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Amelanotic Melanoma Presenting with Plasmacytoid Morphology and BRAF V600 Mutation.

Kocovski L, Bane A, Tang S, Salama S, Alowami S - Rare Tumors (2015)

Bottom Line: The plasmacytoid morphology can be found in a variety of other malignancies including carcinomas, plasma cell neoplasms, lymphoproliferative disorders, and sarcomas.Given that the tumor was noted to be BRAF V600R mutated, the patient was started on single agent dabrafenib.The plasmacytoid morphology can be found in a variety of malignancies.

View Article: PubMed Central - PubMed

Affiliation: Department of Pathology and Molecular Medicine, McMaster University , Hamilton, ON, Canada.

ABSTRACT
Plasmacytoid melanoma is an unusual variant of malignant melanoma. The plasmacytoid morphology can be found in a variety of other malignancies including carcinomas, plasma cell neoplasms, lymphoproliferative disorders, and sarcomas. The authors report a rare case of plasmacytoid amelanotic malignant melanoma in a 78-year-old man presenting with an enlarging palpable, erythematous mass on his left posterior shoulder. A fine needle aspirate showed atypical findings with single amelanotic cells with high nuclear to cytoplasmic ratio, mono- and multi-nucleation with prominent nucleoli and intranuclear inclusions. Review of the excision and immunohistochemical analysis revealed the malignant plasmacytoid cells stained with vimentin, S-100, HMB-45, and other staining patterns consistent with melanoma. Initial evaluation was negative for other sites of disease. However, 4 months later, the patient was noted to have metastatic disease to his lungs and liver. Given that the tumor was noted to be BRAF V600R mutated, the patient was started on single agent dabrafenib. The plasmacytoid morphology can be found in a variety of malignancies. Melanoma should be considered in the differential diagnosis of any malignancy presenting with plasmacytoid features.

No MeSH data available.


Related in: MedlinePlus

Subsequent wide excision with satellite/in transit metastasis of plasmacytoid melanoma. A) Hematoxylin & Eosin (H&E) 20×; B) H&E 40×, C) H&E 100×, D) H&E 200×.
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fig002: Subsequent wide excision with satellite/in transit metastasis of plasmacytoid melanoma. A) Hematoxylin & Eosin (H&E) 20×; B) H&E 40×, C) H&E 100×, D) H&E 200×.

Mentions: A 78-year-old man, with remote history of pigmented skin lesions previously treated with liquid nitrogen, presented with an enlarging palpable, erythematous mass on his left posterior shoulder. A fine needle aspirate (FNA) showed atypical findings with single amelanotic cells with high nuclear to cytoplasmic ratio, mono- and multi-nucleation with prominent nucleoli, and intra-nuclear inclusions. Differential diagnosis at this stage favored sarcoma. A subsequent excision showed a large nodule within the dermis, composed of sheets and nests of amelanotic cells with plasmacytoid morphology (cells with abundant cytoplasm, eccentric nuclei, and pale paranuclear zones) (Figure 1A,B). Less than 5% of the nodule showed pseudopapillary architecture, lined by malignant cells (Figure 1C-E). There was no overlying melanoma in situ or any dysplasia of the epidermis. Review of the excision and immunohistochemical analysis revealed that the malignant plasmacytoid cells stained strongly and diffusely with vimentin, S-100, HMB-45, and melanoma cocktail (HMB-45 + MART-1 + tyrosinase, Biocare Medical), in keeping with melanoma. Following clinical examination (dermoscopy and ophthalmoscopy), imaging (computed tomography and magnetic resonance imaging), and investigations (esophagogastroduodenoscopy and colonoscopy) failed to reveal any other sites of disease of melanoma. A subsequent wide local excision and sentinel lymph node excision revealed a focal positive deep margin, satellite/in transit metastasis (Figure 2), and negative lymph node. The patient underwent 2 weeks of adjuvant radiotherapy to the excision site for management of the positive surgical margin. Four months following the initial excision, however, radiological imaging noted metastatic disease to the lungs and liver, and residual disease at the excision site. Molecular analysis of the melanoma revealed a BRAF V600R gene mutation. Treatment options were discussed including protein kinase inhibitors for unresectable metastatic melanoma (dabrafenib and vemurafenib) and standard chemotherapy with dacarbazine. The patient was commenced on single agent dabrafenib but unfortunately did not tolerate the treatment. He developed significant side effects and his condition deteriorated. The treatment was ceased after 10 days and the patient was transitioned to palliative care.


Amelanotic Melanoma Presenting with Plasmacytoid Morphology and BRAF V600 Mutation.

Kocovski L, Bane A, Tang S, Salama S, Alowami S - Rare Tumors (2015)

Subsequent wide excision with satellite/in transit metastasis of plasmacytoid melanoma. A) Hematoxylin & Eosin (H&E) 20×; B) H&E 40×, C) H&E 100×, D) H&E 200×.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4508639&req=5

fig002: Subsequent wide excision with satellite/in transit metastasis of plasmacytoid melanoma. A) Hematoxylin & Eosin (H&E) 20×; B) H&E 40×, C) H&E 100×, D) H&E 200×.
Mentions: A 78-year-old man, with remote history of pigmented skin lesions previously treated with liquid nitrogen, presented with an enlarging palpable, erythematous mass on his left posterior shoulder. A fine needle aspirate (FNA) showed atypical findings with single amelanotic cells with high nuclear to cytoplasmic ratio, mono- and multi-nucleation with prominent nucleoli, and intra-nuclear inclusions. Differential diagnosis at this stage favored sarcoma. A subsequent excision showed a large nodule within the dermis, composed of sheets and nests of amelanotic cells with plasmacytoid morphology (cells with abundant cytoplasm, eccentric nuclei, and pale paranuclear zones) (Figure 1A,B). Less than 5% of the nodule showed pseudopapillary architecture, lined by malignant cells (Figure 1C-E). There was no overlying melanoma in situ or any dysplasia of the epidermis. Review of the excision and immunohistochemical analysis revealed that the malignant plasmacytoid cells stained strongly and diffusely with vimentin, S-100, HMB-45, and melanoma cocktail (HMB-45 + MART-1 + tyrosinase, Biocare Medical), in keeping with melanoma. Following clinical examination (dermoscopy and ophthalmoscopy), imaging (computed tomography and magnetic resonance imaging), and investigations (esophagogastroduodenoscopy and colonoscopy) failed to reveal any other sites of disease of melanoma. A subsequent wide local excision and sentinel lymph node excision revealed a focal positive deep margin, satellite/in transit metastasis (Figure 2), and negative lymph node. The patient underwent 2 weeks of adjuvant radiotherapy to the excision site for management of the positive surgical margin. Four months following the initial excision, however, radiological imaging noted metastatic disease to the lungs and liver, and residual disease at the excision site. Molecular analysis of the melanoma revealed a BRAF V600R gene mutation. Treatment options were discussed including protein kinase inhibitors for unresectable metastatic melanoma (dabrafenib and vemurafenib) and standard chemotherapy with dacarbazine. The patient was commenced on single agent dabrafenib but unfortunately did not tolerate the treatment. He developed significant side effects and his condition deteriorated. The treatment was ceased after 10 days and the patient was transitioned to palliative care.

Bottom Line: The plasmacytoid morphology can be found in a variety of other malignancies including carcinomas, plasma cell neoplasms, lymphoproliferative disorders, and sarcomas.Given that the tumor was noted to be BRAF V600R mutated, the patient was started on single agent dabrafenib.The plasmacytoid morphology can be found in a variety of malignancies.

View Article: PubMed Central - PubMed

Affiliation: Department of Pathology and Molecular Medicine, McMaster University , Hamilton, ON, Canada.

ABSTRACT
Plasmacytoid melanoma is an unusual variant of malignant melanoma. The plasmacytoid morphology can be found in a variety of other malignancies including carcinomas, plasma cell neoplasms, lymphoproliferative disorders, and sarcomas. The authors report a rare case of plasmacytoid amelanotic malignant melanoma in a 78-year-old man presenting with an enlarging palpable, erythematous mass on his left posterior shoulder. A fine needle aspirate showed atypical findings with single amelanotic cells with high nuclear to cytoplasmic ratio, mono- and multi-nucleation with prominent nucleoli and intranuclear inclusions. Review of the excision and immunohistochemical analysis revealed the malignant plasmacytoid cells stained with vimentin, S-100, HMB-45, and other staining patterns consistent with melanoma. Initial evaluation was negative for other sites of disease. However, 4 months later, the patient was noted to have metastatic disease to his lungs and liver. Given that the tumor was noted to be BRAF V600R mutated, the patient was started on single agent dabrafenib. The plasmacytoid morphology can be found in a variety of malignancies. Melanoma should be considered in the differential diagnosis of any malignancy presenting with plasmacytoid features.

No MeSH data available.


Related in: MedlinePlus