Indian Journal of Pathology and Microbiology

LETTER TO EDITOR
Year
: 2017  |  Volume : 60  |  Issue : 4  |  Page : 622--623

Balloon cell melanoma metastasis to the temporal lobe


Alexandros Iliadis1, Thomas Zaraboukas1, Panagiotis Selviaridis2, Athanasios Chatzisotiriou2,  
1 Department of Pathology, Medical School, Aristotle University, Thessaloniki, Greece
2 Neurosurgery Clinic, Agios Loukas Hospital, Thessaloniki, Greece

Correspondence Address:
Alexandros Iliadis
Department of Pathology, Faculty of Medicine, Aristotle University, University Campus, Thessaloniki 54124
Greece




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;60:622-623


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 2020 Jul 14 ];60:622-623
Available from: http://www.ijpmonline.org/text.asp?2017/60/4/622/222988


Full Text



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}{Figure 2}

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.

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