Acral Lentiginous Melanoma Diagnosed using Combination of

Dermoscopic and Histopathological Examination

Calvin Santosa

, Ni Luh Putu Ratih Vibriyanti Karna

, A. A. Ari Agung Kayika Silayukti

, Herman

Saputra

Dermatovenereology Department Sanglah General Public Hospital, Denpasar, Indonesia

Dermatovenereology Department Mangunsada General Public Hospital, Badung, Indonesia

Pathology Department Sanglah General Public Hospital, Denpasar, Indonesia

Keywords: melanoma, acral lentiginous, dermoscopy, histopathology

Abstract: Melanoma is a malignant tumor, which arises from melanocyte, and most commonly appears initially on the

skin. Melanoma may arise also on mucosal surface even the leptomeningeal. Risk factors for melanoma

could come endogenously and exogenously. Melanoma is still one of the leading causes of death by cancer

in the world. Acral lentiginous melanoma (ALM) is an uncommon type of melanoma and usually diagnosed

in the elderly on the extremities or nails. Clinically acral melanoma may be diagnosed as fungal infection or

benign nevus lesion. Dermoscopy has helped clinician in differentiating between benign and malignant

nevus lesion, hence not all cases need histopathological examination. Pathognomonic findings in melanoma

lesion through dermoscopic examination may assist dermatologist in diagnosing melanoma. Main treatment

for melanoma is still wide excision of the lesion and periodic monitoring post excision necessary to evaluate

the risk of metastasis and mortality.

1 INTRODUCTION

Melanoma is a malignant tumor of melanocytes that

can occur in the skin, mucosa and leptomeningeal. A

clinical feature that may resemble ordinary nevus

often makes the patient unaware of the condition

(Garbe and Bauer, 2012). Epidemiologically

melanoma is more commonly found in Fitzpatrick

skin type I and II who received excessive sun

exposure. In Europe an incidence of 10-25 new

cases per 100,000 population is found per year,

whereas in the United States 20-30 cases per

100,000 people and the highest in Australia is 50-60

cases per 100,000 population (Garbe and Leiter,

2009; Ferlay et al., 2013). In Indonesia alone the

incidence vary but still very low. In RS Dr. M.

Djamil Padang found 9 cases of melanoma during

2002-2007 (Azamris, 2011).

Acral lentiginous melanoma (ALM) is a rare

type of cutaneous melanoma and is often diagnosed

at the later stage with lesions in the palms, soles or

inside or around the nails. This condition tends to be

found in African and Asian racial groups where

rarely found melanoma cases due to excessive sun

exposure (Bradford et al., 2009). The way to

diagnose melanoma still requires histopathological

examination, but with the discovery of dermoscopy

has reduced the number of nevus lesions that do not

show malignant features (Saida et al., 2011).

The main therapy for melanoma is surgical

excision. If there is a sign of metastasis, additional

chemotherapy and immunotherapy should be given

(Saiag et al., 2007).

The following case of acral

lentiginous melanoma is diagnosed using

combination of dermoscopy and histopathology

examination. This case is reported due to a relatively

low incidence in Indonesia and to increase

understanding of melanoma, diagnosis and

appropriate management.

2 CASE

A 53-year-old Balinese mancame to

Dermatovenereology polyclinic of Mangunsada

Badung Hospital with a chief complaint of dark spot

on the right sole of his foot.

Patient has a history oftrauma from a tree thorn 1

year ago and the patient felt that there was a thorn

that is embedded in his foot. Patients tried to remove

Santosa, C., Vibriyanti Karna, N., Silayukti, A. and Saputra, H.

Acral Lentiginous Melanoma Diagnosed using Combination of Dermoscopic and Histopathological Examination.

DOI: 10.5220/0008157503630367

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 363-367

ISBN: 978-989-758-494-7

363

it without any help of medical personnel. About 10

months ago the patient claimed to have black spots

appear on the trauma area on his right sole. Patients

claimed no pain or itching on that area. The dark

spots slowly spread to the adjacent area. History of

previous mole on the area is denied. Patients

mentioned about awound which appear on the black

spots 2 weeks before admission. The patient does

not feel any pain on the when being touched.

Patients claimed to have never treated the

condition since 1 year ago. History of similar

condition in other location was not found. History of

malignancy is denied. History of systemic diseases

such as hypertension, diabetes mellitus, bleeding

disorders are denied by the patient. History of any

immunosuppressive conditions was denied. History

of similar disease in the patient's family is denied.

History of malignancy, asthma, hypertension or

diabetes mellitus in patient families is denied.

Currentlypatient works as a farmer and often does

not use any footwear during work. Patients have no

habit of alcohol consumption or smoking.

Physical examination found the general

condition of the patient good. Blood pressure 120/80

mmHg, pulse 84x/minute, respiratory frequency

20x/minute and axillary temperature 36.4°C.

General status were within normal limit. No

enlarged lymph nodes were found. The

dermatological status onthe right plantar pedis there

are multiple hyperpigmentation macules, well-

defined margin, sized 2x3 cm to 5x7 cm with a

solitary ulcer above it with rising and regular edge,

clean base, round, 1.5 cm in diameter. (Figure 1A)

On the investigation using dermoscopy, there are

found parallel ridge pattern on the hyperpigmented

lesion (red arrow Figure 1B-D) andon the ulcer

showed blood vessel in dots form (red arrow

Figure 1 E), bluish globule (asterisk Figure 1E) and

structureless area (circle Figure 1E). On the edge of

the ulcer there were mass of keratin with a

homogeneous black spot on some foci.

Histopathological examination found epidermal

layer with a picture of acanthosis accompanied by a

thick layer of keratin. There is a proliferation of

atypical melanocyte cells along the basal epidermis

with disturbed cohesion with relatively large sized

morphologies, vacuolized cytoplasm, bizarre

nucleus, hyperchromatic, partially with prominent

nucleus, and irregular nucleic membrane. These

cells contain brownish pigmented granules (melanin).

Some of these cells extend along the superficial

dermis. Mitosis can be found. The superficial dermis

layer looks degenerated and thin. At 1 focus contains

necrotic areas with necrotic debris. This fit with the

morphological picture of an acral-lentiginous

melanoma. (Figure 2).

Based on the dermoscopic and histopathological

examination, this patient was diagnosed with acral

lentiginous melanoma and was performed wide

excision of the lesion with a margin of 1 cm and as

deep as subcutaneous tissue. The tissue obtained

from the excision were examined again and there

were clear margin of the lesion. The patient later on

got a skin graft from calf area to close the surgical

area. The patient was also recommended to do

annual check up for the first 5 year.

Figure 1: (A) Hyperpigmented lesion on right sole with solitary ulcer on it. Dermoscopic pattern of the lesion (B,C,D,E).

A

C

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

364

Figure 2: Histopathological image from the lesion suit with acral lentiginous melanoma.

3 DISCUSSION

Melanoma is a tumor derived from melanocytes and

can be foundon skin, mucosal, eyes and brain

meningeal. Acral melanoma itself is a subtype most

commonly found in non-white populations. This

subtype includes>70% melanoma in African races in

America as well as 50% in Asian racial groups

(Ishihara et al., 2008).

Risk factors from melanoma can be divided into

3 categories including genetic factors, phenotypic

manifestations of genetic and environmental

interactions also environmental factors. Genetic

mutations or polymorphism can increase one

person's tendency for the development of melanoma.

The focus of genes associated with familial

melanoma is CDKN2A, which plays a role in coding

proteins p16 and p14 that function in the course of

cell cycle. In addition, variants of the melanocortin-1

receptor gene (MC1R) were also found to increase

the risk of melanoma formation. Factors that are

phenotypic manifestations of genetic and

environmental interactions are melanocytic nevus,

atypical melanocytic nevus and ephelids and lentigo

solaris. Environmental factors that play a role in the

formation of cutaneous melanoma are ultraviolet

radiation; especially ultraviolet B. Chronic radiation

can cause mutations and DNA damage which disrupt

the cell cycle. In a study that assessed the role of

trauma in the occurrence of ALM in areas not

exposed to sunlight such as soles of the feet, hands

and nails found about 13-55% of cases of ALM has

a history of previous trauma, but its relation to the

development of melanoma is still unclear (Phan et

al., 2006).

Diagnosis of melanoma requires correlation of

clinical features, dermoscopy and histopathology.

Clinically lesions of melanoma appear as

asymmetrical lesions, having irregular edges, has

variety of colors, diameters greater than 5 mm and

found growth of nodules or regression components

in the lesions. The sensitivity of these clinical

features to diagnose melanoma can be as high as

70% if performed by an experienced dermatologist.

The most common and typical dermoscopic features

for ALM are the presence of parallel-ridge patterns

that have a specificity of 99%, sensitivity of 86%

and a positive predictive value of 84%. The next

most common pattern is the brownish-colored

pigment found in ALM in situ and invasive ALM.

Another feature that can be found is a serrated

pattern consisting of a streak image at the edge of

Acral Lentiginous Melanoma Diagnosed using Combination of Dermoscopic and Histopathological Examination

365

the tumor. Not infrequently also found ALM with

ridge pattern accompanied by diffuse pigmentation

area. In the case of an invasive ALM it tends to

destroy the furrow and ridges images so that it can

be seen only structureless pattern and pigmentation

spots. In addition it will show more color and

structure such as firm edges, irregular dots and

globules, atypical streaks, atypical blotches, blue

white veil, regression structure and atypical blood

vessels (Malvehy and Puig, 2012).

Histopathological examination remains a gold

standard in diagnosing melanoma. In ALM,

proliferation of atypical melanocytes in the

hyperplastic epidermal basal layer can be seen.

Atypical melanocytes are arranged one by one in

irregular nests in all layers of the epidermis. In the

stratum corneum layer melanocytes and melanin

granules are spread evenly. In difficult cases

immunohistochemical staining may help diagnosis.

Dyes that can detect antigens in melanocytes such as

HMB45, tyrosinase, Melan-A / MART-1 and S100

are useful in differentiating melanocyte cells with

other cells so as to visualize the extent of primary

melanoma as well as to help see the focus of

melanoma on lymph node biopsy (Garbe and Bauer,

2012; Merkel and Gerami, 2017). The patient in this

case shows the dermoscopic appearance which

suggesting to be a melanoma lesion, which later on

be confirmed from the histopathological

examination.

Management of melanoma can be divided into 3

in primary melanoma (stage 1 and 2), melanoma

with regional metastasis (stage 3) and melanoma

with distant metastasis (stage 4). In primary

melanoma therapy is still with surgical excision with

the aim of preventing local recurrence or persistent

disease. The last recommended guideline for the

management of primary melanoma is for in situ

melanoma cases an excision surgery of 0.5 cm from

the edge of the tumor should be performed, for

melanoma with a depth of ≤ 1 mm requires a 1 cm

margin from the edge of the tumor, for melanoma

depth of ≥ 2 mm minimum 2 cm margin from the

edge of the tumor. For cases in difficult locations

such as acral, mucous membranes or face Mohs

surgery may be a more appropriate choice. Local

recurrence is defined as a recurrence of the lesion

within 2 cm of the post-excision site. This results

from the spread of primary tumor or intralymphatic

spread. In such cases it is necessary to re-execute

and check on the regional lymph nodes to see if

there are any signs of metastasis or not (Garbe and

Bauer, 2012; Garbe et al., 2016). The patient is

diagnosed with primary acral lentiginous melanoma

and was treated with margin of 1 cm and as deep as

subcutaneous tissue, with histopathological

examination there are no melanoma cells on the

edges of the lesion.

The prognosis for melanoma stage 1 is still quite

good with proper and rapid management. The

survival rate in stage 1 of 93-97% decreased in stage

2 to 53-82%, in stage 3 it was found that 40-78%

and got 9-27% for stage 4. Monitoring of patients

with melanoma especially the first 5 years is very

important, where 90% of metastases occur at that

time period. Regular monitoring aims to identify

recurrence or early disease progression, can

diagnose early primary melanoma and skin cancer in

addition to melanoma, provide psychosocial

assistance, provide education to prevent patients and

families, provide education for patients and families

about a self-examination method for early detection

of melanoma, as well as for the administration of

adjuvant therapy if necessary. The recommended

timeframe according to the guidelines in Europe is 2

to 4 times per year for 5 to 10 years (Garbe and

Bauer, 2012; Garbe et al., 2016).

4 CONCLUSION

Reported a case of acral lentiginous melanoma in a

man with a clinical picture of a black spot on the

sole of the foot since 1 year ago without any

complaints. The dermoscopy examination, parallel

ridge pattern is seen that gives a suggestion of a

melanoma lesion. The patient then performed a

biopsy and presented atypical melanocytes with

bizzare nuclei and also found mitosis so that the

diagnosis tends to lead to acral lentiginous

melanoma. Patients were consulted to the surgical

department for further treatment and performed

excision surgery with 1 cm margin. The prognosis of

the patients is still need to be established by deciding

in the tumor stage, however periodic monitoring is

necessary to prevent and diagnose both primary and

metastatic melanoma lesions in order to improve

survival rates, especially the first 5 years.

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