Giant “Bathing Trunk” Nevus With Malignant Melanoma Treated by Excision and Split Thickness Skin Grafting By Ann M. Kosloske, Lester W. Martin,
T
HE “BATHING
TRUNK”
and A. James McAdams
NEVUS is a rare, congenital,
giant pigmented and hairy nevus with an alarming propensity for melanomatous transformation. We have successfully treated an infant with this lesion, employing an aggressive surgical approach consisting of (1) diverting colostomy; (2) staged partial excisions of the nevus to the level of muscle fascia, including bilateral inguinal node dissections; (3) coverage with split thickness Tanner mesh grafts; and (4) closure of the colostomy. CASE
REPORT
A S-mo-old white female presented with a giant pigmented nevus that she had had since birth. It covered the lower abdomen, perineum, lower half of the back, both buttocks, and the right upper thigh (Fig. 1). Numerous large perianal lobulated masses within the nevus were ulcerated and infected secondary to fecal contamination. She had additional light and dark brown nevi of various size scattered over the scalp, extremities, and torso. Remainder of the physical examination was normal. A completely diverting sigmoid colostomy was performed to permit healing of the infected perianal polyps and to provide optimal bacteriologic conditions for subsequent grafts. The nevus was then excised in five procedures staged 2-6 wk apart with the electrocautery knife to minimize blood loss. The level of excision was the muscle fascia, although in occasional areas (labia majora, buttock) a thin layer of fat was retained for cosmesis. Immediate coverage was obtained with split thickness mesh grafts at & inch, m’mimally expanded. The thick skin retained good texture after healing. and the meshing provided optimal drainage. Grafts were secured with a few sutures and a stent, and take was excellent. Immobilization after grafting the buttocks was provided with a full hip spica cast. Bilateral inguinal node dissection was carried out in continuity with excision of the anterior abdominal part of the nevus. Microscopic examination revealed a complex pigmented and neuronevus as typically seen in bathing trunk nevus. Large elements consisted of neurofibroma-like tissue, associated with prominent tactoids, and there were foci of atypical junctional change in the pigmented neural components. Two nodular foci of a small-cell malignant melanoma were present (Fig. 2). The lymph nodes were histologically unremarkable. The colostomy was closed at age 14 mo. She survives in good health at age 2 yr, 8 mo, with no evidence of recurrent or metastatic melanoma. DISCUSSION
Although melanoma is rare before puberty, it occurs in giant pigmented nevi at a reported rate of 1.8x-30%. ‘J If the melanoma spreads to regional nodes or beyond in children, the outlook is dismal; Trozak collected 22 such cases with From the Deparimenis of Surgery and Patholog.v, College of Medicine, University of Cincinnati, and the Surgical and Pathologic Services, Children’s Hospital, Cincinnati, Ohio. Presented before the 6th Annual Meeting of the American Pediatric Surgical Association, San Juan, Puerto Rico, April 10-12, 1975. Addressfor reprint requests: Ann M. Kosloske, M.D., 405 Tammen Hall, 1010 East 19th Ave., Denver, Colo. 80218. 0 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery,
Vol.
10, No.
5
(October),
1975
823
824
KOSLOSKE,
MARTIN,
AND MC ADAMS
Fig. 1. ferinaol portion of the bathing trunk “*“US. Polyps within the nevus, containing ncurofibromotous elements, surround the onus.
no survivors.3 Penman4 reported an unfortunate child with a giant scalp nevus for whom plastic surgery was planned at age 2, but who developed fatal metastatic melanoma at age 1. Feins’ excised a giant nevus with melanoma from the scalp of a l-mo-old infant and reemphasized the risk of malignancy and the need for early operation. Also to be considered in giant nevi is the high incidence of meningeal melanosis, which may be complicated by hydrocephalus and may give rise to melanoma.6 Giant nevi covering a major portion of the body surface have been considered inoperable in the past because of limited donor sites.’ Techniques evolving from the surgery of burns including mesh grafting, staged partial excisions, and “reharvesting” of the same donor sites now permit resurfacing of very extensive areas, with satisfactory cosmetic results. Evidence suggests that staged partial excision of a nevus does not predispose to malignancy in the remaining parts.* Staged excision, begun as early as possible, is the treatment of choice for giant “bathing trunk” nevi, including those with malignant elements.
Fig. 2. Areo of bothing trunk nevus showing melanoma. There ore solid bands of neoplostic cells rep amted by a tmbecular stromo of vosculor connective tissue. The meloin monotonous noma cells am character, show occasion01 mitoses, and occosionolly contain melanin pigment granules in their cytoplasm. Hemotoxylin and eorin stoins, x 160.
“BATHING
TRUNK”
NEVUS
825
REFERENCES 1. Pers M: Naevus pigmentosus giganticus. Ugeskr Laeger 125:613-623, 1963 2. Reed WB, Becker SW, Becker SW Jr, et al: Giant pigmented nevi, melanoma, and leptomeningeal melanocytosis. Arch Dermatol 91: 100-l 19, 1965 3. Trozak DJ, Rowland WD, Hu F: Metastatic malignant melanoma in prepubertal children. Pediatrics 55: 191-204, 1975 4. Penman HG, Stringer HCW: Malignant transformation in giant congenital pigmented news.
Arch Dermatol
103:4288432,
1971
5. Feins NR: Excision of giant born. J Pediatr Surg 8:825, 1973
nevus in new-
6. Fox H, Emery JL, Goodbody Neurocutaneous melanosis. Arch 39:508-516, 1964
RA, et al: Dis Child
7. Greeley PW, Middleton AC, Curtin JW: Incidence of malignancy in giant pigmented nevi. Plast Reconstr Surg 36:26-37. 1965 8. Walton RG: Pigmented North Am 18:8977923, 1971
nevi. Pediatr
Clin
T
HE “BATHING
TRUNK”
and A. James McAdams
NEVUS is a rare, congenital,
giant pigmented and hairy nevus with an alarming propensity for melanomatous transformation. We have successfully treated an infant with this lesion, employing an aggressive surgical approach consisting of (1) diverting colostomy; (2) staged partial excisions of the nevus to the level of muscle fascia, including bilateral inguinal node dissections; (3) coverage with split thickness Tanner mesh grafts; and (4) closure of the colostomy. CASE
REPORT
A S-mo-old white female presented with a giant pigmented nevus that she had had since birth. It covered the lower abdomen, perineum, lower half of the back, both buttocks, and the right upper thigh (Fig. 1). Numerous large perianal lobulated masses within the nevus were ulcerated and infected secondary to fecal contamination. She had additional light and dark brown nevi of various size scattered over the scalp, extremities, and torso. Remainder of the physical examination was normal. A completely diverting sigmoid colostomy was performed to permit healing of the infected perianal polyps and to provide optimal bacteriologic conditions for subsequent grafts. The nevus was then excised in five procedures staged 2-6 wk apart with the electrocautery knife to minimize blood loss. The level of excision was the muscle fascia, although in occasional areas (labia majora, buttock) a thin layer of fat was retained for cosmesis. Immediate coverage was obtained with split thickness mesh grafts at & inch, m’mimally expanded. The thick skin retained good texture after healing. and the meshing provided optimal drainage. Grafts were secured with a few sutures and a stent, and take was excellent. Immobilization after grafting the buttocks was provided with a full hip spica cast. Bilateral inguinal node dissection was carried out in continuity with excision of the anterior abdominal part of the nevus. Microscopic examination revealed a complex pigmented and neuronevus as typically seen in bathing trunk nevus. Large elements consisted of neurofibroma-like tissue, associated with prominent tactoids, and there were foci of atypical junctional change in the pigmented neural components. Two nodular foci of a small-cell malignant melanoma were present (Fig. 2). The lymph nodes were histologically unremarkable. The colostomy was closed at age 14 mo. She survives in good health at age 2 yr, 8 mo, with no evidence of recurrent or metastatic melanoma. DISCUSSION
Although melanoma is rare before puberty, it occurs in giant pigmented nevi at a reported rate of 1.8x-30%. ‘J If the melanoma spreads to regional nodes or beyond in children, the outlook is dismal; Trozak collected 22 such cases with From the Deparimenis of Surgery and Patholog.v, College of Medicine, University of Cincinnati, and the Surgical and Pathologic Services, Children’s Hospital, Cincinnati, Ohio. Presented before the 6th Annual Meeting of the American Pediatric Surgical Association, San Juan, Puerto Rico, April 10-12, 1975. Addressfor reprint requests: Ann M. Kosloske, M.D., 405 Tammen Hall, 1010 East 19th Ave., Denver, Colo. 80218. 0 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery,
Vol.
10, No.
5
(October),
1975
823
824
KOSLOSKE,
MARTIN,
AND MC ADAMS
Fig. 1. ferinaol portion of the bathing trunk “*“US. Polyps within the nevus, containing ncurofibromotous elements, surround the onus.
no survivors.3 Penman4 reported an unfortunate child with a giant scalp nevus for whom plastic surgery was planned at age 2, but who developed fatal metastatic melanoma at age 1. Feins’ excised a giant nevus with melanoma from the scalp of a l-mo-old infant and reemphasized the risk of malignancy and the need for early operation. Also to be considered in giant nevi is the high incidence of meningeal melanosis, which may be complicated by hydrocephalus and may give rise to melanoma.6 Giant nevi covering a major portion of the body surface have been considered inoperable in the past because of limited donor sites.’ Techniques evolving from the surgery of burns including mesh grafting, staged partial excisions, and “reharvesting” of the same donor sites now permit resurfacing of very extensive areas, with satisfactory cosmetic results. Evidence suggests that staged partial excision of a nevus does not predispose to malignancy in the remaining parts.* Staged excision, begun as early as possible, is the treatment of choice for giant “bathing trunk” nevi, including those with malignant elements.
Fig. 2. Areo of bothing trunk nevus showing melanoma. There ore solid bands of neoplostic cells rep amted by a tmbecular stromo of vosculor connective tissue. The meloin monotonous noma cells am character, show occasion01 mitoses, and occosionolly contain melanin pigment granules in their cytoplasm. Hemotoxylin and eorin stoins, x 160.
“BATHING
TRUNK”
NEVUS
825
REFERENCES 1. Pers M: Naevus pigmentosus giganticus. Ugeskr Laeger 125:613-623, 1963 2. Reed WB, Becker SW, Becker SW Jr, et al: Giant pigmented nevi, melanoma, and leptomeningeal melanocytosis. Arch Dermatol 91: 100-l 19, 1965 3. Trozak DJ, Rowland WD, Hu F: Metastatic malignant melanoma in prepubertal children. Pediatrics 55: 191-204, 1975 4. Penman HG, Stringer HCW: Malignant transformation in giant congenital pigmented news.
Arch Dermatol
103:4288432,
1971
5. Feins NR: Excision of giant born. J Pediatr Surg 8:825, 1973
nevus in new-
6. Fox H, Emery JL, Goodbody Neurocutaneous melanosis. Arch 39:508-516, 1964
RA, et al: Dis Child
7. Greeley PW, Middleton AC, Curtin JW: Incidence of malignancy in giant pigmented nevi. Plast Reconstr Surg 36:26-37. 1965 8. Walton RG: Pigmented North Am 18:8977923, 1971
nevi. Pediatr
Clin
