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  Table of Contents    
LETTER TO EDITOR  
Year : 2017  |  Volume : 60  |  Issue : 4  |  Page : 622-623
Balloon cell melanoma metastasis to the temporal lobe


1 Department of Pathology, Medical School, Aristotle University, Thessaloniki, Greece
2 Neurosurgery Clinic, Agios Loukas Hospital, Thessaloniki, Greece

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Date of Web Publication12-Jan-2018
 

How to cite this article:
Iliadis A, Zaraboukas T, Selviaridis P, Chatzisotiriou A. Balloon cell melanoma metastasis to the temporal lobe. Indian J Pathol Microbiol 2017;60:622-3

How to cite this URL:
Iliadis A, Zaraboukas T, Selviaridis P, Chatzisotiriou A. Balloon cell melanoma metastasis to the temporal lobe. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Jun 20];60:622-3. Available from: http://www.ijpmonline.org/text.asp?2017/60/4/622/222988




Editor,

In recognition of the rarity of metastatic melanomas in the brain of the morphological variant of the balloon-cell type,[1],[2],[3] we report a new case of balloon cell melanoma (BCM) metastatic to the convexity of the left temporal lobe. A 54-year-old male presented with difficulty in speech comprehension. Neurological examination disclosed mild sensory dysphasia, with no other localizing signs. Neuroimaging revealed a space-occupying lesion of the left temporal lobe, showing strong enhancement with gadolinium in T1-weighted images [Figure 1]. The patient was subjected to a left temporal craniotomy and total resection of the lesion, which was clearly visible in the cortex and with no connection to the meninges. Histopathological examination revealed diffuse infiltration of the brain tissue by large, tightly packed, pale neoplastic cells, occasionally of giant size, with an abundant, clear, foamy cytoplasm and relatively uniform nuclei with minimal-to-mild atypia, and few mitoses [Figure 2]a and [Figure 2]b. These characteristic balloon cells were amelanotic. The neoplasm was arranged in a solid pattern infiltrating the brain matter. Immunohistochemically, the tumor cells were positive for Vimentin, S100, Melan-A, and HMB-45 [Figure 2]c and [Figure 2]d, but negative for cytokeratins AE1/AE3 and 8/18, PAX8, calretinin, and synaptophysin. The medical history of the patient included a surgically excised cutaneous melanoma without BCM features. He was initially subjected to resection of a lesion in the left forearm with complementary lymph node dissection in the left axilla. Metastasis was then found in the sigmoid and a sigmoidectomy, along with a Whipple procedure, were performed. Preoperatively, he underwent diffusor tensor imaging measurements. The clear cell morphology prompted initial differential diagnostic considerations of various cell types of metastatic carcinoma. However, the positive melanocytic immunohistochemical markers, as well as the preexistent skin lesion, established our final diagnosis.
Figure 1: Gadolinium-enhanced sagittal T1-weighted image shows an enhancing space-occupying mass in the convexity of the left temporal lobe

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Figure 2: The large polyhedral cells are arranged in brain matter infiltrating nests and cords separated by thin fibrous septae, in an almost lobular architecture, showing moderate pleomorphism with focal areas of increased cellularity and nuclear pleomorphism. No spindle-shaped or epithelioid cells and no pigmentation are present. (a) The cells show discernible cytoplasmic membranes, a foamy, clear, or finely vacuolated cytoplasm with occasional pale eosinophilic granules, central, or eccentrically placed round to ovoid, size varying nuclei, many exhibiting prominent nucleoli, highly irregular chromatin content or occasional intranuclear inclusions, and a low nuclear to cytoplasmic ratio, and are variably sized, ranging from 20 to 70 microns in diameter. (b) Variable, mild to strong, perinuclear, cytoplasmic staining reaction for Melan-A (c) and HMB-45 (d). (a: H and E, ×100; b: H and E, ×400; c and d: IHC, ×100)

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BCM features are a rare histologic variant seen in benign melanocytic nevi and malignant melanomas and are characterized by the presence of a large amount of cytoplasm with vacuoles.[4] Although it is generally believed that BCM cells represent a degenerative change, the immunohistochemical and electron microscopic findings suggest that they are most likely metabolically active melanocytic cells and contain round, stage I melanosomes without melanin.[5] Its immunohistochemical positivity for melanocytic markers such as S100, Melan-A, and HMB-45 helps in differentiating BCM from its mimickers.[1]

The differential diagnosis for nonneoplastic clear cells includes lesions containing foamy histiocytes, xanthoma cells, adipocytes, and mucopolysaccharidoses. Nonmelanocytic malignant clear cell tumors include atypical fibroxanthoma, liposarcoma, chondrosarcoma, clear cell sarcoma of soft parts, perivascular epithelioid cell tumors (PEComa), myoepithelial carcinoma, squamous cell carcinoma with clear cell change, sebaceous and other cutaneous adnexal carcinomas, such as (malignant) clear cell acrospiroma and clear cell syringoma, granular (clear) cell, basal cell carcinoma, (malignant) granular cell tumor, renal cell carcinoma, adrenal cortical carcinoma, neuroendocrine tumors with clear cell change, germ cell tumors, and clear cell hepatoma.[4],[5] Immunohistochemistry is helpful in excluding many of these entities. However, one must keep in mind that some clear cell tumors are immunopositive for melanocytic markers, such as Melan-A+ adrenal cortical carcinomas, HMB-45+ PEComas, and hibernomas with balloon-like S-100+ vacuolated cells.[1],[6] There appears to be no difference in prognosis between BCM and other histologic types of cutaneous malignant melanoma.[4],[5]

There have been few reports of metastatic BCM, but we were able to identify only three prior case reports of metastatic BCM specifically to the central nervous system (CNS).[1],[2],[3] BCM has also been reported as a primary lesion of the CNS arising from the leptomeninges.[7] To the best of our knowledge, this is only the fourth reported case of metastatic BCM to the CNS. An additional reason for sharing this interesting case is to demonstrate that BCM can be a challenging diagnosis to make in frozen section and pathology in general. Given the rarity of this entity, it is essential to consider BCM in the large differential diagnosis of clear cell tumors. This sort of cases emphasizes the need for an accurate clinical history and the significance of determining if there is any relevant history of malignancy.[1],[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Richardson MD, Somerset H, Kleinschmidt-DeMasters BK, Waziri A. 76-year-old man with a cerebellar lesion. Brain Pathol 2012;22:861-4.  Back to cited text no. 1
    
2.
Gessi M, Fischer HP, Rösseler L, Urbach H, Pietsch T, van Landeghem FK. Unusual balloon cell features in melanoma brain metastasis: A potential diagnostic pitfall in surgical neuropathology. Clin Neuropathol 2011;30:86-8.  Back to cited text no. 2
    
3.
Ferracini R, Manetto V, Minghetti G, Lanzanova G. Cerebellar balloon-cell metastasis of a melanoma. Tumori 1982;68:177-80.  Back to cited text no. 3
    
4.
Magro CM, Crowson AN, Mihm MC. Unusual variants of malignant melanoma. Mod Pathol 2006;19 Suppl 2:S41-70.  Back to cited text no. 4
    
5.
Kao GF, Helwig EB, Graham JH. Balloon cell malignant melanoma of the skin. A clinicopathologic study of 34 cases with histochemical, immunohistochemical, and ultrastructural observations. Cancer 1992;69:2942-52.  Back to cited text no. 5
    
6.
Bures N, Monaco SE, Palekar A, Pantanowitz L. Cytomorphology of metastatic balloon cell melanoma. Diagn Cytopathol 2015;43:485-7.  Back to cited text no. 6
    
7.
Adamek D, Kaluza J, Stachura K. Primary balloon cell malignant melanoma of the right temporo-parietal region arising from meningeal naevus. Clin Neuropathol 1995;14:29-32.  Back to cited text no. 7
    
8.
Mowat A, Reid R, Mackie R. Balloon cell metastatic melanoma: an important differential in the diagnosis of clear cell tumours. Histopathology 1994;24:469-72.  Back to cited text no. 8
    

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Correspondence Address:
Alexandros Iliadis
Department of Pathology, Faculty of Medicine, Aristotle University, University Campus, Thessaloniki 54124
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_741_16

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