservative surgical approach was adopted and maintained over several decades.

Serum S100--a marker for disease monitoring in metastatic melanoma.

BACKGROUND: S100 proteins are low-molecular-weight calcium-binding proteins and appear to play an important role in various cellular processes such as cell division and differentiation. In histopathology, S100 is widely accepted as the marker of choice for immunohistochemical identification of malignant melanoma. When S100 was detected in the serum of patients with malignant melanoma, it was suggested that serum S100 may be a useful marker for the stage of disease. OBJECTIVE: The aim of this study was to examine serum S100 concentrations of patients with different stages of malignant melanoma and to determine the value of serum S100 in the follow-up of melanoma patients during treatment. METHODS: Sera were obtained from 73 melanoma patients in different stages of the disease. The control group consisted of 130 healthy subjects. In 4 patients with metastatic melanoma, serum S100 was measured serially. Serum levels were measured by a commercially available immunoradiometric assay. RESULTS: While only 1 out of 25 stage I/II patients and 3 of 14 patients with lymph node metastases (stage III, 21.4%) showed detectable serum S100 levels, 27 of 34 patients with disseminated disease (stage IV, 79.4%) had elevated serum S100. Interestingly, rising levels of serum S100 in the serial measurement indicated progression of the disease, and a complete decline reflected 2 patient remissions. CONCLUSION: The data support the value of serum S100 as a clinical marker for progression of metastatic melanoma and serological monitoring during systemic therapies.

Recommendations for therapy of head and neck cutaneous melanoma.

PURPOSE: The essential element in the treatment of a primary cutaneous malignant melanoma is an adequate definitive excision. The breadth and depth of such excisions and the appropriateness of a prophylactic neck dissection, however, remain a source of controversy. METHOD: A review of our experiences with 500 patients with head and neck malignant melanoma treated in our clinic between 1967 and 1987 is presented. RESULTS AND CONCLUSIONS: The thickness of the lesion, the factor that correlated most closely with potential for metastatic development, can be used as a guide for determining the extent of excision and the appropriateness of elective node dissection. Wide excision of invasive lesions varies in their margins from 1 cm for lesions that measure less than .75 mm in thickness to 3 cm if the melanomas measure greater than .75 mm or show ulcerations or have a scalp localization. Prophylactic neck dissection is necessary for lesions between .75 and 1.5 mm in thickness, whereas in tumors with a depth of invasion greater than 1.5 mm the outcome of the disease is not improved by prophylactic neck dissection.