J Cutan Pathol 2015: 42: 1024–1025 doi: 10.1111/cup.12508 John Wiley & Sons. Printed in Singapore
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Letter to the Editor
A painful pigmented nodule in a patient with metastatic melanoma Keywords: cutaneous neoplasm, malignant melanoma, melanocytic lesions, scar To the Editor , Any newly reported pigmented lesion in a patient with metastatic melanoma raises concern for recurrent or metastatic disease. In some instances, however, a foreign body at the indicated location can mimic cutaneous metastasis. An elderly man presented with a dark 10 mm subcutaneous nodule on his right index finger (Fig. 1). The patient reported that the lesion developed following an accident with a cast iron hammer 10 years earlier. Though the site had not significantly changed in size or appearance, it remained painful to the touch and he requested its removal. Four years earlier, the patient was diagnosed with a 0.85 mm deep melanoma of the chest. A sentinel lymph node biopsy was not obtained. Three year later, the patient was evaluated for a 4.33 mm nodular lesion arising adjacent to the excision site. The pathologic features were consistent with a metastatic melanoma deposit and the area was removed with wide local margins. Lymphatic mapping with sentinel lymph node biopsy identified metastatic melanoma involving one lymph node. A subsequent axillary lymph node dissection revealed 13 unaffected lymph nodes. Given the concern for a metastatic deposit, a punch biopsy of the finger was performed. On gross examination, an irregularly shaped 5 × 4 mm metallic gray foreign body was noted. Light microscopy evaluation of the associated soft tissue demonstrated a well-demarcated, circular aggregate of sclerotic collagen surrounding bluish-purple amorphous and granular material (Fig. 2). Non-polarizing foreign material was also noted (Fig. 3). Both the amorphous material and brown pigment stained strongly positive for iron (Fig. 4) but were negative for
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Fig. 1. A pigmented nodule presented on the right index finger in an 80-year-old man with a prior history of melanoma.
melanin and SOX-10. The patient was diagnosed with a foreign body reaction with associated iron deposition. Pigmented lesions arising after traumatic implantation of foreign material are uncommon but may raise the possibility of a melanocytic neoplasm. Frumkin et al.1 described a patient with retained surgical sutures undergoing transepidermal elimination whose lesion mimicked a nodular melanoma. The multifilament silk suture provoked granulomatous dermal inflammation and the lesion’s pigmentation was attributed to posthemorrhagic hemosiderin deposits and the black dye of the silk. McMahon and Bergfeld2 reported the case of jewelry maker with a blue-black band of pigment on the nail fold of her thumb. Microscopically, a focus of sclerotic collagen with fine particulate foreign
Letter to the Editor
Fig. 2. Intradermal basophilic amorphous material with surrounding collagen deposition was observed in routine sections.
Fig. 4. An iron stain demonstrated uptake by the amorphous material and brown pigment in the dermis.
tous inflammation and foreign body giant cells containing flakes of yellow, brown and bluish birefringent pigment consistent with rust and an outer zone of siderophages and fibrosis. The authors hypothesized that secondary trauma to the site resulted in exposure of the iron alloy to the immune system and stimulation of a granulomatous response that eventuated with the zone-like features appreciated pathologically. In contrast, our patient did not recall recent trauma to the site. Perhaps the sclerotic collagen protected the foreign material and prevented a granulomatous immunologic response. Fig. 3. Non-polarizable foreign material was noted in the dermis.
material was noted. X-ray analysis showed the material to be silver. Iron-containing foreign bodies can induce pigmentation and a foreign body reaction. Paproski et al.3 reported a newly pruritic black papule on the forearm of a mineworker suspicious for a melanoma. Thirty years earlier a steel fragment had penetrated his skin. Histopathologic examination revealed an inner zone of granuloma-
Emily Merkel, BA1 Jennifer G. Powers, MD2 Alan S. Boyd, MD2,3 1 School of Medicine Vanderbilt University Medical Center Nashville, TN, USA 2 Department of Medicine (Dermatology) Vanderbilt University Nashville, TN, USA 3 Department of Pathology Vanderbilt University Nashville, TN, USA e-mail: [email protected]
References 1. Frumkin A, Gorbacz S, Lifschitz-Mercer B. Delayed reaction to suture material simulating melanoma. Cutis 1992; 49: 59.
2. McMahon JT, Bergfeld WF. Metallic cutaneous contaminant mimicking malignant melanoma. Cleve Clin Q 1983; 50: 177.
3. Paproski SM, Smith SL, Crawford RI. Ferruginous foreign body: a clinical simulant of melanoma with distinctive histologic features. J Am Acad Dermatol 2002; 46: 397.
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© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Letter to the Editor
A painful pigmented nodule in a patient with metastatic melanoma Keywords: cutaneous neoplasm, malignant melanoma, melanocytic lesions, scar To the Editor , Any newly reported pigmented lesion in a patient with metastatic melanoma raises concern for recurrent or metastatic disease. In some instances, however, a foreign body at the indicated location can mimic cutaneous metastasis. An elderly man presented with a dark 10 mm subcutaneous nodule on his right index finger (Fig. 1). The patient reported that the lesion developed following an accident with a cast iron hammer 10 years earlier. Though the site had not significantly changed in size or appearance, it remained painful to the touch and he requested its removal. Four years earlier, the patient was diagnosed with a 0.85 mm deep melanoma of the chest. A sentinel lymph node biopsy was not obtained. Three year later, the patient was evaluated for a 4.33 mm nodular lesion arising adjacent to the excision site. The pathologic features were consistent with a metastatic melanoma deposit and the area was removed with wide local margins. Lymphatic mapping with sentinel lymph node biopsy identified metastatic melanoma involving one lymph node. A subsequent axillary lymph node dissection revealed 13 unaffected lymph nodes. Given the concern for a metastatic deposit, a punch biopsy of the finger was performed. On gross examination, an irregularly shaped 5 × 4 mm metallic gray foreign body was noted. Light microscopy evaluation of the associated soft tissue demonstrated a well-demarcated, circular aggregate of sclerotic collagen surrounding bluish-purple amorphous and granular material (Fig. 2). Non-polarizing foreign material was also noted (Fig. 3). Both the amorphous material and brown pigment stained strongly positive for iron (Fig. 4) but were negative for
1024
Fig. 1. A pigmented nodule presented on the right index finger in an 80-year-old man with a prior history of melanoma.
melanin and SOX-10. The patient was diagnosed with a foreign body reaction with associated iron deposition. Pigmented lesions arising after traumatic implantation of foreign material are uncommon but may raise the possibility of a melanocytic neoplasm. Frumkin et al.1 described a patient with retained surgical sutures undergoing transepidermal elimination whose lesion mimicked a nodular melanoma. The multifilament silk suture provoked granulomatous dermal inflammation and the lesion’s pigmentation was attributed to posthemorrhagic hemosiderin deposits and the black dye of the silk. McMahon and Bergfeld2 reported the case of jewelry maker with a blue-black band of pigment on the nail fold of her thumb. Microscopically, a focus of sclerotic collagen with fine particulate foreign
Letter to the Editor
Fig. 2. Intradermal basophilic amorphous material with surrounding collagen deposition was observed in routine sections.
Fig. 4. An iron stain demonstrated uptake by the amorphous material and brown pigment in the dermis.
tous inflammation and foreign body giant cells containing flakes of yellow, brown and bluish birefringent pigment consistent with rust and an outer zone of siderophages and fibrosis. The authors hypothesized that secondary trauma to the site resulted in exposure of the iron alloy to the immune system and stimulation of a granulomatous response that eventuated with the zone-like features appreciated pathologically. In contrast, our patient did not recall recent trauma to the site. Perhaps the sclerotic collagen protected the foreign material and prevented a granulomatous immunologic response. Fig. 3. Non-polarizable foreign material was noted in the dermis.
material was noted. X-ray analysis showed the material to be silver. Iron-containing foreign bodies can induce pigmentation and a foreign body reaction. Paproski et al.3 reported a newly pruritic black papule on the forearm of a mineworker suspicious for a melanoma. Thirty years earlier a steel fragment had penetrated his skin. Histopathologic examination revealed an inner zone of granuloma-
Emily Merkel, BA1 Jennifer G. Powers, MD2 Alan S. Boyd, MD2,3 1 School of Medicine Vanderbilt University Medical Center Nashville, TN, USA 2 Department of Medicine (Dermatology) Vanderbilt University Nashville, TN, USA 3 Department of Pathology Vanderbilt University Nashville, TN, USA e-mail: [email protected]
References 1. Frumkin A, Gorbacz S, Lifschitz-Mercer B. Delayed reaction to suture material simulating melanoma. Cutis 1992; 49: 59.
2. McMahon JT, Bergfeld WF. Metallic cutaneous contaminant mimicking malignant melanoma. Cleve Clin Q 1983; 50: 177.
3. Paproski SM, Smith SL, Crawford RI. Ferruginous foreign body: a clinical simulant of melanoma with distinctive histologic features. J Am Acad Dermatol 2002; 46: 397.
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