Cases for Diagnosis
Asymptomatic Facial Nodule
Nódulo asintomático facial
a Unidad de Oncodermatología, Servicio de Dermatología, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
c Servicio de Dermatología, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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B, Immunohistochemistry with Melan-A. C, Immunohistochemistry with S100. D, Hematoxylin-eosin ×20. E, Immunohistochemistry with HMB45.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 37-year-old woman with no history of interest who consulted for a lesion on her right cheek. The lesion was asymptomatic and first appeared more than 5 years previously. It had grown rapidly during the last 3 months.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a poorly defined nodule measuring approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter. The lesion was bluish-gray in color, with no surface ulceration or desquamation, and was attached to the deeper layers (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A complete examination of the skin and mucosa revealed no similar lesions, and no enlarged nodes were found in accessible areas.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The lesion was completely removed, and histopathology revealed a multinodular skin lesion that was well defined with cellular atypia, mitosis, and areas of necrosis. The lesion was not connected to the follicular epithelium or epidermis (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2A and D</a>). Immunohistochemistry was positive in the neoplastic cells for Melan-A, S100, and HMB45 (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2B, C, and E</a>) and negative for cytokeratins. The study was completed with p53 (95% positive), cyclin D1 (31%), Ki-67 (44%), and D2-40 (low).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The extension study comprised positron emission tomography, otorhinolaryngologic and ophthalmic examinations, and computed tomography of the neck, chest, abdomen, and pelvis. No pathologic findings were detected.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Primary dermal melanoma.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The Breslow thickness was 13<span class="elsevierStyleHsp" style=""></span>mm. We extended the margin for study by 2<span class="elsevierStyleHsp" style=""></span>cm and performed a study of the sentinel node, which was negative. The patient was then treated with high-dose adjuvant interferon for 1 year. She remains disease-free 3 years later.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Primary dermal melanoma is a subtype of melanoma that accounts for <1% of malignant melanocytic neoplasms. Its survival rate is higher than might be expected compared with other malignant melanocytic neoplasms with a similar Breslow thickness.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In 2000, Bowen et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> coined the term primary dermal melanoma to refer to dermal melanocytic tumors and tumors of the subcutaneous cellular tissue that fulfilled a series of characteristics, such as location in the dermis, absence of a junctional component or connection with the follicular epithelium, absence of regression and necrosis, and absence of preexisting melanocytic nevus.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In their series published in 2008, Cassarino et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> performed an immunohistochemistry study including p53, cyclin D1, Ki-67, and D2-40 in patients with primary dermal melanoma and found statistically significant differences in the expression of these markers compared with patients diagnosed with metastatic melanoma and nodular melanoma. The authors suggested that low levels of expression of genes associated with oncogenesis (defective p53), the cell cycle, and proliferation (cyclin D1 and Ki-67) could be associated with less aggressive primary dermal melanoma. Furthermore, expression of D2-40, which is related to tumor lymphangiogenesis, has been associated with tumor lymphatic invasion and reduced survival.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Although these findings are not diagnostic criteria in themselves, they could prove useful in the differential diagnosis with other malignant melanocytic neoplasms.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There have been reports of individual cases and small series of patients with primary dermal melanoma.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4,5</span></a> In the Spanish medical literature, we found only 1 published case.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In the present case, we performed an immunohistochemistry study using the panel proposed by Cassarino et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Although levels of expression of cyclin D1 and D2-40 were lower than those observed in metastatic melanoma, we recorded high levels of expression of p53 and Ki-67.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The overall survival rate at 5 years for patients with a single cutaneous metastasis of melanoma is 5%-19%, with a mean survival of 7 to 15 months.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,6</span></a> In their series of patients with primary dermal melanoma, Swetter et al<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> reported a 5-year survival rate of 100%, which clearly differs from that expected in cases of metastatic melanoma and primary cutaneous melanoma with a similar Breslow thickness.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The differences in the prognosis and therapeutic management of primary dermal melanoma and metastatic melanoma have led the former to be considered an independent entity, whose diagnosis depends on an appropriate clinicopathologic correlation and an exhaustive extension study. Therefore, primary dermal melanoma should be taken into consideration in patients with melanoma confined to the dermis and no evidence of primary lesions at other levels.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Espinosa Lara P, Pérez González Y, Jiménez Reyes J. Nódulo asintomático facial. Actas Dermosifiliogr. 2017;108:59–60.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 658 "Ancho" => 900 "Tamanyo" => 100273 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nodule on the right cheek.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 513 "Ancho" => 1502 "Tamanyo" => 359767 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Low-magnification view (hematoxylin-eosin). B, Immunohistochemistry with Melan-A. C, Immunohistochemistry with S100. D, Hematoxylin-eosin ×20. E, Immunohistochemistry with HMB45.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary dermal melanoma: Distinct immunohistochemical findings and clinical outcome compared with nodular and metastatic melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.S. Cassarino" 1 => "E.S. Cabral" 2 => "R.V. Kartha" 3 => "S.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 15 | 26 |
| 2024 October | 90 | 39 | 129 |
| 2024 September | 77 | 24 | 101 |
| 2024 August | 104 | 59 | 163 |
| 2024 July | 86 | 33 | 119 |
| 2024 June | 96 | 49 | 145 |
| 2024 May | 83 | 28 | 111 |
| 2024 April | 81 | 34 | 115 |
| 2024 March | 95 | 33 | 128 |
| 2024 February | 70 | 28 | 98 |
| 2024 January | 74 | 33 | 107 |
| 2023 December | 65 | 12 | 77 |
| 2023 November | 87 | 26 | 113 |
| 2023 October | 87 | 33 | 120 |
| 2023 September | 78 | 33 | 111 |
| 2023 August | 62 | 16 | 78 |
| 2023 July | 91 | 33 | 124 |
| 2023 June | 87 | 23 | 110 |
| 2023 May | 74 | 23 | 97 |
| 2023 April | 56 | 20 | 76 |
| 2023 March | 68 | 20 | 88 |
| 2023 February | 71 | 30 | 101 |
| 2023 January | 65 | 24 | 89 |
| 2022 December | 71 | 33 | 104 |
| 2022 November | 34 | 26 | 60 |
| 2022 October | 33 | 22 | 55 |
| 2022 September | 25 | 43 | 68 |
| 2022 August | 21 | 33 | 54 |
| 2022 July | 21 | 36 | 57 |
| 2022 June | 30 | 21 | 51 |
| 2022 May | 45 | 35 | 80 |
| 2022 April | 53 | 53 | 106 |
| 2022 March | 52 | 49 | 101 |
| 2022 February | 42 | 20 | 62 |
| 2022 January | 58 | 41 | 99 |
| 2021 December | 52 | 43 | 95 |
| 2021 November | 47 | 50 | 97 |
| 2021 October | 45 | 56 | 101 |
| 2021 September | 37 | 35 | 72 |
| 2021 August | 36 | 40 | 76 |
| 2021 July | 30 | 33 | 63 |
| 2021 June | 36 | 35 | 71 |
| 2021 May | 45 | 57 | 102 |
| 2021 April | 77 | 95 | 172 |
| 2021 March | 59 | 40 | 99 |
| 2021 February | 69 | 35 | 104 |
| 2021 January | 50 | 36 | 86 |
| 2020 December | 40 | 20 | 60 |
| 2020 November | 23 | 21 | 44 |
| 2020 October | 21 | 9 | 30 |
| 2020 September | 32 | 20 | 52 |
| 2020 August | 26 | 22 | 48 |
| 2020 July | 23 | 26 | 49 |
| 2020 June | 32 | 31 | 63 |
| 2020 May | 18 | 5 | 23 |
| 2020 April | 23 | 14 | 37 |
| 2020 March | 24 | 16 | 40 |
| 2020 February | 10 | 0 | 10 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 7 | 0 | 7 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 8 | 0 | 8 |
| 2019 April | 3 | 4 | 7 |
| 2019 March | 1 | 0 | 1 |
| 2019 February | 5 | 0 | 5 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 8 | 0 | 8 |
| 2018 February | 24 | 2 | 26 |
| 2018 January | 37 | 7 | 44 |
| 2017 December | 34 | 3 | 37 |
| 2017 November | 31 | 8 | 39 |
| 2017 October | 23 | 7 | 30 |
| 2017 September | 26 | 5 | 31 |
| 2017 August | 22 | 8 | 30 |
| 2017 July | 16 | 3 | 19 |
| 2017 June | 43 | 11 | 54 |
| 2017 May | 22 | 9 | 31 |
| 2017 April | 24 | 9 | 33 |
| 2017 March | 36 | 17 | 53 |
| 2017 February | 63 | 33 | 96 |
| 2017 January | 70 | 33 | 103 |
| 2016 December | 9 | 17 | 26 |
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