Tumor Conference # 1 3 Fatal Amelanotic Nodular Melanoma in a 15-Year Old Girl
ALFRED W. KOPF, M.D. A N D ROBERT S. BART, M.D.
A m a t u r e 15-y e a r - o l d g i r l with well-established menses was first seen in the Oncology Section o f the Skin and Cancer Unit on May 21, 1958 for a nonpigmented, hemispheric papule 8 mm in diameter on the lateral aspect o f her left leg (Fig. 1). The lesion had grown upon the site o f a small, pigmented “m ole” which she had had since “early childhood.” The patient stated that she had occasionally injured the original nevus when she shaved her legs. On May 28, 1958 an excisional biopsy o f the entire visible lesion was performed, the histopathology o f which is shown in Fig. 2. Although there was consid erable discussion about the possibility o f benign juvenile melanoma, most pathologists agreed that the neoplasm was an amelanotic malignant melanoma. TUMOR CONFERENCE (JUNE 25, 1958) Tumor surgeon: This is a young girl with a histologic diagnosis o f malignant melanoma o f the amelanotic variety by a majority o f histopathologists. In my experi ence such lesions have a poorer prognosis than their melanotic counterparts. The leg is a very much more common site o f malignant melanomas in women than in men. Clinically, there is no evidence o f regional lymph node involvement. Nonetheless, I believe that a radical groin dissection should be done because o f the histologic diagnosis o f malignant melanoma. D erm atologist: Malignant melanoma in prepubertal children is very rare. This girl is clearly postpubertal. In the past there was great confusion between benign juvenile melanomas and malignant melanomas. Fortu nately, Dr. Sophie Spitz has aided us greatly in differen tiating these lesions. I would agree with elective lymphnode dissection for this 15-year-old patient. From the Oncology Section, Skin and Cancer Unit, New York University Medical Center and the D epartm ent of Dermatology, New York University School of Medicine, New York, New York. Dr. K opf is Professor of Dermatology and Head of the Oncology Section, Skin and Cancer Unit at the NY U School of Medicine and Post-Graduate Medical School. Dr. Bart is Associate Professor o f Dermatology at the NY U School of Medicine and Post-Graduate Medical School.
490
J. Dermatol Surg. Oncol 3:5 September/October 1977
D erm atopathologist: The slides have been seen in consultation by several pathologists. Most agree we are dealing with malignant melanoma but some hold out for a Spitz nevus. * * * * * *
On October 3, 1958 a wide re-excision o f the primary site and an ipsilateral radical groin dissection were performed. In the surgical material one inguinal lymph node was found to contain metastatic malignant m ela noma. * * * * * *
TUMOR CONFERENCE (JANUARY 1960) During a recent follow-up visit an asymptomatic subcutaneous nodule was noted on the patient’s chest just to the right o f the sternum (Fig. 3). It was noticed shortly before Christmas. Clinically, it is palpable as a firm, movable, somewhat bluish, subcuta neous, spherical mass about 2 cm in diameter. Tumor surgeon: Clinically, the most likely diagnosis is subcutaneous metastatic malignant melanoma. The lesion should be excised. If it is a metastatic malignant melanoma the prognosis is grave indeed.
D erm atologist:
♦ ♦ ♦ ♦ ♦ ♦
Histologic study o f the nodule excised from the chest substantiated the diagnosis o f metastatic malignant melanoma (Figs. 4 and 5). At this time a workup for systemic metastases was negative in findings. In the course o f the next few months, however, widespread metastatic disease became evident. Systemic chem o therapy was instituted with triethylene thiophosphoramide and actinomycin D. She died in June 22, 1960 o f widespread metastasis a little over two years from the discovery o f the primary malignancy. At autopsy the liver, lungs, spleen, ovary, lymph nodes, and omentum were found to be involved with malignant melanoma metastases. SUMMARY The patient was a 15-year-old girl who was found to have a amelanotic nodular m elanoma on a leg. The local
KOPF AN D BART
FIGURE I. Pri m ary am elan otic nodular melanoma on the leg o f a 15year-old girl.
FIGURE 2. Histology o f the primary melanoma. (H
ALFRED W. KOPF, M.D. A N D ROBERT S. BART, M.D.
A m a t u r e 15-y e a r - o l d g i r l with well-established menses was first seen in the Oncology Section o f the Skin and Cancer Unit on May 21, 1958 for a nonpigmented, hemispheric papule 8 mm in diameter on the lateral aspect o f her left leg (Fig. 1). The lesion had grown upon the site o f a small, pigmented “m ole” which she had had since “early childhood.” The patient stated that she had occasionally injured the original nevus when she shaved her legs. On May 28, 1958 an excisional biopsy o f the entire visible lesion was performed, the histopathology o f which is shown in Fig. 2. Although there was consid erable discussion about the possibility o f benign juvenile melanoma, most pathologists agreed that the neoplasm was an amelanotic malignant melanoma. TUMOR CONFERENCE (JUNE 25, 1958) Tumor surgeon: This is a young girl with a histologic diagnosis o f malignant melanoma o f the amelanotic variety by a majority o f histopathologists. In my experi ence such lesions have a poorer prognosis than their melanotic counterparts. The leg is a very much more common site o f malignant melanomas in women than in men. Clinically, there is no evidence o f regional lymph node involvement. Nonetheless, I believe that a radical groin dissection should be done because o f the histologic diagnosis o f malignant melanoma. D erm atologist: Malignant melanoma in prepubertal children is very rare. This girl is clearly postpubertal. In the past there was great confusion between benign juvenile melanomas and malignant melanomas. Fortu nately, Dr. Sophie Spitz has aided us greatly in differen tiating these lesions. I would agree with elective lymphnode dissection for this 15-year-old patient. From the Oncology Section, Skin and Cancer Unit, New York University Medical Center and the D epartm ent of Dermatology, New York University School of Medicine, New York, New York. Dr. K opf is Professor of Dermatology and Head of the Oncology Section, Skin and Cancer Unit at the NY U School of Medicine and Post-Graduate Medical School. Dr. Bart is Associate Professor o f Dermatology at the NY U School of Medicine and Post-Graduate Medical School.
490
J. Dermatol Surg. Oncol 3:5 September/October 1977
D erm atopathologist: The slides have been seen in consultation by several pathologists. Most agree we are dealing with malignant melanoma but some hold out for a Spitz nevus. * * * * * *
On October 3, 1958 a wide re-excision o f the primary site and an ipsilateral radical groin dissection were performed. In the surgical material one inguinal lymph node was found to contain metastatic malignant m ela noma. * * * * * *
TUMOR CONFERENCE (JANUARY 1960) During a recent follow-up visit an asymptomatic subcutaneous nodule was noted on the patient’s chest just to the right o f the sternum (Fig. 3). It was noticed shortly before Christmas. Clinically, it is palpable as a firm, movable, somewhat bluish, subcuta neous, spherical mass about 2 cm in diameter. Tumor surgeon: Clinically, the most likely diagnosis is subcutaneous metastatic malignant melanoma. The lesion should be excised. If it is a metastatic malignant melanoma the prognosis is grave indeed.
D erm atologist:
♦ ♦ ♦ ♦ ♦ ♦
Histologic study o f the nodule excised from the chest substantiated the diagnosis o f metastatic malignant melanoma (Figs. 4 and 5). At this time a workup for systemic metastases was negative in findings. In the course o f the next few months, however, widespread metastatic disease became evident. Systemic chem o therapy was instituted with triethylene thiophosphoramide and actinomycin D. She died in June 22, 1960 o f widespread metastasis a little over two years from the discovery o f the primary malignancy. At autopsy the liver, lungs, spleen, ovary, lymph nodes, and omentum were found to be involved with malignant melanoma metastases. SUMMARY The patient was a 15-year-old girl who was found to have a amelanotic nodular m elanoma on a leg. The local
KOPF AN D BART
FIGURE I. Pri m ary am elan otic nodular melanoma on the leg o f a 15year-old girl.
FIGURE 2. Histology o f the primary melanoma. (H
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