A Disguising Fast-Growing Metachronous Melanoma and COVID-19

Abstract

An unusual case of a 52-year-old female with two metachronous melanomas is presented. An atypical fast-growing nodular melanoma appeared 18 months after the complete excision of an in situ melanoma and one month afterward a SARS-CoV-2 infection. Intra-nodal melanocytic proliferations were identified during lymph node assessment, raising important diagnostic and prognostic concerns. No melanoma susceptibility genes were found. This case report raises the question about the COVID-19 immunosuppression effect on the tumor microenvironment and the oncogenic potential of SARS-CoV-2. It also highlights the importance of clinical follow-up in melanoma patients, which was significantly delayed during the COVID-19 pandemic.

Keywords: covid-19; malignant melanoma; multiple melanomas; nodular melanoma; sars-cov-2; skin cancer.

Figure 1. A 7 mm, smooth-surfaced, solitary, red nodule (arrow) localized on the posterior thorax, with a visible blue central globule.

Figure 2. Digital dermoscopy reveals a nodular, red tumor, with large, blue-gray, ovoid structures.

Figure 3. Nodular melanoma 1.47 mm, vertical growth phase.

A densely cellular melanocytic tumor, consisting of round/oval cells and rare, elongated, bulky cells. Tumor cells present pleiomorphic, atypical, hyperchromatic nuclei, with rare mitoses and brown pigment within the cytoplasm. They are organized in nests at the dermo-epidermal junction or in islands within the dermis. Predominantly, lymphocytic infiltrates are present. Hematoxylin and eosin, original magnification: ×100.

Figure 4. a) Nodular melanoma, vertical growth phase without radial growth phase: high nuclear immunostaining, anti-SOX-10. b) A double staining for Ki67 (DAB) positive in tumor nuclei and Melan-A/MART1 (Fast Red) positive within the cytoplasm. c) Heterogenous cytoplasmic immunostaining, anti-HMB-45. Original magnification: ×100.

DAB, diaminobenzidine; SOX-10, SRY-related HMg-Box gene 10; HMB-45, human melanoma black 45; MART1, melanoma-associated antigen recognized by T cells 1

Figure 5. A cluster of melanocytes embedded within the lymph node capsule showing typical features of a nodal melanocytic nevus.

a) Positive SOX-10 in nevus cells located in the subcapsular region of the lymph node (SOX-10 stain, original magnification: ×200). b) Nodal melanocytes negative for HMB-45; this can be used as an adjunct in the distinction between benign and malignant cells (HMB-45 stain, original magnification: ×100). SOX-10, SRY-related HMg-Box gene 10; HMB-45, human melanoma black 45