Unusual Documentation of the Transformation of a Nevus into Malignant Melanoma

| January 22, 2009
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by LindaSusan Marcus, MD; Robert Carlin, BS; and Neal Carlin, BS.

Dr. Marcus has a Private Practice, Wyckoff, New Jersey; Director–Chair, Department of Dermatology, Valley Hospital, Ridgewood, New Jersey. R. Carlin and N. Carlin work at Dr. Marcus’ Private Practice in Wyckoff, New Jersey.

Abstract

It is well documented that congenital nevi have a statistical chance of becoming malignant; however, it is unusual to actually follow the progression of such an event. A 48-year-old man photographically documented changes in his own nevus, which was present at birth, over a period of six months. Seeing this evolution in one lesion is interesting. Emphasis must not only be placed upon the importance of early diagnosis, but also on the expeditious removal of suspicious nevi and treatment.

(J Clin Aesthetic Derm. 2009;2(1):41–43)

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Congenital nevi are at risk for change into melanoma; therefore, nevi that are larger than 1 to 2cm should be monitored or removed to avoid future problems.[1] The patient in this case came to the office with six months of photographs (all of which he had taken himself) of a changing nevus. This rare documentation of the development of a melanoma is fascinating, but underlines the need for public education about nevi and melanoma and the importance of seeking medical attention early when cure rates are increased.

Methods
A 48-year-old man with a past history of Lyme disease treated for five years including self-intravenous antibiotic therapy was initially seen in August 2007. He first presented with a 1.5-cm, irregular, black nodule with an eccentric triangular brown tail on the anterior thigh (Figure 1). Clinically, this was a malignant melanoma that was widely excised and confirmed to be a 1.3-mm Clark III, without ulceration. The patient stated that he had the nevus since birth, but it started to change, and he had taken photographs of the lesion since February 2007 through July 2007 (Figure 2a, Figure 2b, Figure 2c, and Figure 2d). The changes in the shape, color, and topography of the lesion are clear. Note that the eccentric triangular “brown tail” of the nevus is barely visible in Figure 1, as this area has been overrun and transformed into the nodule (1.3-mm thick) of the melanoma itself. The lesion seemingly decreased in size over the six-month period of time. The possibility of melanoma regression exists; however, this was not documented. Excision at any earlier time would have undoubtedly yielded a melanoma with a better prognosis.

Pathology
The specimen was sent to the department of dermatopathology at the College of Physicians and Surgeons of Columbia University in New York where it was “breadloafed” and submitted in five cassettes. Sections show skin with a broad and irregular proliferation of single and nested melanocytes at the dermal-epidermal junction. Nests of melanocytes vary in size and shape and cytologic atypia of melanocytes is moderate to marked. Focally, single melanocytes predominate over nests. Melanocytes are located at all levels of the epidermis. There are also nests of atypical melanocytes within the dermis as well as nests of melanocytes that appear to mature with progressive descent (Figure 3 and Figure 4).

Discussion

Although malignant melanoma is a preventable and treatable disease, the incidence is more than 60,000 per year with almost 8,000 deaths per year.[2–4] The American Academy of Dermatology holds an annual national skin cancer screening event as do the American Society of Dermatological Surgery and the Women’s Dermatological Society, yet the message is not always clear, as seen with  the patient described in this case, and some patients fall through the cracks.[5–6] Screening techniques, technology, education, and programs have improved; however, the incidence of malignant melanoma has increased, especially in males, from 1973 to 2002.2 Mortality rates have risen slightly to 2.9 per 100,000 in the overall population.

Primary prevention remains the judicious use of sunscreens and sun avoidance with ever-improving public service programs; however, something is getting lost in this effort. Emphasis must also be placed upon saving lives through early detection and “treatment.” The addition of “E” to the American Academy of Dermatology’s ABCDs of melanoma (see below) is beneficial.

Asymmetry—One half of the lesion does not match the other half.

Border irregularity—The edges of the lesion are ragged, notched, or blurred.

Color—The pigmentation of the lesion is not uniform. Shades of tan, brown, and black are present. Red, white, and blue add to the mottled appearance.

Diameter—The width of the lesion is greater than six millimeters (the size of a pencil eraser). Any growth should be cause for concern.

Evolving lesions—Those that change in respect to size, shape, symptoms, shades of color, or surface.

However, identifying the problem is only part of the situation. The patient in this case recognized that his nevus was “changing” through self skin examinations, but allowed it to evolve. The patient was suspicious about his lesion from information available on the Internet and from publicity regarding melanoma, but he did not seek help expeditiously. The message that early diagnosis and treatment increases survival was lost on him.[7]

The cost benefits and cure rate of early treatment as well as detection must also be stressed. It is known that outcomes depend upon proximity and access to a qualified physician as well as socioeconomic, cultural, and sexual influences.[8–12] Many patients, like this patient, are fearful about the diagnosis and concerned about the financial aspect of the situation without considering the life-threatening consequences. Not only is the chance of survival increased with the diagnosis of an early, thin lesion, but the cost, time, and inconvenience necessary for investigative procedures (medical work-up, sentinel or lymph node biopsies, etc.) increases with the depth of the lesion.[9] This is obviously a consideration worth pursuing for some patients. All beneficial aspects of diagnosis and treatment must be presented to the public to entice them to seek early diagnosis and treatment.

Conclusion
It is truly fascinating to observe and document the evolving changes of one congenital nevus as it progresses through the levels of melanoma; however, it points to the inadequacy of public education. Not only must there be an awareness about changing nevi, but there must be communication that early changes, detection, and treatment bring positive results. Time is very important. This patient demonstrated an awareness of an existing situation as exhibited by his self documentation through photographs; however, his fear or feeling that there was time to seek treatment led to the progression of the melanoma and a poor prognosis. Yearly skin examination by a qualified dermatologist to monitor changes in nevi is imperative in order to facilitate recognition of dysplastic nevi and early diagnosis of melanoma. Information about cure rates and early detection must be publicized along with the message of sun protection in order to have more positive outcomes and allay fears.

References
1.    LaVigne EA, Oliveria SA, Dusza SW, et al. Clinical and dermatoscopic changes in common melanocytic nevi in school children: the Framingham school nevus study. Dermatology. 2005;211(3):234–239.
2.    Geller A, Swetter SM, Brooks K, Demierre MF, and Yaroch AL. Screening, early detection, and trends for melanoma: current status (2000-2006) and future directions. J Am Acad Derm. 2007;57:555–573.
3.    Bevona C, Sober AJ. Melanoma incidence trends. Dermatol Clin. 2002;20:589–595.
4.    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–130.
5.    Geller AC, Miller DR, Lew RA, et al. Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts. Am J Public Health. 1996;86:538–544.
6.    American Academy of Dermatology. Help set a Guinness World Record by getting a free skin cancer screening. http://www.aad.org/public/News/NewsReleases/Press+ Release+Archives/Skin+Cancer+and+Sun+Safety/Help+ Set+a+Guinness+World+Record+by+Getting+a+Free+ Skin+Cancer+Screening.htm. Accessed on May 1, 2006.
7.    Goldberg MS, Doucette JT, Lim HW, et al. Risk factors for presumptive melanoma in skin cancer screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program experience 2001-2005. J Am Acad of Derm. 2007;57:60–66.
8.    Robinson JK, Rigel DS, Amonette RA. What promotes skin self-examination? J Am Acad Dermatol. 1998:38(5 pt 1):752–757.
9.    Freedberg KA, Geller AC, Miller DR, Lew RA, Koh HK. Screening for malignant melanoma: a cost-effectiveness analysis. J Am Acad Dermatol. 1999;41(5 pt 1):738–745.
10.    Stitizenberg KB, Thomas NE, Brier SE, Berwick M, Millikan RC. Distance to diagnosing provider as a measure of access for patients with melanoma. Arch Dermatol. 2007;143(8):991–1000.
11.    Ma F, Colladao-Mesa F, et al. Skin cancer awareness and sun protection behaviors in white Hispanic and white non-Hispanic high school students in Miami, Florida. Arch Dermatol. 2007;143(8):983–990.
12.    Ahlgrimm-Siess V, Massone C, Hofmann-Wellenhoff R, Kerl H. Natural course of untreated melanoma. Dermatol Surg. 2008;34(3):371–373.

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Category: 01-2009 (January 2009), Case Report, Melanoma

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