Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 557-558  

Acral lentiginous melanoma


1 Department of Pathology, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur, Chhattisgarh, India
2 Department of Anatomy, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur, Chhattisgarh, India

Date of Web Publication14-Jul-2015

Correspondence Address:
Sachin A Badge
Department of Pathology, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.160817

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  Abstract 

Acral lentiginous melanoma (ALM) is the most common type of melanoma in dark skinned peoples and Asians. The mean age of ALM ranges from 55 to 68 years. We report a case of ALM in a 60-year-old male patient presented with growth over palmer surface of left thumb since 2 years. The prognosis of invasive acral melanoma is poor, but future studies are needed to know more about the clinical outcome of this malignancy.

Keywords: Acral, lentigenous, melanoma


How to cite this article:
Badge SA, Meshram A, Ovhal A. Acral lentiginous melanoma. Med J DY Patil Univ 2015;8:557-8

How to cite this URL:
Badge SA, Meshram A, Ovhal A. Acral lentiginous melanoma. Med J DY Patil Univ [serial online] 2015 [cited 2024 Mar 28];8:557-8. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2015/8/4/557/160817


  Introduction Top


Acral lentiginous melanoma (ALM) is a distinct variant of cutaneous melanoma, which occurs on the palms, soles, and subungual sites, and has a characteristic histologic picture. It was first described by Reed in 1976. [1] ALM is the most common type of melanoma in dark skinned peoples and Asians. [2] Overall, ALM occurs in an older patient population than does superficial spreading or nodular melanoma, and in populations where ALM is common, this tumor more often seen in men than women. ALM is similar to that of lentigo maligna melanoma, peaking in the seventh decade of life. The mean age of ALM ranges from 55 to 68 years in European countries. [3]


  Case Report Top


A 60-year-old male patient presented with growth over palmer surface of left thumb since 2 years. The growth was cauliflower like, hard and blackish in color. Complete surgical excision was done. Microscopically, there was hyperkeratosis, acanthosis, elongation of the rete ridges, and lentiginous proliferation of atypical melanocytes along the basal epidermis at the border of the tumor. The tumor was composed of round to oval cells with pleomorphic hyperchromatic to vesicular nuclei and eosinophilic cytoplasm arranged in solid sheets. The tumor shows abundant intra and extracellular melanin pigment [Figure 1]. Hence, diagnosis of ALM was given.
Figure 1: Tumor cells with abundant intra and extracellular melanin pigment

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  Discussion Top


The term acral has been used differently throughout the literature. Most publications use acral for the nonhair bearing, that is, glabrous skin of the palms and soles, and the nail bed, whereas others also include the dorsal aspect of the hands and feet under this term. In a German study, using the latter definition, acral melanoma occurred on the feet in 87% cases and on the hands in 23%. [4] Acral melanomas in the early stages appear as a pigmented macule similar to lentigo maligna. Acral melanomas commonly exhibit clinical evidence of a biphasic growth pattern, with a more rapid evolution from an entirely flat clinical lesion to a lesion containing an elevated focus. The radial growth phase of ALM is characterized by a macular pigmented lesion with highly irregular, notched borders and varying shades of pigmentation. Within a background of pigmented macule, acral melanomas often develop a clinically apparent vertical growth phase. This is manifest as an elevated papule or nodule, sometimes with a verrucous surface, and corresponds to the histological vertical growth phase of malignant melanocytes. Ulceration is more often seen in ALM than in other types of melanoma. Unfortunately, clinical misdiagnosis is not uncommon in patients with ALM. [5] Therefore, awareness of atypical presentations of ALM that may contribute to misdiagnosis or diagnostic delay assumes particular importance. ALM lesions are frequently treated or followed for considerable time under the clinical diagnosis of wart, callus, fungal disorder, subungual hematoma, keratoacanthoma, nonhealing ulcer, foreign body, nevus, ingrown toenail, etc. [6]

The histology of ALM is characteristic but not distinct. In the radial growth phase, the lesions are characterized by marked acanthosis, expanded cornified layer, elongation of the rete ridges, and lentiginous proliferation of atypical melanocytes along the basal epidermis at the border of the tumor. [4] The intraepidermal component of acral melanoma includes large, atypical melanocytes with large, often bizarre nuclei and nucleoli, and cytoplasm filled with melanin granules. [7] These melanocytes in the basal layer often exhibit long, elaborate dendritic processes. [7] Atypical melanocytes can extend along the sweat ducts into the deep dermis. In the vertical growth phase, tumor nodules often contain predominantly spindle shaped cells and are associated with a desmoplastic reaction. [7] The junctional component of thicker tumors often shows nesting of tumor cells and upward migration to the cornified layer. [4] As in the other types of melanomas, immunohistochemical stainings for S-100 protein, HMB-45, and MART-1 (also known as Melan-A) are of great diagnostic value in ALM. S-100 protein (positive cases, 95%) is a more sensitive marker than either HMB-45 (80%) or MART-1 (70%). [2] However, S-100 protein negative ALM has been reported. [8] The intesitity of HMB-45 but not of S-100 protein is correlated well with the melanin content. HMB-45-negative cases are all amelanotic, but amelanotic cases are not all negative for HMB-45. [2] The melanoma cells also express vimentin. [2] Focal staining for CAM5. 2 or epithelial membrane protein may occasionally be found. [2] In general, the prognosis of invasive acral melanoma is poor. This can party be explained by the above described diagnostic delay and increased tumor thickness at the time of diagnosis. However, there are some studies suggesting that acral melanomas may undergo a more aggressive course independent of tumors thickness. [4] In a study from Germany, 63 out of 64 patients (98.5%) with melanoma of the sole subsequently developed metastases; a corresponding figure from Japan in 1983 was 35%. [7],[9]


  Conclusion Top


Future studies using refined criteria including genetic information are necessary to assess the prognosis of this melanoma type.

 
  References Top

1.
Reed RJ. Acral lentigineous melanoma. In: Harmann W, Kay S, Reed RJ, editors. New Concepts in Surgical Pathology of the Skin. John Wiley & Sons, Inc.; New York: 1976. p. 89-90.  Back to cited text no. 1
    
2.
Kim YC, Lee MG, Choe SW, Lee MC, Chung HG, Cho SH. Acral lentiginous melanoma: An immunohistochemical study of 20 cases. Int J Dermatol 2003;42:123-9.  Back to cited text no. 2
    
3.
Fortin PT, Freiberg AA, Rees R, Sondak VK, Johnson TM. Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995;77:1396-403.  Back to cited text no. 3
    
4.
Kuchelmeister C, Schaumburg-Lever G, Garbe C. Acral cutaneous melanoma in caucasians: Clinical features, histopathology and prognosis in 112 patients. Br J Dermatol 2000;143:275-80.  Back to cited text no. 4
    
5.
Cassileth BR, Temoshok L, Frederick BE, Walsh WP, Hurwitz S, Guerry D, et al. Patient and physician delay in melanoma diagnosis. J Am Acad Dermatol 1988;18:591-8.  Back to cited text no. 5
    
6.
Soon SL, Solomon AR Jr, Papadopoulos D, Murray DR, McAlpine B, Washington CV. Acral lentiginous melanoma mimicking benign disease: The Emory experience. J Am Acad Dermatol 2003;48:183-8.  Back to cited text no. 6
    
7.
Seiji M, Takematsu H, Hosokawa M, Obata M, Tomita Y, Kato T, et al. Acral melanoma in Japan. J Invest Dermatol 1983;80 Suppl:56s-60.  Back to cited text no. 7
    
8.
Argenyi ZB, Cain C, Bromley C, Nguyen AV, Abraham AA, Kerschmann R, et al. S-100 protein-negative malignant melanoma: Fact or fiction? A light-microscopic and immunohistochemical study. Am J Dermatopathol 1994;16:233-40.  Back to cited text no. 8
    
9.
Franke W, Neumann NJ, Ruzicka T, Schulte KW. Plantar malignant melanoma - A challenge for early recognition. Melanoma Res 2000;10:571-6.  Back to cited text no. 9
    


    Figures

  [Figure 1]


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