Melanoma Developing from an Intradermal Nevus: Report on Two Patients.

Daniela Ledić Drvar, Jaka Radoš, Ivana Manola, Ana Mataić, Snježana Dotlić, Božo Krušlin
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Abstract

Dear Editor, Approximately 25-33% of cutaneous melanomas arise from nevi (1). Shitara et al. suggested that junctional and compound nevi are more likely give rise to melanoma than intradermal nevi, but this has not been definitively confirmed (2). Based on these results and our own clinical observation on rare malignant transformation in intradermal nevi, we present two patients with melanoma developing from an intradermal nevus. The first patient, a 63-year-old woman, presented with a suspicious lesion in 2017 on the upper back in the form of a dark brown macula juxtapositioned next to the dermal nevus (Figure 1, a). Dermoscopy of a flat part showed a dark-brown reticular, slightly structureless pattern (Figure 1, b). The patient was therefore referred to surgical excision. Histopathology of the elevated part showed aggregates of intradermal nevus cells of normal morphological characteristics. Atypical and irregularly sized melanocytes were observed in the flat part, infiltrating the entire depth of the epidermis and the upper parts of the papillary dermis. The diagnosis of malignant melanoma developing from a dermal nevus was established (Breslow 0.4 mm, pT1A) (Figure 1, c). The second patient, a 71-year-old man, presented in 2018 with a pendular non pigmented intradermal nevus on middle part of the back. The left-hand lateral side of the intradermal nevus showed a brown to dark-brown spot which measured 12 mm (Figure 2, a). A central blue white veil, atypical pigment network, and dots and globules of various sizes and shapes were observed on dermoscopy (Figure 2, b). The base of the nevus showed an asymmetric pigmentation. Because the lesion was highly suspicious of melanoma, an urgent excision was indicated. The histopathology of the elevated part (dermal nevus) showed a regular maturation of the nest of nevus cells in the dermis. The histopathology of the dark-brown macule showed proliferation of atypical melanocytes with well-marked nucleoli throughout the epidermis with the infiltration of the suprabasal epidermal layers and papillary dermis. The lesion was classified as melanoma with a partial regression (Breslow 1.3 mm, pT2A), arising in association with an acquired intradermal nevus (Figure 2, c). Case reports with melanoma developed from a small congenital or acquired dermal nevus are extremely rare in the literature. In all published cases, histopathology revealed a melanoma component situated below or laterally, next to the merging dermal nevus (3) and in one case next to and above the dermal component (4), which is very similar to our cases. In both of our cases, melanoma presented an epidermal component with atypical, large melanocytes next to or above the typical and small intradermal melanocytes of the Unna nevus. Despite the fact that the reported statistical occurrence of malignant transformation of every individual nevus is very low in the elderly population (>60 years of age), 1 in 33,000 (5), we believe our two presented cases show a striking similarity in the melanoma manifesting in the vicinity of a previously existing lesion, indicating nevus-associated melanoma (NAM). This letter presents an interesting finding of two cases, with a form of melanoma (NAM) that is statistically very rare in older patients but occurred twice within the span of a year within the same town and was diagnosed in the same hospital. Intradermal nevi are most commonly considered to be benign skin lesions. However, previous research and our two cases shows that intradermal nevi are not immune to malignant alteration. Based on these results, we suggest a detailed clinical and dermoscopic evaluation of each skin lesion, including intradermal nevi. Flat melanocytic parts in the vicinity of intradermal nevi should always raise suspicion and warrant excision with histopathological evaluation of the lesion so as to allow timely response to any malignant alteration.

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由真皮内痣形成的黑色素瘤:两例患者的报告。
尊敬的编辑,大约25-33%的皮肤黑色素瘤是由痣引起的(1)。Shitara等人认为交界痣和复合痣比皮内痣更容易引起黑色素瘤,但这一点尚未得到确切证实(2)。基于这些结果和我们自己对皮内痣罕见恶性转化的临床观察,我们介绍了两名由皮内痣发展而来的黑色素瘤患者。第一位患者是一位63岁的女性,2017年,她在上背部出现了一个可疑的病变,表现为与真皮痣并列的深棕色黄斑(图1,a)。平坦部分的皮肤镜检查显示深棕色网状,轻微无结构图案(图1,b)。因此,该患者被转诊接受手术切除。隆起部分的组织病理学显示具有正常形态特征的皮内痣细胞聚集体。在扁平部分观察到非典型和不规则大小的黑色素细胞,浸润整个表皮深度和乳头状真皮上部。确定了由真皮痣发展而来的恶性黑色素瘤的诊断(Breslow 0.4mm,pT1A)(图1,c)。第二名患者是一名71岁的男性,于2018年出现背部中部下垂的无色素皮内痣。皮内痣的左侧显示一个棕色至深棕色斑点,尺寸为12毫米(图2,a)。在皮肤镜检查中观察到中心蓝白色面纱、非典型色素网络以及各种大小和形状的点和球(图2,b)。痣的基底呈现不对称的色素沉着。由于病变高度可疑为黑色素瘤,因此需要紧急切除。隆起部分(真皮痣)的组织病理学显示真皮中痣细胞巢有规律成熟。深棕色黄斑的组织病理学显示非典型黑色素细胞增殖,整个表皮有明显的核仁,基底上表皮层和乳头状真皮浸润。病变被归类为黑色素瘤,并伴有部分消退(Breslow 1.3 mm,pT2A),与获得性皮内痣有关(图2,c)。由小的先天性或后天性真皮痣引起的黑色素瘤病例报告在文献中极为罕见。在所有已发表的病例中,组织病理学显示黑色素瘤成分位于合并真皮痣下方或侧面(3),在一个病例中位于真皮成分旁边和上方(4),这与我们的病例非常相似。在我们的两个病例中,黑色素瘤都呈现出一种表皮成分,在Unna痣的典型和小的皮内黑色素细胞旁边或上方有非典型的大黑色素细胞。尽管据报道,在老年人群(>60岁)中,每个痣的恶性转化的统计发生率非常低,为1/33000(5),但我们相信,我们的两个病例在先前存在的病变附近表现出的黑色素瘤具有惊人的相似性,表明痣相关黑色素瘤(NAM)。这封信介绍了两例有趣的发现,一种黑色素瘤(NAM)在老年患者中非常罕见,但在一年内在同一个城镇发生了两次,并在同一家医院被诊断出来。真皮内痣通常被认为是良性皮肤病变。然而,先前的研究和我们的两个病例表明,皮内痣不能免疫恶性改变。基于这些结果,我们建议对每种皮肤损伤进行详细的临床和皮肤镜评估,包括皮内痣。皮内痣附近的扁平黑色素细胞部分应引起怀疑,并应进行切除,对病变进行组织病理学评估,以便对任何恶性变化做出及时反应。
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