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Mejbel HA, Nelson KC, Pradhan D, Ivan D, Zaleski M, Nagarajan P, Tetzlaff MT, Curry JL, Torres-Cabala CA, Prieto VG, Aung PP. Cutaneous neoplasms composed of melanoma and carcinoma: A rare but important diagnostic pitfall and review of the literature. J Cutan Pathol 2020; 47:36-46. [PMID: 31361351 DOI: 10.1111/cup.13551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 01/03/2023]
Abstract
We report two cases of combined cutaneous tumors composed of melanoma and carcinoma. The first tumor presented as a 5-mm pink-blue macule over the right zygomatic arch in an 85-year-old man. Shave biopsy and immunohistochemical studies revealed that the tumor was composed of melanoma (highlighted by SOX10 and MART-1, with high Ki-67 proliferative index) intermixed with nodular basal cell carcinoma (highlighted by pan-cytokeratin and Ber-EP4). The neoplastic melanocytes were confined to the basal cell carcinoma nodules, and a diagnosis of combined melanoma in situ and basal cell carcinoma was rendered. After therapeutic excision, the patient was disease-free at 9 months after the initial diagnosis. The second tumor presented as a 6-mm pink-brown crusted papule on the right forehead in an 89-year-old man. Shave biopsy and immunohistochemical studies revealed that the tumor was composed of malignant melanoma (MM) (highlighted by S100 and MART-1) intermixed with squamous cell carcinoma (SCC) (highlighted by cytokeratin and p63), and a diagnosis of combined MM-SCC was rendered. These two cases highlight the importance of recognizing these rare types of melanocytic-epithelial cutaneous neoplasms to arrive at an accurate diagnosis that may inform appropriate disease stage and therapy.
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MESH Headings
- Aged, 80 and over
- Biomarkers, Tumor/metabolism
- Carcinoma, Basal Cell/diagnosis
- Carcinoma, Basal Cell/metabolism
- Carcinoma, Basal Cell/pathology
- Diagnosis, Differential
- Humans
- Male
- Melanoma/diagnosis
- Melanoma/metabolism
- Melanoma/pathology
- Neoplasm Proteins/metabolism
- Neoplasms, Second Primary/diagnosis
- Neoplasms, Second Primary/metabolism
- Neoplasms, Second Primary/pathology
- Skin Neoplasms/diagnosis
- Skin Neoplasms/metabolism
- Skin Neoplasms/pathology
- Melanoma, Cutaneous Malignant
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Affiliation(s)
- Haider A Mejbel
- Department of Pathology, East Tennessee State University, Johnson City, Tennessee
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly C Nelson
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dinesh Pradhan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Doina Ivan
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Zaleski
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan L Curry
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos A Torres-Cabala
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor G Prieto
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Phyu P Aung
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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2
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Basomelanocytic Neoplasms: A Report of Two Similar Tumors With Divergent Treatments. Am J Dermatopathol 2019; 42:530-532. [PMID: 31688006 DOI: 10.1097/dad.0000000000001555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Basomelanocytic neoplasms are tumors consisting of elements of both basal cell carcinoma and melanoma. These tumors are exceedingly rare and present a unique challenge as to how the melanoma component should be classified. Due to the paucity of cases, there are no clear-cut evidence-based guidelines as to how these tumors should be staged and which treatment options provide the optimal outcome. We present 2 separate patients with similar cases of colonizing basomelanocytic tumors that were treated in drastically different ways, highlighting the differing approaches to treatment. We discuss theses treatment modalities and the challenges inherent to diagnosing and treating basomelanocytic neoplasms.
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3
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Tchernev G, Lozev I, Pidakev I, Yungareva I, Naskova-Popova T, Temelkova I. High-Risk BCC Of the Lower Eyelid in Patient with Presternal Located Cutaneous Melanoma and BCC Of the Shoulder: Melolabial Advancement Flap Combined with Undermining Surgical Approach As Promising Complex One Step Treatment Option! Open Access Maced J Med Sci 2018; 6:2147-2151. [PMID: 30559879 PMCID: PMC6290402 DOI: 10.3889/oamjms.2018.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND: It is assumed that the occurrence of keratinocyte and melanocytic tumours is multifactorial driven. Certain risk factors such as solar radiation, p53 protein and Melanocortin-1 receptor (MC1R) prove to be common to their development, which at the same time shows that their simultaneous manifestation in the same patients, for example, is quite possible. Such a manifestation could be observed as collision tumours within the same solitary lesion or as a simultaneous occurrence within two completely different lesions that are clearly distinguished from one another. CASE REPORT: An 85-year-old patient is presented with three primary cutaneous tumours located in region presternal, infraorbital sinistra and scapularis extra. The lesions were removed during a single surgical session. For the high-risk basal cell carcinoma (BCC) in the lower eyelid, the so-called melolabial advancement flap was applied, and for the tumours located in the other two areas, the undermining surgical approach was applied. The subsequent histological analysis found that the case referred to two keratinocyte tumours (BCC) and one melanocyte tumour (cutaneous melanoma). CONCLUSIONS: The patient presented is interesting with regard to 1) the simultaneous presentation of three primaries with different localization (so far not described in the world literature, namely 2 basal cell carcinomas and one melanoma in the same patient concurrently), 2) one of the basal cell tumours belongs to the group of high-risk (according to the localization) and meanwhile advanced BCC (according to the infiltration degree of the underlying tissue-infiltration of the musculature) and 3) their simultaneous successful surgical treatment in a single surgical session under local anaesthesia.
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Affiliation(s)
- Georgi Tchernev
- Medical Institute of Ministry of Interior (MVR), Department of Dermatology, Venereology and Dermatologic Surgery, General Skobelev Nr 79, Sofia, Bulgaria.,Onkoderma - Policlinic for Dermatology and Dermatologic Surgery, General Skobelev 26, Sofia, Bulgaria
| | - Ilia Lozev
- Medical Institute of the Ministry of Interior, Surgery, Sofia, Bulgaria
| | - Ivan Pidakev
- Medical Institute of the Ministry of Interior, Surgery, Sofia, Bulgaria
| | - Irina Yungareva
- Medical Institute of Ministry of Interior (MVR), Department of Dermatology, Venereology and Dermatologic Surgery, General Skobelev Nr 79, Sofia, Bulgaria
| | - Tanya Naskova-Popova
- Department of Clinical Hematology University Multiprofile Hospital for Active Treatment "Sveti Ivan Rilski", 15, Acad. Ivan Geshov Blvd., Sofia 1431, Bulgaria
| | - Ivanka Temelkova
- Medical Institute of Ministry of Interior (MVR), Department of Dermatology, Venereology and Dermatologic Surgery, General Skobelev Nr 79, Sofia, Bulgaria
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4
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Dinehart M, Abate MS, Jennings T, Kaley JR, Shalin SC. Colliding, colonizing or combining? Four cases illustrating the unique challenges presented by melanoma arising in conjunction with basal cell carcinoma. J Cutan Pathol 2018; 45:443-452. [PMID: 29484694 DOI: 10.1111/cup.13137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 11/30/2022]
Abstract
Biphasic lesions comprised of melanocytic and epithelial components are rare entities believed to arise either as a collision of 2 histologically distinct lesions in the same anatomic location or as a singular progenitor tumor differentiating along 2 differing lineages. Regardless of mechanism of origin, these tumors present unique challenges in pathologic interpretation and in determining appropriate measurements, which assigns subsequent prognosis to the patient. We present 4 tumors of melanoma co-existing with basal cell carcinoma (BCC) and discuss relevant literature regarding these biphasic entities. Patients consisted of 3 males and 1 female, ranging in age from 62 to 93, with lesions located on the shoulder, frontal scalp, forearm and nose. Three of 4 lesions showed melanoma cells limited to BCC tumor lobules, without evidence of direct dermal invasion by melanoma cells, raising the question of whether or not these tumors should be classified as in situ or invasive melanoma. These cases highlight the complexity that such lesions pose to dermatopathologists, in terms of their uncertain origin and variable microscopic appearance. In the absence of data regarding outcomes for these tumors (given their rarity), it is important to utilize a case-by-case approach, with careful clinical correlation and appropriate use of ancillary techniques.
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Affiliation(s)
- Matthew Dinehart
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mallory S Abate
- Department of Dermatology, Saint Louis University, St. Louis, Missouri
| | - Thomas Jennings
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jennifer R Kaley
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sara C Shalin
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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5
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Medeiros PM, Alves NRDM, Silva CCD, Faria PCPD, Barcaui CB, Piñeiro-Maceira J. Collision of malignant neoplasms of the skin: basosquamous cell carcinoma associated with melanoma. An Bras Dermatol 2016; 90:39-42. [PMID: 26312670 PMCID: PMC4540504 DOI: 10.1590/abd1806-4841.20153845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/11/2014] [Indexed: 11/22/2022] Open
Abstract
Collision tumors are characterized by the coexistence of two cancers in the same anatomical site and its pathogenesis remains controversial. Although uncommon, the association of basal cell carcinoma and melanocytic nevus is the most common among combinations of skin tumors. Even rarer is the association of two malignant tumors. We report a case of tumor collision representing melanoma and basosquamous cell carcinoma, a combination not previously described in the literature, since there are no reported cases of melanoma with this type of basal cell carcinoma.
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Mancebo SE, Marchetti MA, Hollmann TJ, Marghoob AA, Busam KJ, Halpern AC. Melanoma in situ colonizing basal cell carcinoma: a case report and review of the literature. Dermatol Pract Concept 2015; 5:25-30. [PMID: 25692077 PMCID: PMC4325687 DOI: 10.5826/dpc.0501a04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/27/2014] [Indexed: 12/20/2022] Open
Abstract
Colonization of basal cell carcinoma (BCC) by melanoma cells is a unique and uncommonly reported cutaneous entity. We describe a bluish nodule on the left forearm found during routine skin cancer surveillance examination with suspicious dermatoscopic findings including central-blue-white veil, sparse atypical dots, and a surrounding pink vascular blush with focal irregular tan-brown pigmentation at the periphery. Histopathology demonstrated a pigmented BCC with an overlying and adjacent melanoma in situ (MIS), as well as colonization of the BCC nodule by melanoma cells. We performed a review of the literature on the topic and discuss other presentations of cutaneous neoplasms composed of both BCC and melanoma, including collision, combined, and biphenotypic tumors. The prognostic and management challenges inherent to this distinctive neoplasm are summarized.
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Affiliation(s)
- Silvia E Mancebo
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael A Marchetti
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Travis J Hollmann
- Dermatopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ashfaq A Marghoob
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Klaus J Busam
- Dermatopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allan C Halpern
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Shiau CJ, Thompson JF, Scolyer RA. Controversies and evolving concepts in the diagnosis, classification and management of lentigo maligna. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.13.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Malignant melanoma within squamous cell carcinoma and basal cell carcinoma: is it a combined or collision tumor?--a case report and review of the literature. Am J Dermatopathol 2013; 35:226-34. [PMID: 22588546 DOI: 10.1097/dad.0b013e3182545e27] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report a case of a very unusual combined and collision basosquamous melanocytic malignant tumor on the chest of an 84-year-old man. To our knowledge, this is the first case report describing this entity. We attempt to address the diagnostic challenge and the clinical and histological characteristics of these rare neoplasms with a review of the English literature to further categorize and summarize what has been previously reported about these extraordinary tumors.
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Recurrent lentigo maligna melanoma commingling the tumour nests of a basal cell carcinoma. J Plast Reconstr Aesthet Surg 2013; 66:e227-8. [PMID: 23623186 DOI: 10.1016/j.bjps.2013.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 02/22/2013] [Accepted: 03/08/2013] [Indexed: 11/21/2022]
Abstract
There are various types and combinations of coexisting cutaneous neoplasms which have been documented in the past but are uncommon. In this report we describe a case of basal cell carcinoma (BCC) colonised by recurrent lentigo maligna melanoma. A review of the literature has established the coexistence of lentigo maligna and BCC in six cases. The unusual combination of melanoma and BCC poses a therapeutic and prognostic dilemma. BCC is known to have a favourable outcome whereas melanoma tends to behave in a more aggressive manner leading to a less favourable outcome. There are conflicting views as to whether these lesions should be treated as BCC's or lentigo maligna melanoma. Our case appears to be unique, in that it was a recurrent lentigo maligna melanoma which was colonising the BCC. We treated our patient with wide local excision and full thickness skin graft and will continue to observe him on an outpatient basis. There needs to be long term follow up of a larger number of patients for us to truly appreciate the biological significance of parasitism of BCC by lentigo maligna melanoma.
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10
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Smith LJ, Husain EA. Colonisation of basal cell carcinoma and actinic keratosis by malignant melanoma in situ in a patient with xeroderma pigmentosum variant. Clin Pract 2012; 2:e47. [PMID: 24765446 PMCID: PMC3981299 DOI: 10.4081/cp.2012.e47] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 03/23/2012] [Accepted: 04/02/2012] [Indexed: 12/11/2022] Open
Abstract
Although malignant melanoma (MM) and both basal cell carcinoma (BCC) and actinic keratosis (AK) are sun-induced lesions, the coexistence of these entities at the same anatomical site (collision tumour) is exceedingly rare. We report the case of a 54-year-old woman with a known history of xeroderma pigmentosum variant (XPV) who presented with 2 separate skin lesions over the middle and upper right forearm, respectively. The clinical impression was that of BCCs or squamous cell lesions. On histological examination, both specimens showed features of melanoma in situ (MIS). In the first lesion, MIS merged with and colonised a superficial and focally invasive BCC. In the second lesion, MIS merged with an AK. No separate invasive nests of malignant melanoma were seen in either specimen. The atypical melanocytes were highlighted by Melan-A and HMB-45 immunostaining, whereas the epithelial cells in both the BCC and AK stained with the pancytokeratin MNF-116. The patient had a previous history of multiple MMs and non-melanomatous skin cancers and finally developed widespread metastatic malignant melanoma, which proved fatal. The rare and interesting phenomenon of collision tumours may pose diagnostic difficulties. To our knowledge, this is the first reported simultaneous presentation of cytologically malignant collision tumours in a patient with XPV.
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Affiliation(s)
- Louise J Smith
- Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ehab A Husain
- Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK
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11
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Martorell A, Botella-Estrada R, Nagore E, Guillen-Barona C. Dermoscopic features of a collision tumour composed of a pigmented basal cell carcinoma and a melanoma. J Eur Acad Dermatol Venereol 2010; 24:982-4. [DOI: 10.1111/j.1468-3083.2010.03594.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Hilliard NJ, Huang C, Andea A. Pigmented extramammary Paget's disease of the axilla mimicking melanoma: case report and review of the literature. J Cutan Pathol 2009; 36:995-1000. [PMID: 19674203 DOI: 10.1111/j.1600-0560.2009.01174.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pigmented Paget's disease is a rare variant that is often confused clinically and histologically with melanoma in situ. Herein, we describe a case of pigmented extramammary Paget's disease involving the axilla of a 79-year-old white male thought initially to represent malignant melanoma clinically and histologically. Review of the literature reveals that pigmented variant of Paget's disease, either mammary or extramammary, could be initially misdiagnosed as melanoma unless this entity is considered in the differential diagnosis, and additional confirmatory studies are performed.
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Affiliation(s)
- Nicholaus J Hilliard
- Department of Dermatopathology, University of Alabama-Birmingham, Birmingham, AL 35249, USA
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13
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Satter EK, Metcalf J, Lountzis N, Elston DM. Tumors composed of malignant epithelial and melanocytic populations: a case series and review of the literature. J Cutan Pathol 2009; 36:211-9. [PMID: 18727668 DOI: 10.1111/j.1600-0560.2008.01000.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Calista D, Riccioni L. A brownish macule on the tip of the nose. J Eur Acad Dermatol Venereol 2008; 21:1281-2. [PMID: 17894737 DOI: 10.1111/j.1468-3083.2007.02177.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Taibjee SM, Gee BC, Sanders DSA, Smith A, Carr RA. Lentigo maligna involving the tumour nests and stroma of a nodular basal cell carcinoma. Br J Dermatol 2007; 157:184-8. [PMID: 17578442 DOI: 10.1111/j.1365-2133.2007.07904.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND The combination of malignant melanoma (MM) and basal cell carcinoma (BCC) within a single tumor is an unusual finding. CASE REPORT An 84-year-old white man with a pigmented tumor on the back showing a combination of MM and BCC. RESULTS A 1.5 x 1.5-cm irregular brown lesion on the back was clinically suggestive of MM. Histopathologically, the lesions turned out to be a combined tumor consisting of a superficial BCC and a regressive MM with a tumor thickness of 1.25 mm. The conglomerates of the BCC lay within the MM and were admixed with a high number of Melan-A-positive melanocytic cells. CONCLUSION By reviewing the low number of published cases, we found that a combined MM-BCC tumor exists in two variants: a collision type in which components of each cell type are clearly demarcated and an intermingled type in which both cell types grow intimately together. Although both types occur as a mere incidence, in particular, the intermingled type may be diagnostically challenging and the evaluation of its dignity may be questionable.
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Affiliation(s)
- Markus Braun-Falco
- Department of Dermatology, University Medical Center Freiburg, Freiburg, Germany.
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17
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Papa G, Grandi G, Pascone M. Collision tumor of malignant skin cancers: a case of melanoma in basal cell carcinoma. Pathol Res Pract 2006; 202:691-4. [PMID: 16876964 DOI: 10.1016/j.prp.2006.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2005] [Accepted: 01/16/2006] [Indexed: 10/24/2022]
Abstract
The coexistence of two malignant skin tumors intermingling in the same histologic specimen is rare. We report a case of melanoma in a basal cell carcinoma collision tumor. The presence of two intermingled neoplasms was confirmed by immunohistochemistry, which showed strong positivity for S-100 and HMB-45. A review of the literature and a case analysis allow for some pathogenetic and prognostic considerations.
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Affiliation(s)
- Giovanni Papa
- Department of Plastic and Reconstructive Surgery, University of Trieste, Ospedale di Cattinara, Strada di Fiume 447, Trieste, Italy.
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