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Nevoid Melanoma: Case Report and Literature Review James Connors DPM1, Michael Coyer DPM1, Gina Hild DPM2, Mark Hardy DPM, FACFAS3 1

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Nevoid Melanoma: Case Report and Literature Review James Connors DPM1, Michael Coyer DPM1, Gina Hild DPM2, Mark Hardy DPM, FACFAS3 1 Nevoid Melanoma: Case Report and Literature Review James Connors DPM1, Michael Coyer DPM1, Gina Hild DPM2, Mark Hardy DPM, FACFAS3 1. Podiatric Medicine and Surgery Resident, Mercy Health, Cleveland Ohio, NOFA Member 2. Mercy Health Podiatric Medicine and Surgery Residency Training Program Faculty, CCF Cleveland Ohio, NOFA Alumni 3. Director of Foot and Ankle Surgery, Mercy Health, Cleveland Ohio, Director NOFA Foundation Statement of Purpose Case Report Discussion We report on a 45 year old male who presents for an initial Nevoid melanoma is often misdiagnosed due to its similarity to the Recognition of nevoid melanomas of smaller cell types requires a high common nevi. Small and intermediate cell types are sometimes called appointment for diabetic foot care. Past medical history significant for diabetes mellitus with peripheral neuropathy, retinopathy, HTN, index of suspicion and recognition of subtle architectural and cytologic ‘‘minimal deviation melanoma’’ or ‘‘Lawyer’s melanoma’’ because they features [7]. Architectural features are basic symmetry, with good may not be diagnosed until after they have metastasized and obstructive sleep apnea, general OA, and hyperpotassemia. States he has had the dark lesion on his right ankle for several years and has not circumscription in a nodular or verrucous pattern lacking any significant medicolegal action may follow. The low power microscopic features radial growth phase or epidermal invasion [8]. Long, thin rete ridges, often are misleading due to the similarities of a benign nevi. Melanoma noticed any changes to size, shape, or color. Past surgical history of lipoma excision, left thigh in 2007. No significant family medical history. expansile or sheetlike growth, and pseudomaturation are common [9]. frequently has a deceptively bland nevus-like histological appearance The low power microscopic features of this complex skin lesion can be and it is doomed to be overlooked as a nevus, especially by On physical examination, pedal pulses were palpable bilateral. quite deceiving [10]. The use of fluorescence in situ hybridization (FISH) pathologists not familiar with dermatopathology. It is only at Capillary refill time measured less than 3 seconds to all digits bilateral. analysis demonstrated cytogenic abnormalities that were pathologic intermediate and high power magnification that suspicion for melanoma No loss of protective sensation was noted distal to ankle level bilateral. features of melanoma [12]. Genetic analyses of melanomas have arises based on its subtle histological features. The use of Vibratory sensation was diminished distal to the medial malleolus Biopsy: Histological examination showed nevoid lesion with sharp lateral border expanding into papillary dermis and reaching reticular revealed a number of recurrent aberrations that are absent in fluorescence in situ hybridization analysis demonstrated cytogenic bilateral. Dermatologic examination revealed an elevated nodular black unequivocally benign lesions[6]. In an attempt to develop a fluorescence abnormalities that were pathologic features of melanoma. The goal of lesion to the anterior right ankle, measuring 6 mm x 8 mm with regular dermis with sparse lymphocytic infiltrate at the base (40x, HE). Nevoid lesions consisted ofCase clusters Report and sheets Continued of medium to large sized nevus in situ hybridization (FISH) assay to detect common aberrations in this case study is to strengthen recognition of an overlooked metastatic borders (Figure 1). No erythema, increase in warmth, tenderness to melanoma, probes against 20 different genomic regions were evaluated skin lesion. palpation, or edema noted. No lymphangitis noted. The remainder of cells, which focally showed atypia and few mitotic figures (400x, HE), Nevus cells showed maturation in the deeper portions of the lesions [3]. Unequivocal melanomas showed that patients with a positive test the neurovascular and musculoskeletal examination were were significantly more likely to develop metastases or die of melanoma unremarkable. (200x, HE). Introduction Histologic results: Originally diagnosed atypical compound nevus with compared with patients whose melanomas were negative by FISH [1,11]. moderate melanocytic dysplasia, completely but narrowly excised. Accurate pathologic diagnosis of melanocytic tumors requires a Report diagnosis amended to acral nevoid melanoma. Significant Acknowledgements suitable biopsy, assessment of many histologic criteria, awareness of cytologic atypia and the neoplastic melanocytes had prominent nucleoli. Steven D. Billings MD, co-section head of anatomic pathology, Cleveland Clinic, potential pitfalls, relevant experience, and in difficult cases, judicious Given this finding, additional molecular testing was performed. FISH for providing the pictures of the histological slides and biopsy description. consultation [1]. Correlation of basic morphologic and clinical features was positive for chromosomal aberrations associated with melanoma. The Northern Ohio Foot and Ankle Foundation is necessary, because many of the individual characteristics are shared This result also favored the diagnosis of melanoma. With these results, Web: www.nofafoundation.org E-mail: [email protected] by both nevi and melanomas. Small lesions may appear more the diagnosis was changed to melanoma. References consistent with an intradermal melanocytic nevus and larger cells may Larger melanocytes with abundant pale cytoplasm were present. FISH resemble Spitz's nevus [2]. The tumor cells are relatively small with 1. North JP et al. Fluorescence In Situ Hybridization as an Ancillary Tool in the Diagnosis of Ambiguous Melanocytic Neoplasms. showed aberrations in the larger melanocytes only. Diagnosis— Am J Surg Pathol 2014;38:824–831 little cytoplasm giving them a nevocellular appearance. The small cell 2. Diwan AH, Lazar AJ. Nevoid Melanoma. Clin Lab Med 2011;31:243–253 melanoma arising in a melanocytic nevus (hematoxylin and eosin). 3. Gerami P, Jewell SS, Morrison LE, et al. Fluorescence in situ hybridization (FISH) as an ancillary diagnostic tool in the diagnosis nature resembles that of the common nevi [3]. A true diagnosis is of melanoma. Am J Surg Pathol. 2009;33:1146–1156. These findings are consistent with a diagnosis of Nevoid Melanoma; 4. McCarthy, SW et al. Pitfalls and Important Issues in the Pathologic Diagnosis of Melanocytic Tumors. The Ochsner Journal usually missed until after metastasis. Histological examination may be 2010;10:66–74 Clark's level II. 5. Barr RJ, Linden KG, Rubinstein G, Cantos KA. Analysis of heterogeneity of atypia within melanocytic nevi. Arch Dermatol misleading due to the lack of pushing borders, high mitotic activity, and 2003;139:289–292 pleomorphism which are indicative of melanoma [4]. The nevoid Figure 1: Clinical photographs of right anterior ankle lesion 6. Bastian BC, Xiong J, Frieden IJ, Williams ML, Chou P, Busam K, Pinkel D, LeBoit PE. Genetic changes in neoplasms arising in congenital melanocytic nevi: differences between nodular proliferations and melanomas. Am J Pathol 2002;161:1163–1169 melanomas possess histologic features that differ only slightly in Plan: 7. Scolyer RA, Thompson JF, Stretch JR, Sharma R, McCarthy SW. Pathology of melanocytic lesions: new, controversial, and clinically important issues. J Surg Oncol. 2004;86(4):200-211. nature. The silhouette of the lesion at low power can be rather Surgical excision of the specimen: The lesion was excised in total with a 8. McNutt NS, Urmacher C, Hakimian J, et al. Nevoid malignant melanoma: morphologic patterns and immunohistochemical reactivity. J Cutan Pathol 1995;22: 502–17. symmetrical and not overtly suspicious for melanoma [5]. Although the 3:1 ellipse. Pathologic specimen was analyzed by FISH. 9. Carlson JA, Ross JS, Slominski AJ. New techniques in dermatopathology that help to diagnose and prognosticate melanoma. Clin Dermatol 2009;27:75–102. cells are nevoid, there is pleomorphism and nuclear atypia which 10. Zembowicz A, McCusker M, Chiarelli C, et al. Morphological analysis of nevoid melanoma. A study of 20 cases with a review of requires examination at higher power [4]. Mitoses can be found in the the literature. Am J Dermatopathol 2001;23:167–75. 11. Massi G. Melanocytic nevi stimulant of melanoma with medicolegal significance. Virchows Arch 2007;451:623–47. deeper portions of the lesion [6]. The lesion is defined as a 12. Corona R, Mele A, Amini M, et al. Interobserver variability on the histopathologic diagnosis of cutaneous melanoma and other pigmented skin lesions. J Clin Oncol. 1996;14:1218–1223. melanocyctic nevi [4]. 13. Murali R, Hughes MT, Fitzgerald P, Thompson JF, Scolyer RA. Interobserver variation in the histopathologic reporting of key prognostic parameters, particularly Clark level, affects pathologic staging of primary cutaneous melanoma. Ann Surg. 2009;249(4): The following is a case report of a patient found to have an initial 641-647. 14. Welch HG, Woloshin S, Schwartz LM. Skin biopsy rates and incidence of melanoma: population based ecological study. BMJ. diagnosis of benign nevus, but the diagnosis was later amended to 2005;331:481. 15. Vogt T, Stolz W, Glassl A, et al. Multivariate DNA cytometry discriminates between Spitz nevi and malignant melanomas nevoid melanoma following fluorescence in situ hybridization analysis. because large polymorphic nuclei in Spitz nevi are not aneuploid. Am J Dermatopathol. 1996;18:142–150. .
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