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Year : 2011  |  Volume : 54  |  Issue : 1  |  Page : 196-198
Metachronous pleomorphic liposarcoma and melanoma: A rare case report


Department of Pathology, Meenakshi Medical College, Hospital and Research Institute, Enathur, Kancheepuram - 631 552, Tamil Nadu, India

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Date of Web Publication7-Mar-2011
 

How to cite this article:
Gupta RK, Kathiah R, Prakash G, Venkatasubramaniam B. Metachronous pleomorphic liposarcoma and melanoma: A rare case report. Indian J Pathol Microbiol 2011;54:196-8

How to cite this URL:
Gupta RK, Kathiah R, Prakash G, Venkatasubramaniam B. Metachronous pleomorphic liposarcoma and melanoma: A rare case report. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Dec 10];54:196-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/1/196/77404


Soft tissue sarcomas (STSs) and melanomas are both rare tumors, accounting for less than 1 and 3% of cancers, respectively, in the United States of America. [1] Coexistence of both these uncommon cancers in a single patient has been reported in recent times, leading workers to postulate about a possible association between the two. Liposarcoma is regarded as one of the most common STSs in adult patients; yet, coexistence of melanoma and liposarcoma in the same patient is a very rare finding. [2],[3],[4] We herein report a case of metachronous pleomorphic liposarcoma (PLS) and cutaneous melanoma occurring in an 82-year-old male patient.

An 82-year-old male farmer presented with a large 25 × 19 × 6 cm, round, lobulated, nontender soft tissue swelling in his left subscapular region, a 4 × 3 cm grayish-black oval ulcerative growth over the medial plantar aspect of his right foot and a 5 × 4 cm hard swelling in his right inguinal region which appeared to be matted lymph nodes.The back swelling although present in the patient since past 20 years had recently witnessed a sudden growth-spurt in the past 3 months.. Pain while walking made him notice the plantar growth and the inguinal swelling appeared soon after. No family history of malignancy was elicited. Fine needle aspiration cytology (FNAC) of the back and the inguinal swelling was done in the same sitting while imprint smears were taken from the foot lesion. FNAC of the subscapular swelling revealed a cellular smear composed of pleomorphic round to oval cells with few giant cells, while smear from the inguinal node showed many malignant appearing oval cells containing intracellular melanin. Imprint smear from the foot lesion revealed a picture similar to that of the inguinal node FNAC. Provisional diagnoses of pleomorphic round cell tumor (probably an STS) for the subscapular mass and malignant melanoma of the right foot with secondaries to the right inguinal node were given [Figure 1] and [Figure 2].
Figure 1: (a) Huge subscapular mass in the patient. (b) Resected specimen of the same at surgery. (c) Ulcerated lesion in his right foot. (d) Swelling in his right inguinal region

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Figure 2: (a) FNAC appearance of the subscapular mass showing a cellular smear composed of pleomorphic round to oval cells (H and E, ×100). (b) FNAC appearance of right inguinal node also showing a cellular smear composed mainly of large oval cells containing intra-cellular melanin amidst scant lymphoid cells (H and E, ×100)

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A wedge biopsy of the foot lesion and a wide local excision of the soft tissue mass in the back were done. Grossly, the resected subscapular mass was 25 × 20 cm, ovoid and superficially resembled a lipoma. Cut section showed an encapsulated yellowish tumor with a single focal subcapsular 8 × 5 cm grayish-white firm area [Figure 3]. Multiple sections from the mass largely showed benign adipocytes (adult-type) as seen in a usual lipoma. The whitish firm area, however, showed a highly cellular neoplasm composed predominantly of pleomorphic spindle cells resembling malignant fibrous histiocytoma (MFH), along with areas showing multivacuolated lipoblasts with hyperchromatic, scalloped nuclei and scattered multinucleated giant cells, mitotic figures and foci of necrosis [Figure 4]. Wedge biopsy of the foot lesion showed an ulcerated squamous epithelium overlying a tumor composed of round to oval cells with pleomorphic nuclei and prominent nucleoli along with intra- and extra-cellular melanin pigment. Immunohistochemistry (IHC) showed that the tumor cells were positive for HMB-45 [Figure 5]. The final diagnoses were given as PLS of the subscapular mass (MFH-type) and malignant melanoma of the right foot. As the patient declined to undergo any further treatment because of financial constraints, he was discharged from our hospital with advice for regular follow-up.
Figure 3: (a) Gross appearance of the subscapular mass. (b) Close-up view of the white firm area within the mass (red arrow)

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Figure 4: (a) Scanner view of the subscapular mass showing both "MFH-like" and "lipoblastic" areas (H and E, ×40). (b) Scanner view of a MFH-like area within the tumor showing areas of necrosis (H and E, ×40). (c) Low power view of a "lipoblastic" area within the tumor (H and E, ×100). (d) High power view of the malignant lipoblasts (H and E, ×400)

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Figure 5: (a) Low power view of the foot lesion showing slightly ulcerated squamous epithelium overlying malignant round to oval cells with intra- and extra-cellular melanin (H and E, ×100). (b) High power view of the same (H and E, ×400). (c) HMB-45 positivity of the lesion (IHC, ×100)

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The coexistence of STS and melanoma in the same individual, either synchronously or metachronously, has been reported in a few studies throughout the world, pointing to the possibility of an association between the two. Some workers have even hinted at a "melanoma/sarcoma syndrome". [2],[3] Somatic mutations in CDK4, MDM2 or p53 genes have been proposed as a common pathogenetic pathway for these two tumors. [2],[4]

Surprisingly, although liposarcoma is known to be the most commonly diagnosed STS in adults, in a large study of 48 patients with both melanoma and sarcoma, only one patient had a diagnosis of liposarcoma. [2] PLS is known to be the rarest liposarcoma subtype, accounting for only 5% of liposarcomas, and can be distinguished from other high-grade pleomorphic sarcomas only by the presence of multivacuolated lipoblasts with hyperchromatic, scalloped nuclei and occasionally intracytoplasmic hyaline droplets which were not seen in our case. [5] Two predominant histologic patterns usually occur in PLS - MFH-like (as in our case) and epithelioid-like. [5] Another rare interesting observation in our case was the longstanding history of the subscapular tumor which suggests that the PLS had developed within the pre-existing subcutaneous lipoma. [6]

The cutaneous melanoma in our patient had classical histologic features with HMB-45 positive tumor cells showing large nuclei and prominent nucleoli along with intra- and extra-cellular melanin. Such a metachronous appearance of pleomorphic liposarcoma and melanoma in a single patient has not been previously reported in literature to the best of our knowledge. More studies are needed to explore this sarcoma-melanoma association for the benefit of patients and clinicians alike.


   Acknowledgment Top


Dr. Srivatsa Prakhya, MBBS, Postgraduate (MD) Resident, Department of Pathology, Meenakshi Medical College, Hospital and Research Institute, is gratefully acknowledged.

 
   References Top

1.Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics, 1996. CA Cancer J Clin 1996;46:5-27.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Berking C, Brady MS. Cutaneous melanoma in patients with sarcoma. Cancer 1997;79:843-8.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Dunbar SF, Marks LB, Sober AJ, Rosenberg A, Suit HD. Connective tissue tumors in patients with cutaneous melanoma. J Am Acad Dermatol 1994;31:216-9.  Back to cited text no. 3
[PUBMED]    
4.Jeong TJ, Lee EJ, Haw S, Shin MK, Haw CR. Coexistence of amelanotic melanoma and liposarcoma. Ann Dermatol 2009;21:409-12.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hornick JL, Bosenberg MW, Mentzel T, McMenamin ME, Oliviera AM, Fletcher CD. Pleomorphic liposarcoma: clinicopathologic analysis of 57 cases. Am J Surg Pathol 2004;28:1257-67.  Back to cited text no. 5
    
6.Sternberg SS. Liposarcoma arising within a subcutaneous lipoma. Cancer 1952;5:975-8.  Back to cited text no. 6
[PUBMED]    

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Correspondence Address:
Rajib K Gupta
Department of Pathology, Meenakshi Medical College, Hospital and Research Institute, Enathur, Kancheepuram - 631 552, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.77404

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