Case and Research Letter
Malignant Blue Nevus: A Challenge for Dermatologists and Dermatopathologists
Nevus azul maligno: un desafío para dermatólogos y dermatopatólogos
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Toledo-Pastrana, I. Rodríguez Pérez, P. Eguino Gorrochategui" "autores" => array:3 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Toledo-Pastrana" "email" => array:1 [ 0 => "ttoledop@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Rodríguez Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Eguino Gorrochategui" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Dermatology Department, Donostia University Hospital, San Sebastián, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pathology Department, Donostia University Hospital, San Sebastián, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Dermatology Department, Bidasoa Regional Hospital, Fuenterrabía, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nevus azul maligno: un desafío para dermatólogos y dermatopatólogos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 564 "Ancho" => 1500 "Tamanyo" => 134754 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Panoramic view of the lesion (a; HE ×10) and with red chromogen and HMB45 (b; HE ×10).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Melanocytic pigmented lesions pose a real challenge for clinicians and pathologists. They are clinically and histologically very similar and it is essential to know the evolution of these lesions to establish a proper diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 87-year-old man came to the Dermatology Department for the evaluation of a tumor in the right shoulder. The lesion had developed over 20 years and had presented changes in the last three months (growth and hyperpigmentation). He did not have other accompanying symptoms.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We observed a 1.7-cm indurated, pigmented nodule, which seemed embedded in the skin of the right shoulder with apparently no subcutaneous component. A simple excision adjusted to palpable limits of the lesion was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). After surgery we observed a macroscopically intense pigmentation affecting the deep dermis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), so we sent the sample to the Pathology Department with a suspected diagnosis of malignant melanoma.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histologically we observed one intensely pigmented lesion, localized in the dermis and subcutaneous tissue, with no intraepidermal component or connection to the epidermis, which was flattened and showed some hyperkeratosis. The lesion itself showed a pattern of expanding growth with various lobes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). The central area consisted of numerous melanophages (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a), while the periphery and deep lesion area were composed of melanocytic cells with an epithelioid or slightly fusocellular nature, moderate cytologic atypia and pleomorphism (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>b). Those cells were of medium and large size, with slightly eosinophilic cytoplasm and vesicular nuclei, most of them with a central nucleolus or smaller sized nucleoli. We counted up to four mitoses per HPF in the proliferation areas, some of them showing atypia (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>c). A scarce inflammatory component – consisting of lymphocytes interspersed with tumor cells – was observed. We did not observe any foci of necrosis or images of lymphovascular or perineural invasion. An immunohistochemistry analysis using red chromogen revealed that the melanocytic cells were only found in the deep and peripheral part of the lesion, while the rest of the cells corresponded entirely to melanophages (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). With these findings, the diagnosis of malignant blue nevus (MBN) was established.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We carried out an extension study on the patient, including a complete clinical examination to rule out the presence of another pigmented lesion that could be considered the primary tumor, but it turned out completely normal. We also performed blood tests with WBC, biochemistry and liver panels, and also a PET-CT with no altered results from average normal ranges: no systemic disease was evident. Twelve months after surgery, no signs suggesting recurrence or systemic disease were observed and the patient remains asymptomatic from all points of view.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Malignant blue nevus (MBN) was a term introduced by Allen and Spitz to describe lesions that are similar to blue nevi but can show a malignant behavior, even lethal.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Currently, the term MBN is controversial and some authors like Ackerman<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> do not recommend its use.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This diagnosis has been used in different clinicopathologic situations, such as melanomas that arise on a blue nevus, usually on the cellular ones. This probably could be our case if we consider the evolution of the lesion. MBN could also refer to new melanomas that contain elements that are reminiscent of a blue nevus. Critics of the term claim the supposed incongruity of referring to a malignant nevus, when the definition of nevus includes benignity. Therefore, a synonym for MBN that has been proposed today is <span class="elsevierStyleItalic">blue-nevus-like melanoma</span>. This seems to be the most appropriate way to refer to these lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We can find several published series of MBN where the lesions had the same clinical outcomes as <span class="elsevierStyleItalic">regular</span> malignant melanomas, especially if we consider survival and recurrence. But some isolated studies suggest that the clinical course is usually more aggressive in the MBN cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The histological criteria for the diagnosis of MBN are not well defined, but almost every published paper agrees that these lesions show cytological atypia, a high mitotic index and the presence of atypical mitosis. They usually present necrosis and an infiltrative growth rate.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Differential diagnosis of these lesions can be complicated. First, distinguishing between nodular and metastatic melanoma is needed. This is mandatory in order to determine if the lesion we are studying is a skin metastasis or a primary tumor. Some imaging tests may be helpful for this task, such as PET-CT. Another important differential diagnosis to consider is what is called “animal-type melanoma,” which has a low mitotic index and a slight melanophagic component.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The third differential diagnosis must be made with pigmented epithelioid melanocytoma (PEM), which is very similar to the animal-type melanoma and also to the benign blue nevus. PEM is usually a “de novo” lesion, more frequent in young patients. It also shows a low mitotic index and melanophagic component. Finally, we should consider the differential diagnosis with the atypical cellular blue nevus, which is usually a well-demarcated lesion with intermediate atypia and a low mitotic index, but with no necrosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 776 "Ancho" => 1500 "Tamanyo" => 109591 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cuneiform resection of the lesion (a) showing an intense pigmented component affecting the dermis (b).</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" => 564 "Ancho" => 1500 "Tamanyo" => 134754 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Panoramic view of the lesion (a; HE ×10) and with red chromogen and HMB45 (b; HE ×10).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1363 "Ancho" => 1800 "Tamanyo" => 502716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Superficial part of the tumor, with abundant melanophages with no connection to the epidermis (a; HE ×10). Central part of the lesion with atypical epithelioid cellularity (b; HE ×20). Cells with marked pleomorphism and presence of mitosis (arrows) (c; HE ×20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blue nevi and related lesions: a review highlighting atypical and newly described variants, distinguishing features and diagnostic pitfalls" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Murali" 1 => "S.W. McCarthy" 2 => "R.A. Scolyer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PAP.0b013e3181bb6b53" "Revista" => array:6 [ "tituloSerie" => "Adv Anat Pathol" "fecha" => "2009" "volumen" => "16" "paginaInicial" => "365" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19851128" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "“Atypical” blue nevus, “malignant” blue nevus, and “metastasizing” blue nevus: a critique in historical perspective of three concepts flawed fatally" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.M. Mones" 1 => "A.B. Ackerman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2004" "volumen" => "26" "paginaInicial" => "407" "paginaFinal" => "430" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15365375" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blue nevi and variants: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Zembowicz" 1 => "P.A. Phadke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1043/2009-0733-RA.1" "Revista" => array:6 [ "tituloSerie" => "Arch Pathol Lab Med" "fecha" => "2011" "volumen" => "135" "paginaInicial" => "327" "paginaFinal" => "336" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21366456" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Animal-type melanoma: a clinical and histopathological study of 22 cases from a single institution" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.V. Ludgate" 1 => "D.R. Fullen" 2 => "J. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2009.09271.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2010" "volumen" => "162" "paginaInicial" => "129" "paginaFinal" => "136" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19709103" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pigmented epithelioid melanocytoma: a low-grade melanocytic tumor with metastatic potential indistinguishable from animal-type melanoma and epithelioid blue nevus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Zembowicz" 1 => "J.A. Carney" 2 => "M.C. Mihm" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Am J Surg Pathol" "fecha" => "2004" "volumen" => "28" "paginaInicial" => "31" "paginaFinal" => "40" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14707861" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0168827812003534" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000002/v1_201803020443/S1578219018300404/v1_201803020443/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000002/v1_201803020443/S1578219018300404/v1_201803020443/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018300404?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 21 | 14 | 35 |
| 2024 October | 206 | 30 | 236 |
| 2024 September | 222 | 21 | 243 |
| 2024 August | 277 | 56 | 333 |
| 2024 July | 350 | 34 | 384 |
| 2024 June | 282 | 27 | 309 |
| 2024 May | 281 | 36 | 317 |
| 2024 April | 282 | 23 | 305 |
| 2024 March | 299 | 25 | 324 |
| 2024 February | 355 | 33 | 388 |
| 2024 January | 320 | 35 | 355 |
| 2023 December | 283 | 19 | 302 |
| 2023 November | 331 | 23 | 354 |
| 2023 October | 392 | 33 | 425 |
| 2023 September | 339 | 37 | 376 |
| 2023 August | 235 | 9 | 244 |
| 2023 July | 211 | 29 | 240 |
| 2023 June | 144 | 27 | 171 |
| 2023 May | 145 | 27 | 172 |
| 2023 April | 112 | 21 | 133 |
| 2023 March | 106 | 28 | 134 |
| 2023 February | 106 | 33 | 139 |
| 2023 January | 96 | 31 | 127 |
| 2022 December | 96 | 51 | 147 |
| 2022 November | 57 | 23 | 80 |
| 2022 October | 65 | 24 | 89 |
| 2022 September | 56 | 39 | 95 |
| 2022 August | 40 | 30 | 70 |
| 2022 July | 29 | 32 | 61 |
| 2022 June | 33 | 19 | 52 |
| 2022 May | 78 | 38 | 116 |
| 2022 April | 91 | 40 | 131 |
| 2022 March | 69 | 47 | 116 |
| 2022 February | 50 | 27 | 77 |
| 2022 January | 62 | 32 | 94 |
| 2021 December | 49 | 46 | 95 |
| 2021 November | 45 | 45 | 90 |
| 2021 October | 47 | 60 | 107 |
| 2021 September | 34 | 44 | 78 |
| 2021 August | 36 | 33 | 69 |
| 2021 July | 24 | 30 | 54 |
| 2021 June | 34 | 32 | 66 |
| 2021 May | 30 | 46 | 76 |
| 2021 April | 89 | 71 | 160 |
| 2021 March | 89 | 37 | 126 |
| 2021 February | 58 | 36 | 94 |
| 2021 January | 49 | 34 | 83 |
| 2020 December | 51 | 42 | 93 |
| 2020 November | 35 | 39 | 74 |
| 2020 October | 20 | 18 | 38 |
| 2020 September | 31 | 33 | 64 |
| 2020 August | 36 | 32 | 68 |
| 2020 July | 32 | 27 | 59 |
| 2020 June | 23 | 34 | 57 |
| 2020 May | 18 | 7 | 25 |
| 2020 April | 24 | 9 | 33 |
| 2020 March | 20 | 18 | 38 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 0 | 7 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 1 | 2 | 3 |
| 2018 September | 1 | 0 | 1 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 1 | 2 | 3 |
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