|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 1 | Page : 115-117
Nodular malignant melanoma with metastasis in the lung and adrenal gland
Chanramath Sujatha Vinod1, Simran Chawla2, Narendranath Kudva3
1 Professor and HOD of Dermatology, MVJ Medical College and Research Hospital, Bangalore, Karnataka, India
2 Consultant Dermatologist, MVJ Medical College and Research Hospital, Bangalore, Karnataka, India
3 Professor of Radio Diagnosis, MVJ Medical College and Research Hospital, Bangalore, Karnataka, India
|Date of Web Publication||4-Jun-2014|
Chanramath Sujatha Vinod
Flat No. T2, Sai Greens, Kalyan Nagar, Bangalore - 560 043, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vinod CS, Chawla S, Kudva N. Nodular malignant melanoma with metastasis in the lung and adrenal gland. Arch Med Health Sci 2014;2:115-7
Malignant melanoma is a tumor arising from the epidermal melanocyte. It is one of the most aggressive malignancies in human and is responsible for almost 60% of the lethal skin tumors. Malignant melanoma is reported to metastasize to most of the organs of human body including the lungs, mediastinal lymph nodes, and gastrointestinal tract.  Hereby, we are reporting a case of nodular malignant melanoma with secondaries in the lungs, mediastinal nodes, and adrenals.
A 75-year-old male patient presented with painless brownish black swellings over the left calf region of 1-year duration. Patient gave history of a rapid increase in the size of the lesions, loss of appetite, and significant loss of weight since 2 months and a dull aching chest pain since 1 month.
Examination revealed multiple brownish black dome-shaped nodules, each measuring about 2 × 2 cm, coalescing to form lobulated mass over the flexor aspect of the left leg, fixed to the underlying muscles [Figure 1]. The left inguinal lymph nodes were enlarged, measuring 2 × 1 cm, hard in consistency, and fixed. Systemic examination was unremarkable.
|Figure 1: Multiple brownish black dome-shaped nodules coalescing to form lobulated mass over the flexor aspect of the left leg|
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Hematological investigations including hemoglobin, total and differential counts, blood sugar, and liver and renal function tests were within the reference range. Erythrocyte sedimentation rate was raised (45 mm/h). An incisional biopsy was performed from one of the nodules and the histopathological examination revealed neoplasm in the epidermis and dermis composed of spindle-shaped cells with hyperchromatic nucleus and melanin pigment separated by fibrotic stroma [Figure 2]. Chest X-ray posteroanterior (PA) view showed mediastinal widening and right paracardial opacity. Computerized tomography of the chest and abdomen was performed, which revealed subcarinal and parenchymal metastasis in the right upper lobe and adrenal metastasis [Figure 3]. Hence, the diagnosis of nodular malignant melanoma with metastasis to right lung, mediastinal nodes, and adrenal gland was made. Patient was referred to a tertiary care center for cancer for the further management.
|Figure 2: Histopathological examination revealing neoplasm in the epidermis and dermis composed of spindle-shaped cells with hyperchromatic nucleus and melanin pigment separated by fibrotic stroma|
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|Figure 3: Computerized tomography of the chest and abdomen showing subcarinal and parenchymal metastasis in the right upper lobe and adrenal metastasis|
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Melanoma (from Greek - melas, meaning dark) is a malignant tumor of melanocytes. Although malignant melanoma comprises less than 5% of malignant skin tumors, it is responsible for almost 60% of the lethal skin neoplasia.  Incidence of melanoma is rising in Caucasians, although it is a rare presentation in India.  In 1969, Wallace Clark and coworkers classified malignant melanoma into superficial spreading, lentigo maligna, and nodular types.  Later Dr. Richard Reed added a fourth type called acral lentiginous malignant melanoma.  Nodular melanoma is a rare type of primary cutaneous malignant melanoma that is invasive and lack intraepidermal component.
Melanoma presents three clinically and histomorphologically discernable steps in tumor progression.
- Malignant melanoma confined to the epidermis (melanoma in situ), which is called radial growth phase (RGP)-confined melanoma.
- RGP-confined microinvasive, which shows some malignant cells present in superficial papillary dermis.
- Vertical growth phase (VGP), which means melanoma has entered the tumorogenic and/or mitogenic phase. 
Nodular melanoma by definition has no RGP and could be nodular, polypoid, or pedunculated. Recognition of nodular melanomas can be problematic as they lack many of the conventional clinical features. Of all varieties of malignant melanomas, nodular melanoma carries a poorer prognosis because of vertical spread and more rapid invasion.  In nodular melanomas, instead of ABCD (A: Asymmetry, B: Border, C: Color, D: Diameter) of flat melanomas, EFGs (E: Elevated, F: Firm to touch, G: Growing progressively) are important for early detection.  They are not detected early and often removed after significant delay or life threatening metastasis have occurred. Dermoscopy is emerging as the ultimate tool for the early diagnosis of all types of melanomas. When a progressively growing melanocytic nodule that shows symmetrical pattern in dermoscopic examination is identified, nodular melanoma needs to be excluded.  Argenziano et al., described a new dermoscopic predictor of nodular melanoma, namely, the presence of blue and black color within the lesion.  Blue-black color is suggested to reflect the combination of pigment localized in the mid-deep dermis (blue) and the epidermis (black).
| References|| |
|1.||Liang KV, Sanderson SO, Nowakowski GS, Arora AS. Metastatic malignant melanoma of the gastrointestinal tract. Mayo Clin Proc 2006;81:511-6. |
|2.||Radoviæ-Kovaceviæ V, Pekmezovil T, Adanaja B, Jarebinsk M, Marinkoviæ J, Tomin R. Survival analysis in patients with cutaneous malignant melanoma. Srp Arch Celok Lek 1997;125:132-7. |
|3.||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;42:820-6. |
|4.||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. |
|5.||Reed RJ. Acral lentiginous melanoma, in new concepts in surgical pathology of the skin. New York: Wiley Publications; 1976. p. 89-90. |
|6.||Guerry D 4th, Synnestvedt M, Elder DE, Schultz D. Lessons from tumor progression: The invasive radial growth phase of melanoma is common, incapable of metastasis, and indolent. J Invest Dermatol 1993;100:342S-5. |
|7.||Weinstock MA, Morris BT, Lederman JS, Bleicher P, Fitzpatrick TB, Sober AJ. Effect of BANS location on the prognosis of clinical stage 1 melanoma: New data and meta-analysis. Br J Dermatol 1988;119:559-65. |
|8.||Chamberlain AJ, Fritschi L, Kelly JW. Nodular melanoma: Patients' perceptions of presenting features and implications for earlier detection. J Am Acad Dermatol 2003;48:694-701. |
|9.||Menzies SW, Moloney FJ, Byth K, Avramidis M, Argenziano G, Zalaudek I, et al. Dermoscopic evaluation of nodular melanoma. JAMA Dermatol 2013;149:699-709. |
|10.||Argenziano G, Longo C, Cameron A, Cavicchini S, Gourhant JY, Lallas A, et al. Blue-black rule: A simple dermoscopic clue to recognize pigmented nodular melanoma. Br J Dermatol 2011;165:1251-5. |
[Figure 1], [Figure 2], [Figure 3]