True Amelanotic melanoma: the great Masquerader (original) (raw)

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010

Abstract

Figure 1 (a) Pink lesion on the neck. (b) Epiluminescence dermoscopy with polarized light showed an atypical vascular pattern (circles) and transverse lighter bands (arrows). The rarity of true amelanotic melanoma and its elusive features make this a challenging disease for all dermatologists. Dermoscopy is a noninvasive technique that can assist the clinician in diagnosing skin lesions. The use of dermoscopy for true amelanotic melanoma has not been fully validated yet because of the lack of studies that are based on large series of these rare tumours. A 24-year-old woman presented with an erythematous lesion on the neck that appeared about 12 months earlier. The lesion had been mistaken for ringworm and then for discoid lupus erythematosus and treated with antimycotics (isoconazole nitrate 1%) and topical steroids (diflucortolone valerate 0.1%), respectively, without clinical improvement. Dermatological examination showed a roundish, slightly raised, non desquamative, erythematous lesion with clear borders (Figure 1a). Epiluminescence dermoscopy with polarized light showed an atypical vascular pattern with milky red globules, pinpoint vessels (dotted vessels) and transverse lighter bands (Figure 1b). An excisional biopsy was therefore performed. Histological examination indicated amelanotic epithelioid-cell melanoma, Clark level III, Breslow thickness 0.7 mm, with evidence of regression and abundant periand intralesional lymphocytic infiltrate. The dermal component showed no evidence of maturation. Mitotic figures were present in dermal melanocytes (1/mm2), including mitoses identified in deep dermal melanocytes. Amelanotic melanoma may appear as erythematous, sometimes scaly, macules, nodules or plaques with irregular borders, simulating benign inflammatory plaques or other benign and/or malignant skin neoplasms. The differential diagnosis for ‘true’ amelanotic melanoma is extremely wide. It frequently simulates basal cell carcinoma, squamous cell carcinoma, actinic keratosis, Paget’s or Bowen’s disease and discoid lupus erythematosus. In its most insidious forms, it mimicks even vascular lesions, such as haemangioma and pyogenic granuloma. Our case report demonstrates the relevance of dermoscopy in the early diagnosis of true amelanotic melanoma. Compared to non polarized, polarized dermatoscopes (noncontact

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