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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 52-54

An unusual case of acral lentiginous melanoma with leukoderma


Department of Dermatology, Venerology and Leprosy, Dr. D. Y. PatilMedical College and Hospital & Research Centre, Pune, India

Date of Submission11-May-2020
Date of Decision06-Sep-2020
Date of Acceptance11-Sep-2020
Date of Web Publication07-Apr-2021

Correspondence Address:
Dr. Shreya Deoghare
Department of Dermatology, Venerology and Leprosy, Dr. D. Y. Patil Medical College and Hospital & Research Centre, Sant Tukaram Nagar, Pimpri, Pune 411018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Melanoma is an aggressive skin cancer with high mortality. The sole of the foot is an uncommon site where it may remain unnoticed or be misdiagnosed. Melanoma-associated leukoderma (MAL) may be an early sign and a high index of suspicion in late-onset vitiligo may result in early diagnosis. We present a case of MAL with acral lentiginous melanoma (ALM) in an elderly female.

Keywords: Acral lentiginous melanoma, melanoma associated eukodermamelanoma-associated leukoderma, acral lentiginous melanoma, melanoma differentiation antigens


How to cite this article:
Deoghare S, Kumar A, Deora M. An unusual case of acral lentiginous melanoma with leukoderma. Pigment Int 2021;8:52-4

How to cite this URL:
Deoghare S, Kumar A, Deora M. An unusual case of acral lentiginous melanoma with leukoderma. Pigment Int [serial online] 2021 [cited 2021 Apr 15];8:52-4. Available from: https://www.pigmentinternational.com/text.asp?2021/8/1/52/313130



Key Messages: An elderly patient presenting with depigmented patch should be viewed with suspicion and a thorough dermatological examination should be carried out to look for any lesion resembling melanoma. Melanoma should also be kept as an important differential diagnosis for hyperpigmented papular lesion presenting on the sole of foot.


  Introduction Top


Melanoma associated leukoderma (MAL) may be defined as the development of depigmented macules at sites distant from the primary tumor.[1],[2]. It is symmetrical and mainly on sun-exposed sites, though confetti-like lesions and localization on the trunk may occur.[3],[4],[5] Spontaneous or immunotherapy induced MAL occurs in 2–16% of melanoma patients prior to or after detection of the tumor.[1],[2]

Melanoma differentiation antigens recognized by cytotoxic T lymphocytes (CTLs) include tyrosinase-related proteins 1 and 2, tyrosinase, melanoma antigen recognized by T cells, and glycoprotein 100.[2] These antigens are expressed not only by melanoma cells but also by normal melanocytes.[4] Hence, a CTL immune response targeting these antigens may cause destruction of normal melanocytes resulting in the development of depigmented areas.[2],[4]

Though MAL may have symmetrically distributed confetti-like macules with irregular borders, it cannot be differentiated clinically from vitiligo.[6] Hence, older patients who develop leukoderma should undergo a thorough examination of the skin, including mucous membranes, as well as ocular examination for suspected melanocytic lesions.[5],[6] Various studies have demonstrated that melanoma patients with leukoderma have higher survival rates.[7],[8]


  Case Report Top


A 65-year-old female presented in the dermatology outpatient department with complaints of white patches on the forehead, hands, and forearms as well as a dark swelling on the sole of left foot of one one1-year duration. The swelling on the foot was insidious in onset but showed a rapid increase in size during the past two months leading to discomfort on walking.

Dermatological examination revealed well-defined depigmented patches on the forehead and dorsa of hands and forearms ([Figure 1]). A firm nodular swelling 3 cm (x 3 cm in size with hemorrhagic crusting was observed on the plantar aspect of left foot overlying the head of fifth metatarsal. ([Figure 2]).. It was tender to touch and fixed to deeper structures.
Figure 1 Multiple depigmented macules on the dorsa of hands and forearms

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Figure 2 A solitary hyperpigmented nodule of size 3 cm x 3 cm with haemorrhagic crusting and raw areas on the plantar aspect of left foot overlying the head of fifth metatarsal

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General physical and systemic examination did not reveal any abnormalities. The left inguinal lymph nodes were not enlarged. Routine hematological and biochemical investigations including thyroid function tests were within normal limits.

On the basis of the findings of a firm nodule on the plantar aspect of left foot and vitiligo-like depigmentation, a provisional diagnosis of acral lentiginous melanoma (ALM) was made and a differential diagnosis of epithelioma cuniculatum considered. A wedge biopsy was taken that revealed dense diffuse infiltration of the dermis by groups and nests of melanocytes with a pigment prominence. A few cells had hyperchromatic pleomorphic nuclei with prominent nucleoli. Dermal capillaries were congested and a chronic inflammatory infiltrate was also present. ([Figure 3]). Breslow depth was 5.5 mm and Clark level was five. The histopathological findings were suggestive of malignant melanoma and this was confirmed by the tumor markers S100 and HMB45, which were found to be strongly positive. ([Figure 4]). Ultrasonography and imaging studies were carried out and contrast enhanced tomography of chest revealed a well-defined round soft tissue attenuated nodule in the right lung indicative of metastasis. Positron emission tomography for metastatic disease could not be carried out due to financial constraints. The patient underwent palliative ray amputation of the fourth and fifth toes of the left foot followed by chemotherapy.
Figure 3 HPE (H and E x 100) showing dense and diffuse infiltration of groups and nests of melanocytes in the dermis and a pigment prominence in the upper dermis. A few cells had hyperchromatic and pleomorphic nuclei with prominent nucleoli. HPE, histopathological examination

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Figure 4 Immunohistochemistry showing strong positivity for tumor marker S100

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  Discussion Top


Melanoma is an aggressive skin cancer arising from melanocytes and early detection may improve the outcome.[9] Acral lentiginous melanoma (ALM) accounts for up to 45% of melanomas in the Asian population.[10] Though it presents initially as a discrete brown or black macule on the sole, it may not be noticed until a nodule or ulceration develops at the site, which is often mistaken for a wart or trophic ulcer.[9] Hence, a large proportion of ALMs are diagnosed at an advanced stage.[10]

Melanoma associated leukoderma (MAL) may develop prior to the detection of melanoma, and hence patients above the age of 50 years presenting with vitiligo-like lesions must be subjected to a thorough dermatological and ophthalmological examination.[2],[5],[6] A high index of suspicion in these cases may result in an early diagnosis of melanoma. Though our patient had developed depigmented patches on sun sun-exposed sites as well as a swelling on left sole one 1 year back, she failed to report for treatment until she had discomfort due to the development of a nodule over the sole.

Various studies have reported the association between vitiligo-like depigmentation and melanoma as well as its prognostic implications.[3],[6],[7] A prospective cohort study has demonstrated that in advanced stages of melanoma, the subgroup of patients with MAL not only have prolonged overall survival but also prolonged distant metastasis free survival.[8] Though our patient had a delayed diagnosis of melanoma, the presence of leukoderma is indicative of a favorable prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naveh HP, Rao UN, Butterfield LH. Melanoma-associated leukoderma − immunology in black and white? Pigment Cell Melanoma Res 2013;26:796-804.  Back to cited text no. 1
    
2.
Speeckaert R, van Geel N, Vermaelen KV, Lambert J, Van Gele M, Speeckaert MM, Brochez L. Immune reactions in benign and malignant melanocytic lesions: lessons for immunotherapy. Pigment Cell Melanoma Res 2011;24:334-44.  Back to cited text no. 2
    
3.
Teulings HE, Lommerts JE, Wolkerstorfer A, Nieuweboer-Krobotova L, Luiten RM, Bekkenk MW et al. Vitiligo-like depigmentations as the first sign of melanoma: a retrospective case series from a tertiary vitiligo centre. Br J Dermatol 2017;176:503-506.  Back to cited text no. 3
    
4.
Failla CM, Carbone ML, Fortes C, Pagnanelli G, D’Atri S. Melanoma and vitiligo: in good company. Int J Mol Sci. 2019;20:5731.  Back to cited text no. 4
    
5.
Saleem MD, Oussedik E, Schoch JJ, Berger AC, Picardo M. Acquired disorders with depigmentation: a systematic approach to vitiliginoid conditions. J Am Acad Dermatol 2019;80(5):1215-1231.e6.  Back to cited text no. 5
    
6.
Lommerts JE, Teulings HE, Ezzedine K, van Geel N, Hartmann A, Speeckaert R et al. Melanoma-associated leukoderma and vitiligo cannot be differentiated based on blinded assessment by experts in the field. J Am Acad Dermatol 2016;75:1198-204.  Back to cited text no. 6
    
7.
Rodríguez-Cuevas S, López-Chavira A, Zepeda del Río G, Cuadra-García I, Fernández-Diez J. Prognostic significance of cutaneous depigmentation in Mexican patients with malignant melanoma. Arch Med Res 1998;29:155-8.  Back to cited text no. 7
    
8.
Quaglino P, Marenco F, Osella-Abate S, Cappello N, Ortoncelli M, Salomone B et al. Vitiligo is an independent favourable prognostic factor in stage III and IV metastatic melanoma patients: results from a single-institution hospital-based observational cohort study. Ann Oncol 2010;21:409-14.  Back to cited text no. 8
    
9.
Grob JJ, Gaudy‐Marqueste C. Melanoma clinicopathology. In: Griffiths CEM, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook’s Textbook of Dermatology, 9th ed. Oxford: Wiley Blackwell 2016; :p143.1-143.20.  Back to cited text no. 9
    
10.
Garbe C, Bauer J. Melanoma. In: Bolognia JL, Schaffer JV, Cerroni L, editors. Dermatology, 4th ed. China: Elsevier; 2018; p:1989-2019.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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