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DERMATOPATHOLOGY

403

Cartilaginous melanoma: case report and review of the literature*Melanoma cartil


agneo: caso clnico e reviso da literatura
Joana Devesa Parente1
Jos Manuel
Pereira da Silva Labareda2
Elvira Augusta Felgueira Leonardo Fernandes Brtolo3
Maria Fernanda Sachse Pin
to Fonseca Santos4Esmeralda Maria Seco do Vale5
DOI: http://dx.doi.org/10.1590/abd1806-4841.20131595
Abstract: Malignant melanoma can present a variety of histopathological patterns
. Cartilaginous change in theabsence of osteogenic differentiation is extremely
rare in malignant melanoma, being among the least frequentof the wide range of m
elanoma histologic patterns. We report a case of a 47-year-old woman with a subu
ngualnodule on her right great toe for many years. Histopathological examination
of the lesion led to a diagnosis ofmalignant melanoma with cartilaginous differ
entiation devoid of concomitant osseous areas. It would appearthat this unusua
l form of melanoma has a predilection for acral location, particularly
the subungual region.Malignant melanoma with chondroid stroma should therefo
re be considered in the differential diagnosis of car-tilaginous lesions of the
toes and fingers. Careful examination of the overlying epidermis and identificat
ion of anin situ component of melanoma may be necessary in order to establish th
e correct diagnosis.
Keywords: Cartilage; Melanoma; Toes

Resumo: O melanoma maligno pode apresentar uma grande variedade de padres histopa
tolgicos. A presenade diferenciao cartilagnea, na ausncia de diferenciao osteo
a, extremamente rara no melanomamaligno. O melanoma cartilagneo est entre os
padres histolgicos menos frequentes. Relatamos um caso deuma doente do sexo femini
no de 47 anos de idade com um ndulo subungueal no 1 dedo do p direito com mui-tos a
nos de evoluo. O exame histopatolgico da leso revelou melanoma cartilagneo, sem reas d
e diferencia-o osteognica. Esta variante de melanoma parece ter predileo pel
a extremidades, sobretudo pela regiosubungueal. Assim, o melanoma maligno com
diferenciao condride, deve ser tido em considerao no diag-nstico diferencial de leses
acrais cartilagneas. A observao cuidadosa da epiderme e a identificao de umcomponente
do melanoma in situ podem ser necessrios para estabelecer um diagnstico correto.
Palavras-chave: Cartilagem; Dedos do p; Melanoma
INTRODUCTION
Malignant melanoma can present a wide variety of histopathological patterns, mimicking other
The clinical significance of such aberrations is
uncertain, as are their underlying mechanisms.
malignant tumors. A number of variants have been
Carti
laginous
change
in
the
absence
ofdescribed in addition to
the classic forms of
osteogenic differentiation is extremely r

are in maligmelanoma, such as polypoid, verrucous, desmoplas-tic, myxoid, chondroid, ba


llooning cell, rhabdoid, ani-mal type, amelanotic, spitzoid, and nevoid.1
Divergent differentiation is a rare phenomenonand, when it occurs, can be missed
by unwary pathologists and lead to diagnostic uncertainty.
nant melanoma,2 being among the least frequent of thewide range of melanoma his
tologic patterns.2 To dateonly 12 reported cases have shown cartilaginous differentiation devoid of concomitant osseous areas.2-11

Received on 07.12.2011.
Approved by the Advisory Board and accepted for publication on 31.05.2012.
* Study conducted at the Department of Dermatology, Santarm Hospital, EPE (HDS)
Santarm, Portugal.Financial support: None.
Conflict of interests: None.
1
MD - Department of Dermatology, Santarm District Hospital, EPE (HDS) San
tarm, Portugal.
2
MD - Department of Dermatology, Lisbon Medical-Surgery Dermatology Depa
rtrment Lisbon, Portugal.3
MD - Department of Dermatology, Hospital Garc
ia de Orta, EPE (HGO) Almada, Portugal.
4
MD - Department of Dermatology, Francisco Gentil Lisbon Portuguese Inst
itute of Oncology (IPOLFG) Lisbon, Portugal.5
MD - Department of Dermatop
athology, Lisbon Medical-Surgery Dermatology Departrment Lisbon, Portugal.
2013 by Anais Brasileiros de Dermatologia
An Bras Dermatol. 2013;88(3):403-07.
404
Parente JD, Labareda JMPS, Brtolo EAFLF, Santos MFSPF, Vale EMS

CASE REPORT
A 47-year-old woman presented with a painful
subungual lesion on the right big toe which appeared
On the periphery of the specimen hyperplasiaand acanthosis of epidermis were obs
erved as well as
intracytoplasmic melanin pigment in small aggregates
one year before as a hyperkeratotic lesion and treated
(Figure 3). Ne
sts of atypical melanocytes werewith oral terbinafine, with no impr
ovement. Twelve
observed at the dermoepidermal junction without evi-year
s ago she underwent laser therapy for a lesion at
dence of pagetoid
spread, and isolated atypical
the same location. A histopathological examination
was not performed.
melanocytes were present in the upper dermis (Figure
4).
Physical examination revealed a painful subunImmunohistoche
mistry showed positivity of
gual nodule on her right big toe. There was no region-al lymphadenopathy.
An excisional biopsy of the nodule was per-formed. Histopathological ex
amination showed anulcerated tumor extending in a diffuse pattern fromt
he epidermis to the inferior limit of the specimen.Rounded cells with
vesicular nucleus, scant cyto-plasm, numerous mitotic figures, dyskerato
tic and

apoptotic cells were observed (Figure 1).


the junctional component and of melanocytes in theupper dermis for S-1
00 protein and positivity of thetumor cells for HMB-45 (Figures 5, 6 and 7)
. The carti-laginous component showed positivity for S-100 pro-tein and for n
euron specific enolase (Figure 8). Wediagnosed melanoma with cartilagino
us differentia-tion. The tumor had a Breslow depth higher than 5mm (Cl
ark level V).
The patient subsequently underwent amputaThe presence of nests of large, bizarre chondrotion of the distal
phalanx of the big right toe.cytes embedded in a chondroid matrix w
as observed
Histopathological examination of the lesion con-in
around one third of the lesion, strongly suggesting
firmed the biopsy
findings of malignant melanomapositivity for Alcian Blue (Figure 2).
with cartilaginous differentiation, with
a Breslow

FIGURE 1: Rounded cells with vesicular nucleus, scant cytoplasm,numerous mitoti


c figures, and dyskeratotic and apoptotic cells(hematoxylin and eosin stain, x 4
0 objective)

FIGURE 2: Nests of large, bizarre chondrocytes embedded in a


chondroid matrix (hematoxylin and eosin stain, x 40 objective)
FIGURE 3: Hyperplasia and acanthosis of epidermis, intracytoplas-mic melanin pi
gment in small aggregates (hematoxylin and eosinstain, x 10 objective)

FIGURE 4: Nests of atypical melanocytes at the dermoepidermal


junction (hematoxylin and eosin stain, x 40 objective)
An Bras Dermatol. 2013;88(3):403-07.
Cartilaginous melanoma: case report and review of the literature
405

FIGURE 5: Junctional component positivity for S-100 protein (S-100protein, x 40


objective)

FIGURE 8: Cartilaginous area positivity for S-100 protein (S-100protein, x 40 o


bjective) and for neuron specific enolase(NSE, x 40 objective)

FIGURE 6: Melanocytes in the upper dermis positivity for S-100protein (S-100 pr


otein, x 40 objective)

FIGURE 7: Cellular area positivity for HMB 45 (HMB 45, x 40


objective)
thickness of 9,9 mm and a Clark level of V. Sentinellymph node bio
psy was also performed, whichproved negative for tumor. According t
o the TNMstaging this malignant melanoma was T4b N0 M0,stage II B.
Two years after surgery an ulcerated lesion atthe same location appear
ed. This was excised andproved by histopathological examination to be a loca
lrecurrence. The big and second toes were amputated.This subsequent wider exc
ision showed no residualmelanoma.
Neither local recurrence nor metastasis wereobserved during the following t
hree years of follow-up.
DISCUSSION
There have been some reports of melanomaswith pure cartilaginous different
iation, including pri-mary melanomas and metastatic melanoma.2-11
Eight cases of primary melanomas with cartilaginous differentiation have been reported.2,3,4-8 In two
An Bras Dermatol. 2013;88(3):403-07.