Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 3, 2010, pp. 404-406

Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 404-406

Letter to the Editor

Malignant melanoma with nodal involvement in a 17-year-old female

Shigeto Matsushita¹, Kentaro Mera¹, Hidemichi Kubo¹, Kouichiro Takeda¹, Tsuyoshi Ishihara², Takuro Kanekura¹

¹ Department of Dermatology, Field of Sensory Organology, Kagoshima University, Graduate School of Medical and Dental Sciences, Japan
² Department of Plastic and Reconstructive Surgery, Faculty of Medical and Pharmaceutical Sciences, Kumamoto University, Japan

Correspondence Address:Shigeto Matsushita, Department of Dermatology, Field of Sensory Organology, Kagoshima University, Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima 890-8520, Japan, shige@m2.kufm.kagoshima-u.ac.jp

Code Number: cr10105

PMID: 21119295

DOI: 10.4103/0973-1482.73335

Sir,

Melanoma in the young is very rare; it accounts for only 0.3-7.1% of all cancers developed in individuals between 5 and 19 years of age. ^[1] We report a 17-year-old Japanese woman who presented with malignant melanoma with nodal involvement. She had noticed a nodular tumor on her right thigh two years earlier. Because more than 10 liquid nitrogen cryosurgeries performed at a local clinic were ineffective and the tumor continued to enlarge gradually over a two-year period, in September 2005 she was referred to the plastic and reconstructive surgery department of another hospital for evaluation of the tumor. According to the medical record, the lesion was an irregularly-shaped brown tumor measuring 28 mm in diameter [Figure - 1]. Dermoscopy was not performed. Palpation revealed lymphadenopathy on her right groin and she underwent excisional biopsy with a 3mm margin. Histological examination of the resected specimen disclosed asymmetrical nodules consisting of highly atypical cells and significant inflammatory infiltrates in the vicinity of the nodules in the dermis [Figure - 2]a. Invasive growth was observed at the periphery of the nodules comprising a 5.5mm-thick lesion [Figure - 2]b. The tumor cells were negative for HMB45 and Melan-A and positive for S100 protein. Under a diagnosis of malignant melanoma, she was referred to our department.

Positron emission tomography showed highly increased glucose uptake in the right groin. Computed tomography confirmed inguinal lymph node metastasis. The results of hematologic and serum biochemical examinations, including the serum 5-S-CD level, were within normal limits. On the basis of these results, we performed subtotal integumentectomy including the primary tumor site, blue-dye-navigated lymph channels through the regional lymph nodes, and right inguinal, iliac, and obturator lymph node dissection. The surgical defect was reconstructed with full-thickness autologous skin grafts. Of 14 dissected lymph nodes, 3 inguinal nodes on the right side were macroscopically affected by melanoma; one external iliac node on the right side was affected microscopically. Careful histological examination disclosed no residual disease at the primary cutaneous site. Under a diagnosis of stage IV (pT4aN2bM1a) melanoma, she received four cycles of adjuvant chemotherapy consisting of DTIC, ACNU, VCR, and IFN-β (DAV-feron). However, six months after her second operation, an in-transit metastatic lesion manifesting as a 2mm dark brown freckle appeared on the grafted site. This was addressed with the local injection of IFN-β and hyperthermia to the periphery of the primary tumor site. Five months after these treatments, we are continuing the local injection of IFN-β once a week. Three years after her second operation, there is no evidence of local recurrence or distant metastasis.

The diagnosis of melanoma in young individuals is difficult. About 40% of these lesions are associated with congenital or acquired nevi; many are amelanotic and nodular, and their appearance is similar to pyogenic granuloma. ^[2],[3] Stiller ^[4] reported a far lower incidence of melanoma among adolescents from South and East Asia than Europe and Oceania. Even for experienced pathologists, the histopathological differentiation between nevi and melanoma in children is difficult. ^[5] We made our diagnosis hesitantly because, possibly due to her previous therapy, there was no histological junctional activity. Moreover, histologically there was no residue of nevus cells. Therefore, it was difficult to determine whether the original tumor was associated with nevi. Ours is a rare case of a malignant melanoma with nodal involvement occurring in the second decade of life in which in-transit metastasis manifested after radical dissection.

Our experience strongly suggests that malignant melanoma should be considered in young patients presenting with atypical tumors. Careful follow-up is required for the early detection of recurrence and metastasis in young patients with malignant melanoma. Considering that a histological diagnosis is difficult unless the pigmented lesion is removed surgically, we strongly suggest that all melanocytic lesions need to be examined histologically.

References

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