AnBrasDermatol.2020;95(6):748---750
Anais
Brasileiros
de
Dermatologia
www.anaisdedermatologia.org.brIMAGES
IN
DERMATOLOGY
Cauliflower-like
exophytic
mass
on
the
skin:
polypoid
melanoma.
Clinical,
dermoscopic,
and
histologic
features
夽,夽夽
Ambra
Di
Altobrando
∗,
Annalisa
Patrizi
,
Emi
Dika
,
Francesco
Savoia
DermatologyDivision,DepartmentofExperimental,DiagnosticandSpecialtyMedicine,UniversityofBologna,Bologna,Italy Received15January2020;accepted13April2020
Availableonline11September2020
KEYWORDS
Dermoscopy; Histopathology; Melanoma
Abstract Polypoidmelanomaisavariantofnodularmelanoma,whosepoorprognosisdepends onitsthickness andthepresenceofulcerationatthetimeofdiagnosis.Theauthorsreport twocasesofpolypoidmelanoma,presentingasbroad,cauliflower-like,polypoidmasses. Der-moscopywascharacterizedbyamulticoloredpattern,atypicalpolymorphicvessels,andthe fiber sign. Clinical anddermoscopicfeatures can helpto diagnosepolypoid melanomaand excludeotherpossibledifferentialdiagnoses.However,histologyremainsmandatorytoconfirm thediagnosticsuspicion.
©2020PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia. ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/ by/4.0/).
Case
reports
Case1
A 59-year-old woman was referred to this service for an exophyticmasslocatedonherleftleg,ofsixmonths dura-tion.Onclinicalexamination,thelesionwas1.8×4.5cmin
夽 Howtocitethisarticle:DiAltobrandoA,PatriziA,DikaE,Savoia
F.Cauliflower-likeexophyticmassontheskin:polypoidmelanoma. Clinical,dermoscopic,andhistologicfeatures.AnBrasDermatol. 2020;95:748---750.
夽夽StudyconductedattheUniversityofBologna,Bologna,Italy. ∗Correspondingauthor.
E-mail:ambra.dialtobrando@studio.unibo.it(A.DiAltobrando).
itsgreatestdimensions, showednecrotic-hemorrhagicand fibrinousareas,anddeformedtheunderlyingerythematous skin(Fig.1A).Dermoscopyrevealedamulticoloredpattern withadiffuseyellowbackgroundandirregularlydistributed red, brown,and grayareas. Observationof atypical poly-morphic vessels was impaired due to serohematic crusts andgauzefilamentsthatweretrappedintheirregular sur-face ofthe lesion(Fig.2A andB). Histopathologyshowed an aggressive polypoid melanoma (PM) with a Breslow’s depthof12mm,ulceration,3---6mitoses/mm2,
lymphovas-cularinvolvement,fibroepithelialbranchesthatsubdivided thetumorintolobules,andpleomorphicvessels(Fig.3A). Althoughnodalinvolvementwaspositive,nodistant metas-taseswerefound. Anti-PD-1 therapywasinitiated. During thefirstyearof follow-up,therewasnoinstrumental evi-denceofrecurrence.
https://doi.org/10.1016/j.abd.2020.04.010
0365-0596/©2020PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia.Thisisanopenaccessarticle undertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Cauliflower-likeexophyticmassontheskin:polypoidmelanoma 749
Figure1 (A)Sessilenodularmass,1.8×4.5cmonitsgreatest dimension,surroundedbyanerythematoushaloontheanterior areaoftheleg.Necroticandfibrinousareasandgauzefilaments incorporated within the tumor surface can be observed. (B) Broad-basedsessilenodule(1.5×3.8cmonitsgreatest dimen-sion)ontheanteriorareaoftheleg,deformingtheunderlying skin.Necroticandfibrinousareasandbleedingareevident.
Case2
An 82-year-oldItalian womanwasreferred tothisservice duetoasix-month-historyofanodularmassonherleftleg. Onphysicalexamination,thelesionwassessile,hadbroad dimensions (1.5×3.8cm),with an irregular crusty bleed-ing surface. The lesion deformed the underlying skin and was surrounded by an erythematous halo (Fig. 1B). Der-moscopyrevealed polymorphic vesselsanda multicolored pattern,withadiffuseredandwhitebackgroundandsome irregularly spread yellow, brown, and gray areas (Fig. 2C andD).HistopathologyshowedaBreslow’sdepthof10mm, ulceration,>11mitoses/mm2,lymphovascularinvolvement,
Figure3 (A)Histopathology shows fibroepithelial branches subdividingthetumorintolobules.Pigmentdistributionis irreg-ular,bothintermsofquantityanddepth.Pleomorphicvessels andulcerationarevisiblethroughoutthelesions.(B) Histolog-ical findings include ulceration,atypical polymorphic vessels with scattered depositions of pigment, and absence of rete ridges.Inflammatoryinfiltrateisscarce.
atypicalpolymorphicvesselswithscattered depositionsof pigment, absenceof rete ridges and scarce inflammatory infiltrate (Fig. 3B). The patient, who was staged as IIIC melanoma given the positive nodal involvement and neg-ativedistantmetastases,wasreferredtoanotherhospital, closertoherabode.
Inbothcases,molecularanalysisshowednegativeBRAF mutation (pyrosequencing of exon 15) and positive NRAS mutationinexon3(pyrosequencingofexon2and3).
Discussion
PMischaracterizedbyanirregularsurfaceand cauliflower-likeprofile.1---3Although PMtypicallyaffectsthemucosae,
Figure2 (A)Dermoscopyshowsamulticoloredpattern,withadiffuseyellowbackground(*)andsomeirregularlydistributed red,brown,andgrayareas(**).‘‘Fibersign’’:observationoftheatypicalpolymorphicvascularcomponentishinderedbygauze filamentstrappedintotheirregularsurfaceofthetumor.(B)Vesselsappearatypical,polymorphic,andmainlydilated(arrows). (C)Dermoscopyrevealsamulticoloredpattern,withadiffuseredandwhitebackgroundandsomeyellow,brown,andgrayareas irregularlyspreadonit(triangle).(D)Atypicalvesselsoveraredandwhitebackgroundareclearlyvisible.
750 DiAltobrandoAetal. wheninvolving theskin,itusuallyaffectstheback.2,3
His-tologically, PM shows marked cytological atypia, nuclear pleomorphism, and a plentiful mitotic count.3,4 The
ini-tial radial-horizontal growth phase rapidly evolves into a nodular-vertical phase, with an important risk of vascu-lar embolism.2,3 To date, there are few reports of the
use of dermoscopy onPM. Hikawa etal. reported a case of PM overlapping a superficial spreading melanoma with anirregularmulticomponentpattern,characterizedbythe presenceof an atypicalnetwork, globules, andblotches.1
Cabreraetal.describedacaseofPMshowingablue-white veilin the exophyticpart of the lesion and big blue-gray nestsandwhitish areasat thebase ofthe stalk.5
Accord-ingly to Hikawa et al., a clear dermoscopic analysis of thetumor can beimpeded by the presenceof crusts and fibers of clothing, gauzes, or patient’s own hair, the so-called‘‘fibersign’’,thatisanindirectdermoscopicclueof ulceration.6
To thebestof the authors’knowledge, thisis thefirst reporttofindnotonlysimilarmacroscopicclinicalfindings andthesameunusuallocalization,butalsosimilar dermo-scopic features: in both cases, the tumor presented with an irregular crusted-fibrinous cauliflower-like surface and somebleedingareas,imprintingtheunderlying erythema-tousskin,asinthecasereportedbyPérez-Wilsonetal.The mostrelevantdermoscopicfindingofthepresentcasesofPM weretheatypicalpolymorphicvesselsandthemulticolored pattern:the yellowcolor wasmainly relatedtothe pres-enceoffibrin;thebrown,black,andredbackgroundwere associatedwiththe‘‘true’’surfaceofthetumor, whereas thewhitishstreakswereduetothefibrouscomponentsof thetumor.
Dermoscopycanbeusefulforthedifferentialdiagnosisof PMwithothermalignantentities,evenifitmaybe challeng-ing.Poorlydifferentiatedsquamouscellcarcinomashowsa predominance of red color, erosion/ulceration,and resid-ualwhitestructures.7 Pigmentedsquamouscellcarcinoma
is characterizedby homogeneous grey-bluepigmentation, ulceration,radialstreaks,andglobules.8 Themain
dermo-scopicfeaturesofMerkelcellcarcinomaincludemilkyred areasalongwithpolymorphous,shinywhiteareaswithinthe bodyofthetumor,aswellaslinear,irregular,andarborizing vessels.9
Histopathologyremainsmandatoryforadefinitive diag-nosisofPM.Thelumpycauliflower-likeappearance,aswell asthewhitishstreaksofthepresenttwocasesofPMwere due tothe presence of fibroepithelial branches that sub-dividedthetumorsintolobules,whereasthemulticolored pattern represented the dermoscopic counterpart of the irregularpigmentdistributiononhistology.
Both cases showed NRAS mutation; this finding is in accordancewiththe literature,sinceNRAS mutations are reportedtobeassociatedwithnodularmelanomaand local-izationonthelimbs.10
Financial
support
Nonedeclared.
Authors’
contributions
AmbraDi Altobrando:Approval of thefinal version ofthe manuscript; design and planning of the study; drafting
and editing of the manuscript; collection, analysis, and interpretation of data; effective participationin research orientation; intellectual participationin the propaedeutic and/or therapeutic conduct of the studied cases; critical reviewoftheliterature.
Annalisa Patrizi: Approval of the final version of the manuscript;effectiveparticipationinresearchorientation.
EmiDika:Criticalreviewofthemanuscript.
Francesco Savoia: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participationin research orientation; intellectual participationin the propaedeutic and/or therapeutic conduct of the studied cases; critical reviewoftheliterature;criticalreviewofthemanuscript.
Conflicts
of
interest
Nonedeclared.
Acknowledgments
SpecialthankstoDr.CosimoMiscialiandDr.CarlottaBaraldi forthehistologicimages.
References
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