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CASE REPORT  
Year : 2012  |  Volume : 55  |  Issue : 4  |  Page : 538-539
A case of collision tumor or transdifferentiation between malignant melanoma and leiomyosarcoma


1 Department of Plastic Surgery and Reconstruction, Herlev University Hospital, Herlev Ringvej 75, Herlev, Copenhagen, Denmark
2 Department of Pathology, Herlev University Hospital, Herlev Ringvej 75, Herlev, Copenhagen, Denmark

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Date of Web Publication4-Mar-2013
 

   Abstract 

A 73-year-old woman was referred to the hospital due to a pigmented, asymptomatic nevus on her right arm that had changed in size and color. The histopathological examination showed a superficial spreading malignant melanoma, Clark level III, 2.26 mm in thickness. Two years later, the patient presented a 10 cm rapidly growing mass in her right axilla. The mass in the axilla measured 12.5 ΄ 9 ΄ cm. It revealed a lymph node metastases with a tumor growth composed of two different contiguous morphological and immunohistochemical components, respectively, melanosomes and leiomyosarcoma. The combination of a melanocytic nevus with other tumor of epidermal or adnexal origin has been described before, but still the co-existence of two different neoplasms within a lesion is still uncommon. The most common combination is basal cell carcinoma and melanocytic nevus or one of them together with a seborrheic keratosis. There have also been occasional reports of rhabdomyosarcomatous differentiation. However, mesenchymal differentiation, and in this case leiomysarcoma, with formation of heterologous elements in melanocytic tumor is very rare. Another plausible explanation may be that malignant melanoma cells could have transdifferentiated into a leiomyosarcomatoid phenotype with resulting metastases of either type. Malignant melanomas have shown a wide variety of cytological changes and can mimic carcinomas, lymphomas, and sarcomas. Spindle cell melanomas commonly simulate spindle cell carcinomas. It has also been documented that desmoplastic melanomas can change into fibroblastic, Schwannian, and myofibroblastic differentiation.

Keywords: Collision tumor, leiomyosarcoma, malignant melanoma, pathology

How to cite this article:
Ul-Mulk J, Rasmussen H, Breiting L, Siim E. A case of collision tumor or transdifferentiation between malignant melanoma and leiomyosarcoma. Indian J Pathol Microbiol 2012;55:538-9

How to cite this URL:
Ul-Mulk J, Rasmussen H, Breiting L, Siim E. A case of collision tumor or transdifferentiation between malignant melanoma and leiomyosarcoma. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Sep 19];55:538-9. Available from: http://www.ijpmonline.org/text.asp?2012/55/4/538/107806



   Case Report Top


A 73-year-old woman was referred to the Department of Plastic Surgery and Reconstruction at a University Hospital due to a pigmented, asymptomatic nevus on her right arm. The lesion had increased in size and became darker during the last few months. After excision, the histopathological examination showed a superficial spreading malignant melanoma, Clark level III, 2.26 mm in thickness. The patient underwent sentinel lymph node biopsy and re-excision of the primary lesion, and a Positron Emission Tomography (PET) scan was performed according to National Melanoma Guidelines. These were all negative.

Two years later, the patient presented a 10 cm rapidly growing mass in her right axilla. An axillary lymph node dissection was performed and the tumor was radically removed.

The latest PET scan has shown that there are multiple metastases to the liver, lungs, breast, and skin. The patient was referred to oncology department for further treatment and is still alive today.


   Pathology Top


The mass in the axilla measured 12.5 × 9 × 6 cm. It revealed a lymph node metastases with a tumor growth composed of two different contiguous morphological and immunohistochemical components [Figure 1]a and b. Numerous mitosis and atypical forms were noted. In one part of the lesion; the cells were large, oval melanocytes with moderate nuclear pleomorphism and large amounts of intracytoplasmic pigment with a nodular pattern of growth. The atypical melanocytes were strongly immunoreactive for Melan A, S100 and tyrosinase and negative for desmin, CD34, actin and caldesmon. Ultrastructural studies revealed that tumor cells in this area contained large amounts of intracytoplasmic membrane bound melanosomes.
Figure 1: Morphological and immunohistochemical features of a patient with metastatic malignant melanoma and leiomyosarcoma (a) Atypical melanocytes in the axillary lymph node. Hematoxylin-eosin stain, ×200 magnification (b) Atypical melanocytes show strong immunoreactivity to S-100 in contrast to S-100 negative area of the tumor. Immunostain, ×100 magnification (c) In the same slide as shown in Figure 1b, illustrates an area with leiomyosarcomatoid differentiation. Area of sarcomatoid differentiation in the axillary lymph node. Hematoxylin-eosin stain, ×200 magnification

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The same slide showed an area where tumor cells had a fusiform morphology with a storiform growth pattern [Figure 1]b. These tumor cells were strongly immunoreactive to actin and desmin, but negatively to S100 and Melan A. Ultrastructural studies showed that these cells contained large amounts of intermediate filaments and no intracytoplasmic membrane bound granules. This part of the tumor seemed to be ultrastructurally and morphological consistent with a malignant mesenchymal tumor most likely leiomyosarcoma.


   Discussion Top


The combination of a melanocytic nevus with other tumor of epidermal or adnexal origin has been described before, but still the co-existence of two different neoplasms within a lesion is still uncommon. Most common combination is basal cell carcinoma and melanocytic nevus or one of them together with a seborrheic keratosis. [1],[2],[3]

Desmoplastic malignant melanomas may show a Schwannian, fibroblastic or myofibroblastic differentiation at the ultrastructural level. Schwannian differentiation in melanocytic lesions is not that rare because both melanocytes and Schwann celles are derived from the neural crest. There have also been occasional reports of rhabdomyosarcomatous differentiation. [4] It is described in a few cases of congenital nevi with or without an association of malignant melanoma. However, it is extremely rare in adults. [5] Mesenchymal differentiation, and in this case leiomysarcoma with formation of heterologous elements in melanocytic tumor is very rare.

The pathology report showed that tumor cells were strongly immunoreactive and positive for muscle markers, either actin or desmin. Carlson et al.[6] demonstrated muscle actin positivity in 12 (52%) of the 26 cases of desmoplastic neurotropic melanoma, but could not find this in the ultrastructural level. Hence, they concluded that it was a non-specific phenomenon. Banerjee et al.[1] also pointed out that to their knowledge there is not any documented case of melanoma showing the full immunophenotypic and ultrastructural smooth muscle differentiation.

Another plausible explanation may be that malignant melanoma cells could have transdifferentiated into a leiomyosarcomatoid phenotype with resulting metastases of either type. [4] As a pathologist one should be very aware as it can lead to diagnostic uncertainty. A carefully immunhistochemical panel and the input of electron microscopy can help clarify the nature of cellular differentiation of these tumors and lead to a correct diagnosis. Furthermore, as conventional chemotherapy has a poor impact on this tumor type, it is even more advisable to be precise in the diagnosis of these tumors. [4],[5],[6],[7] More work needs to be put in understanding malignant melanoma and to clarify differentiation processes. To the best of our knowledge, this kind of tumor is very rare and, therefore, represents a unique case.

 
   References Top

1.Banerjee SS, Bishop PW, Nicholson CM, Eyden BP. Malignant melanoma showing smooth muscle differentiation. J ClinPathol1996;49:950-1.  Back to cited text no. 1
[PUBMED]    
2.Braun-Falco M. Combined malignant melanoma and basal cell carcinoma tumor of the intermingled type.J CutanPathol 2007;34:731-5.  Back to cited text no. 2
[PUBMED]    
3.González-Vela MC, Val-Bernal JF, González-López MA, Novell M, Fernández-Llaca H. Collision of pigmented benign tumours: A possible simulator of melanoma. Acta Derm Venereol 2008;88:92-3.  Back to cited text no. 3
    
4.Gattenlöhner S, Brocker EB, Muller-Hermelink HK. Malignant melanoma with metastatic rhabdomyosaromatoid trans differentiation. N Engl J Med 2008;358:649-50.  Back to cited text no. 4
    
5.Banerjee SS, Eyden B. Divergent differentiation in malignant melanoma: A review. Histopathology 2008;52:119-29.  Back to cited text no. 5
    
6.Carlson JA, Dickersin GR, Sober AJ, Barnhill RL. Desmoplastic neurotropic melanoma. Aclinicopathologic analysis of 28 cases. Cancer 1995;75;478-94.  Back to cited text no. 6
    
7.Hacker NF, Moore JG. Essentials of Obstetrics and Gynecology. Philadelphia: WB Saunders Company; 1998.  Back to cited text no. 7
    

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Correspondence Address:
Jamshaid Ul-Mulk
Department of Plastic Surgery and Reconstruction, Herlev University Hospital, Herlev Ringvej 75, Herlev, Copenhagen
Denmark
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.107806

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