The Importance of In Vivo Reflectance Confocal Microscopy in a Case of Desmoplastic Melanoma

Abstract

Desmoplastic melanoma accounts for 5% of all cases of melanoma, but its diagnosis can be difficult due to its frequent clinical presentation with amelanotic lesions. Histologically, spindled melanocytes surrounded by a collagenous stroma are observed. Compared with other types of melanoma, the desmoplastic types presents greater local aggression, and is more prone to local recurrence, but has a lower risk of lymph node metastasis. Early detection, accurate staging, and proper surgical management are the main factors associated with higher survival rates in melanoma patients. Reflectance confocal microscopy (RCM) has proven to be a valuable imaging tool in the diagnosis of skin neoplasms, being useful for orientating practitioners towards the diagnosis of melanoma and indicating the necessity of performing a diagnostic biopsy. We present the case of 52-year-old woman, who presented to the dermatology department with an irregular, dark-colored plaque in the right deltoid region. Dermoscopy showed asymmetry with an atypical network and some areas of regression. RCM revealed pagetoid cells in the upper epidermis, cell atypia, non-edged papillae, dermal inflammation, and nucleated cells in the dermis, which are highly suggestive of melanoma. A biopsy was also performed. A histopathology exam confirmed the diagnosis of superficially spreading melanoma with a desmoplastic component, and revealed a Breslow index of 0.9 mm, Clark level IV, an absence of mitoses, angiolymphatic invasion and regression, and complete excision. The CT and PET-CT scans were negative. A biopsy of the axillary sentinel lymph node was conducted, with a negative result obtained, establishing the IB stage of the disease. The patient will remain under follow-up to look for a recurrence or a new primary melanoma.

Keywords: dermoscopy; desmoplastic melanoma; diagnosis; histopathological subtype; prognostic; reflectance confocal microscopy.

Figure 1

Clinical aspects: slowly growing, brown heterogenous plaque measuring 15 × 12 mm, with imprecise borders and asymmetry, and with a dark-brown papule developed in the inferior part of the lesion (yellow arrow).

Figure 2

Dermoscopic aspects: asymmetry of pattern and colors; atypical pigment network; abrupt ending of the pigment network in the superior part of the lesion (red arrow); angulated lines (blue arrow); pseudopodes (orange arrow); central area with pigment blotches that alternate with fibrose-like discoloration.

Figure 3

(A–D). Reflectance confocal microscopy aspects (VivaScope 1500/3000). (A) Arrows: pagetoid cells at the level of the epidermis; (B) yellow circle: small hyper reflective inflammatory cells; (C) yellow square: cerebriform nest; (D) yellow circle: disarray of dermal papillae.

Figure 3

(A–D). Reflectance confocal microscopy aspects (VivaScope 1500/3000). (A) Arrows: pagetoid cells at the level of the epidermis; (B) yellow circle: small hyper reflective inflammatory cells; (C) yellow square: cerebriform nest; (D) yellow circle: disarray of dermal papillae.

Figure 4

Histological examination, hematoxylin–eosin stain (10×): melanocyte proliferation at the dermo-epidermal junction, atypical melanocytes arranged lentiginously and continuously; pagetoid invasion of the epidermis and formation of anisomorphic nests; lympho-histiocytic dermal infiltrate.

Figure 5

Immunohistochemical expression of SOX 10 in the melanocytic lesion (4×).