dermatomal multiple nodular melanomas at thoracal IV-X on the right back and ribs.

LIJ S ITA SY LV I A,SR1 LESTAR

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Background

r --.:-^ of
^{ melanocy'te
that has yerlical
-^r^^^Nodular melanor ra (NM) results from the malignanttransformation

growth.Nodularnelano,narsdifficulttoreco0nizeintheearlyStagethatcancaUsethelateof
management.
Case
n so v,u|. old lndonesian nan

with multiple nodular melanomas on the right back and ribs was

on the right back 2 years aqo that growing {ast
reported. lnitially, there was a blue black tumour
back and ribs in lastthree months There were
right
the
lV'X
on
became multiple tumours atthoracat

plaque
The tumours were grouping papules' noduls and
burning sensation, painful and easy bleeding
erytematous)'
and
(blue-black'
amelanotic
colour
atth0racal lv-X on the right back and ribs, variety

defined border, harcj consisrenr smooth surface,
unilateral distribution, u.rirr, ,n.p. and size,
"
the lesions. There were enlarge,rrerrt of right colli,
and some of them rrao niact'crusts on top of
revealed
exarnrnation
Histophatoiogy
nodes.
lymph
supraclavicula, infraclavicuL. axillae, and inguinal
granulosum
and
corneunl
stratum
under
chromatin
melanocpe cells with urr.l.rt* nuciei and Joarse
pigments
reticulardermis {venrlal.gr_lwth) and brown

layers, pleomo.t, rnur r*punorJ to papillary and
suggested
0ncologist
staging.
patientwas rn s.q, iric based on AJCC 2002 melanoma
on dermis.This

a month later'
chemotherapy, but he refused the therapy and died

Discussion
in lnrionesra' Tlris was the first case of
Nodular melanoma is the highest number of melanomas
enlargentetrt of lynlph rrodes suggested
The
Department
in
our
dermatomal multlple nodular melanoma
Clrernotherapy nray be useful'

melanoma
for
metastatic
therapy
no
standard
metastatic. There is
Keywords: Nodular meIanona, verticaI growth'

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Dermatomal multiple nodular melanomas at thoracal W-X
on the right back and ribs

Lusita Sylvia Sri Lestari, *Rusjdi Abbas, **Aznmris
Dermatolo gy - Venereology Deparment
* Patholo gy-Anatomy DeParffnent,
**Surgery Departrnent of Dr.M.Djamil HospitaV Medical Faculty
Andaias University, Padang, lndonesia

of

Abstract

Background

: Nodular melanoma (l'it\4)

results from the malignant

transformation of melanoclte that has vertical growth. Nodular melanorna is
difficult to recognize in the early stage that can cause the late of management.
Case : A 50 year old Indonesian man with multiple nodular melanomas on the
right back and ribs was reported. Initially, there was a blue black tumour on the
right back 2 years ago that grow'ing fast became multiple tumours at thoracal IVX on the right back and ribs in last three months. There were burning sensation,
painful and easy bleeding. The rumours \r€Ie grouping papules, noduls and plaque
at thoracal IV-X on the right back and ribs, variety colour (blue-black, amelanotic
and erytematous), unilateral distribution. variety shape and size, defined border,
hard consistency, smooth surface. and some of them had black crusts on top of
the lesions. There were enlargement of right colli, supraclavicul4 infraclavicul4
axillae, and inguinal l1mph nodes. Histophatology examination revealed
melanocyte cells with vescicular nuclei and coarse chromatin under stratun

corneum and granulosum layers. pleomorf. that expanded to papillary and
reticular dermis (vertical gror*rh) and bro*n pigments on dermis. This patient was
in stage IIIC based on AJCC 2002 melanoma staging. Oncologist suggested
chemotherapy, but he refused the therapl and died a month later.
Discussion : Nodular melanoma is the higlest number of melanomas in
lndonesia. This was the hnt case of dermatomal multiple nodular melanoma in
our DeparLment. The enlargement of llmph nodes suggested metastatic. There is
no standard therapy for metastatic meianoma. Chemotherapy may be useful.
Key words : Nodular melanoma- I'ertical gro*-th.

Dermatomal multiple nodular melanomas at thoracal IV-X
on the right back and ribs

Introduction
Melanoma results &om the malignant transformation of melanocyte. Four
major growth patterns of melanoma are lentigo melanom4 superficial spreading,
and acral lentiginous melanoma.l'2

"oa"fui,Melanoma has drawn considerable attention in the last decades due to its
2002
sharp increase in incidence. The American Cancer Society estimate that in
is
rare
melanoma
lndonesia
alone melanoma will have developed in 87,800. ln
case, l-3 % of all cancers in f988. The second most common subtype of
melanoma is noduiar melanoma (NM) with frequency of 154A% but in Indonesia
nodular melanoma is the highest number of melanoma. Study by Lestari S, there
were 16,2Yo malignant ,n.lurro*u during 2000-2003 in Anatomic pathologic of
West Sumatera. This was the fust case of dermatomal multiple nodular
melanomas in our Departrnent. Risk factors for melanoma are Sun exposure'
phenotype, reaction ofitre skin to sunlight, occupation and social status, familial
melanomq melanocytic nevi, gender *J ho.-onal factors'l'3{
The trunk, head, and neck are the most frequent anatomic sites for NM.
The peak incidence occurs > 50 years of age. Nodular Melanoma typically

or

amelanotic papule or nodule.
Nfrrf may appear as a blueberry-shaped nodule with a thundercloud-gray
upp"*uo"". Ulceration and bleeding from the lesion occurs frequently. Early
recognition of NM can be difficult because they lack many of the conventional
cliniial features of melanoma. In certain cases, it may be difficulty to discriminate
beween NM and small hemangiom4 pyogery! gfanulomas, blue naevus, ecrine
poroma, and pigmented basal cells caicinoma.'''
'
Histoiogic picture of NM may show large epitheloid cells with vescicular
nuclei and coarse chromatin, spindle cells, small malignant melanocltes, or
mixtures of all three. Usually, the tumors mass fills and expands the papillary
dermis or invades between coarse collagen fibers of reticular dermis (vertical
r'8
growth).
Nodular Melanoma has poor prognosis. The treatment of choice is surgery.
Current recommendations include the excision of a margin of normal-appearing
skin around the tumors to ensure its complete removal. Lymph node dissection
can be performed. In high-risk patient with lymph node involvement, high-dose
interferon-a has demonstrated an improvement in disease-free and overall
survival. There is no standard therapy for metastatic melanoma. Dacarbazine
(DTIC) remains for initial chemotherapy for metastatic melanoma. Radiation
th".upy is an option as a palliative form of treatment for painful cutaneous lesions
or foi tfrose large tumors that cause bleeding or neurologic or vascular
compression. A combination of chemotherapy and biologic response modifier, is
vaccines have been
*otir., alternative for metastatic melanoma. Several
12'8'10
developed for treatment of stage III or IV melanoma'
appears as a ruriform dark blue-black, bluish-red,

Case

report

Indonesian man came to the Dermato-Venereology Outpatient
Department of Dr.M.Djamil Hospital on March t6th, 2005 with chief complaint

A 50-year-old

there were blue-black tumors that growing fast on his right back and ribs skrn
since 3 months ago. lnitially, there was a blue black tumor on the right back 2
years ago. The tumor was growing fast lsseme multiple turnors on the right back
and ribs in last three months. At fust, some of them appeared as red pimples or
amelanotic pimples, and then became dark (blue-black) and larger. Those lesions
were painful" buming sensation, and easy bleeding.There were lumps on his right
neck 3 months ago, and on his upper right thigh (tight inguinal) 2 months ago.
There was no herpes zoster history. There was no breathing complain. There was
no intensive headache. There was no decreased of his body weight. There were no
family who suffered from this disease. He w-as a farmer with low-social economic
state.

Physical Examination revealed general appearance

in normal state.

Dermatology examination, the tumours'vvere grouping papules. noduls and plaque
at thoracal IV-X on the right back and ribs, variery colour @lue-black, amelanotic
and erytematous), unilateral distribution. varier,v* shape and size. defined border,
hard consistency, smooth surface, and some of them had black crusts on top of
the lesions. There were two enlargement of colli dextra lymph nodes (A i 2 cm),
three enlargement of supraclavicula & infraclavicula dextra l.omph nodes (A t 1,5
cm), three enlargement of axilla dextra lymph nodes (A = 3 cm). trvo enlargement
of inguinal dextra lymph nodes (g ! 2 cm). All of lymph nodes were dense,
mobile, and pain.
Laboratory finding were routine blood- chemical blood and routine urine in
normal limit. The working diagnosis rl'as susp€ct malignant melanoma (nodular
qpe) and the differential diagnosis u'as keloid. We suggested to biopsy of the
tumor and lymph nodes, thoracal X-ra1' and abdominal USG. Histophatology
examination revealed melanocy'te cells with vescicular nuclei and coarse
chromatin under stratum comeum and granulost,.m layers, pleomorf, that
expanded to papillary and reticular dermis (vertical gowth) and brown pigments
on dermis. Thoracal X-ray revealed cord and pulmonary were norrnal, there was
no metastatic sign. Abdominal USG result : there was no metastatic sign to the
liver and to lymph nodes parznorta.
Diagnosis was dermatomal multiple nodular melanoma stage IIIC based on
AJCC 2002 melanoma staging. Prognosis were quo ad vitam malam, quo ad
sanam malam. quo ad cosmeticum malam. We consulted to Oncologist (Surgery
Deparhnen| and decided chemotherapy for this patient. Unfortunately, the
patient refused the therapies. Finally. he died amonth later.
Discussion
ln Anatomic pathologic deparment FKUI, there were 17 cases (11,6 %) of
malignant melanoma that 8 cases were nodular melanoma in 1988. Study by
Lestari S, there were 16,20/o malignant melanoma during 2000-2003 in Anatomic
pathologic of West Sumatera This was the first case of dermatomal multiple
6'e
nodular melanoma in our Department.
At the first time, we confuced the clinical features of this desease with keloid
as a result herpes zoster because of the lesions were painful and burning sensation
like neuralgia post herpetic. There were hyperpigmented masses which some of
them were smooth surface that their arrangement ware herpetiformis and
unilateral. Finally we could excluded keloid because from anamnesis, this disease

appeared without history of herpes zoster disease. Histophatology finding didn't
consistent with keloid.
The diagnosis based on anarlnesis, physical examination, and histophatology

examinatioo. Fro.o anamnesis, we presumed that the disease was one of a
malignancy of cutaneous. Because, the lesions growth rapidly, pain, itchy, and
easy bleeding. He was a farmer that he often didn't wear blouse when digging the
field. Ue got intensively sun exposure that had high risk for malignancy of
cutaneous- Physical examination, the tumors were grouping papules, noduls and
plaque at thoracal IV-X on the right back and ribs, variety colour (blue-black,
amelanotic and erytematous), uniiateral distribution, variety shape and size,
defined border, hard consistency, smooth surface, and some of them had black
crusts on top of the lesions. There were enlargement of right colli, supraclavicula,
infraclavicul4 axillae, and inguinal lymph nodes. Lymph nodes enlargement
suggested the metastatic. Histophatology examination revealed melanocyte cells
wii[ vescicular nuclei and coarse chromatin under stratum corneum and
granulosum layers, pleomorf, that expanded to papillary and reticular dermis
(vertical growth) and brown pigments on dermis. Histophatology examination
consistent with nodular melanoma.
Accurate documentation of the extent of melanoma is essential for
determining the optimal treatment of patient and for assessing prognosis. The
AJCC (American Joint Committee on Cancer) and the UICC (lnternational Union
Against Cancer) TNM (Tumor Node Metastasis) committees have approved a
new melanoma staging system. which was implemented in 2002. This patient was
in stage IIIC based on AJCC 2002 melanoma staging, its meant that this patient
had a poor prognosis.

Table: the2002 version of AJCC melanoma staging system

Melanom''t
Pro;xrsed Stage Crouping5 for Cutaneous
PArHrxrx;tt sTActrci

CuNtcAt. Strctruc;'

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o
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lrl()

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ltA

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lilr
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llli

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l.i{}

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Llrl

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I{{)

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r{0

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T.ta
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-l'l

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IIIA

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T I -4.'t
Tl

iltB

-4lr

ll4lr
I

\rlr

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I -.1,r

T

l-44

Nlb

N{{l

lV

Arrt'T

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N

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N.{(}

I -lalr
I I {l-r

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Exerpting from reference I

There is no effective treatment for this tumor when it has disseminated. We
dicided chemotherapy for this patient. Unfortunately, the patient refused the
therapy. Finally, he died a month later.

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WolffK,
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