Unknown: Rapidly growing hemorrhagic papule on the cheek of a 54-year-old man

8/7/2019 Unknown: Rapidly growing hemorrhagic papule on the cheek of a 54-year-old man

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Unknown: Rapidly growing hemorrhagicUnknown: Rapidly growing hemorrhagicpapule on the cheek of a 54papule on the cheek of a 54--yearyear--old manold man

Marianne Junck BS, Christopher J Huerter MD,Marianne Junck BS, Christopher J Huerter MD,

Deba P Sarma MDDeba P Sarma MD

Dermatology Online Journal 17 (1): 11 (2011)Dermatology Online Journal 17 (1): 11 (2011)


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Figure 1


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A 54A 54--yearyear--old man sought medical attention for a growthold man sought medical attention for a growthon his right cheek that had been present for three months.on his right cheek that had been present for three months.

The growth began as a small, brown pimple thatThe growth began as a small, brown pimple thatgradually increased in size over time. In the two weeksgradually increased in size over time. In the two weeksprior to his appointment, the site bled daily afterprior to his appointment, the site bled daily aftershowering. The patient denied any prior history of skinshowering. The patient denied any prior history of skincancer or family history of skin cancer. Physicalcancer or family history of skin cancer. Physicalexamination revealed a 9 mm wellexamination revealed a 9 mm well--circumscribedcircumscribed

erythematous papule with a hemorrhagic crust locatederythematous papule with a hemorrhagic crust locatedover the right cheek (Figure 1). On dermoscopy, the lesionover the right cheek (Figure 1). On dermoscopy, the lesionwas completely vascular appearing, with no pigmentwas completely vascular appearing, with no pigmentvisualized.visualized.

What is the diagnosis?

What is the diagnosis?


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Answer:Answer: Amelanotic melanomaAmelanotic melanoma

AbstractAbstract A54A54--yearyear--old man sought medical attention for aold man sought medical attention for a

growth on his right cheek that had been present forgrowth on his right cheek that had been present forthree months. The growth began as a small, brownthree months. The growth began as a small, brownpimple that gradually increased in size over time.pimple that gradually increased in size over time.Physical examination revealed a 9 mm wellPhysical examination revealed a 9 mm well--circumscribed erythematous nodule with a hemorrhagiccircumscribed erythematous nodule with a hemorrhagiccrust. On dermoscopy, the lesion was completelycrust. On dermoscopy, the lesion was completelyvascular appearing, with no pigment visualized. Avascular appearing, with no pigment visualized. Aclinical diagnosis of pyogenic granuloma was made. Theclinical diagnosis of pyogenic granuloma was made. Thelesion was biopsied and histopathologic examinationlesion was biopsied and histopathologic examinationrevealed a 2.8 mm thick, Clark level IV, ulcerated,revealed a 2.8 mm thick, Clark level IV, ulcerated,amelanotic nodular melanoma. Because the literatureamelanotic nodular melanoma. Because the literaturecontains reports of nodular melanoma mimicking thecontains reports of nodular melanoma mimicking thepresentation of a pyogenic granuloma, all such lesionspresentation of a pyogenic granuloma, all such lesions

should be biopsied for histopathologic diagnosis.should be biopsied for histopathologic diagnosis.


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IntroductionIntroduction

The ABCD (asymmetry, boarder irregularity, colorThe ABCD (asymmetry, boarder irregularity, color

variation, diameter greater than 6 mm) criteria werevariation, diameter greater than 6 mm) criteria weredeveloped in order to raise awareness among the laydeveloped in order to raise awareness among the laypublic and primary care providers of the commonpublic and primary care providers of the commonfeatures of superficial spreading melanoma [features of superficial spreading melanoma [11]. Often]. Oftennodular melanoma may present without these features.nodular melanoma may present without these features.

On occasion, nodular amelanotic melanoma may beOn occasion, nodular amelanotic melanoma may bedifficult clinically to distinguish from pyogenicdifficult clinically to distinguish from pyogenicgranulomas or other benign vascular neoplasms [granulomas or other benign vascular neoplasms [22,, 33].].This report describes a case of nodular amelanoticThis report describes a case of nodular amelanoticmelanoma that clinically and dermoscopically mimickedmelanoma that clinically and dermoscopically mimicked

the presentation of a pyogenic granuloma.the presentation of a pyogenic granuloma.


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Case reportCase report

A54A54--yearyear--old man sought medical attention for aold man sought medical attention for a

growth on his right cheek that had been present forgrowth on his right cheek that had been present forthree months. The growth began as a small, brownthree months. The growth began as a small, brownpimple that gradually increased in size over time. Inpimple that gradually increased in size over time. Inthe two weeks prior to his appointment, the site bledthe two weeks prior to his appointment, the site bleddaily after showering. The patient denied any priordaily after showering. The patient denied any prior

history of skin cancer and family history of skinhistory of skin cancer and family history of skincancer.cancer.

Physical examination revealed a 9 mm wellPhysical examination revealed a 9 mm well--circumscribed erythematous nodule with acircumscribed erythematous nodule with ahemmorhagic crust located over the right cheekhemmorhagic crust located over the right cheek

(Figure 1). On dermoscopy, the lesion was completely(Figure 1). On dermoscopy, the lesion was completelyvascular appearing, with no pigment visualized. Avascular appearing, with no pigment visualized. Aclinical diagnosis of pyogenic granuloma was made.clinical diagnosis of pyogenic granuloma was made.


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The papule was biopsied andThe papule was biopsied andhistopathologic examination revealed ahistopathologic examination revealed a2.8 mm thick, Clark level IV, ulcerated2.8 mm thick, Clark level IV, ulceratedamelanotic nodular melanoma (Figures 2amelanotic nodular melanoma (Figures 2through 6). The neoplastic cells werethrough 6). The neoplastic cells were

positive for Spositive for S--100, Melan100, Melan--A, and MITFA, and MITFwith a high proliferative activity on Ki 67with a high proliferative activity on Ki 67immunostains. The tumor cells wereimmunostains. The tumor cells werenegative for HMBnegative for HMB--45, CKAE 1/3, CK 20,45, CKAE 1/3, CK 20,SMA, Factor VIII, CD 34 and CD 68.SMA, Factor VIII, CD 34 and CD 68.


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Figure 2


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Figure 3


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Figure 4


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Figure 5. Tumor cells are strongly positive for S-100immunostain.


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Figure 6. MITF (Microphthalmia-associatedtranscription factor) stain is positive for the nuclei ofthe tumor cells suggesting melanocytes.


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The patient underwent a wide excision of theThe patient underwent a wide excision of thelesion and sentinel node biopsy, as well as flaplesion and sentinel node biopsy, as well as flap

rotation for reconstruction. Preoperativerotation for reconstruction. Preoperativemetastatic work up with a PET CT failed tometastatic work up with a PET CT failed toshow evidence of metastatic disease outside ofshow evidence of metastatic disease outside ofthe neck. Intraoperative sentinel node mappingthe neck. Intraoperative sentinel node mappingidentified two suspicious nodes in the highidentified two suspicious nodes in the high

jugular chain at the level of the posterior bellyjugular chain at the level of the posterior bellyof the digastrics. However, histopathologicof the digastrics. However, histopathologicexamination of these nodes did not showexamination of these nodes did not showmetastatic melanoma. The disease was stagedmetastatic melanoma. The disease was stagedas T3b N0 M0 malignant melanoma of the rightas T3b N0 M0 malignant melanoma of the right

cheek. Presently, the patient is being followedcheek. Presently, the patient is being followedclosely and is without evidence of recurrenceclosely and is without evidence of recurrence13 months post13 months post--operatively.operatively.


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DiscussionDiscussion The ABCD acronym (asymmetry, boarderThe ABCD acronym (asymmetry, boarder

irregularity, color variation, and diameterirregularity, color variation, and diametergreater than 6 mm) was devised in 1985 ingreater than 6 mm) was devised in 1985 inorder to aid the lay public and primary careorder to aid the lay public and primary carephysicians of the common clinical features ofphysicians of the common clinical features ofmelanoma and to provide simple parameters tomelanoma and to provide simple parameters to

guide the necessity of further evaluation of theguide the necessity of further evaluation of thelesion by a specialist [lesion by a specialist [11]. A fifth characteristic,]. A fifth characteristic,evolving, referring to lesions that haveevolving, referring to lesions that havechanged over time, has prompted some tochanged over time, has prompted some toadvocate the expansion of the mnemonic toadvocate the expansion of the mnemonic to

ABCDE. It is important to note that melanomaABCDE. It is important to note that melanomamay not present with all of thesemay not present with all of thesecharacteristics. Rather, it is in combination thatcharacteristics. Rather, it is in combination thatthese features increase suspicion of malignancythese features increase suspicion of malignancy[[11].].


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Whereas the ABCD criteria have been shown by threeWhereas the ABCD criteria have been shown by threestudies to be a valuable clinical predictor of melanoma,studies to be a valuable clinical predictor of melanoma,the criteria are intended to describe only a subset ofthe criteria are intended to describe only a subset of

melanomas, particularly superficial spreading melanomamelanomas, particularly superficial spreading melanoma[[11]. These criteria may exclude many cases of nodular]. These criteria may exclude many cases of nodularmelanoma. Nodular melanoma, especially early in itsmelanoma. Nodular melanoma, especially early in itspresentation, may lack asymmetry, boarder irregularity,presentation, may lack asymmetry, boarder irregularity,and color variation; it may have a diameter less than 6and color variation; it may have a diameter less than 6mm. However, all subtypes of melanoma, including bothmm. However, all subtypes of melanoma, including bothnodular and superficial spreading melanoma, frequentlynodular and superficial spreading melanoma, frequentlychange or evolve. This change is not limited to size,change or evolve. This change is not limited to size,but also includes shape, symptoms such as itching orbut also includes shape, symptoms such as itching ortenderness, surface changes such as bleeding ortenderness, surface changes such as bleeding orulceration, and shade of color changes. Because of theulceration, and shade of color changes. Because of the

significance of the evolution of a lesion as a feature of allsignificance of the evolution of a lesion as a feature of allmelanoma subtypes, the expansion of the wellmelanoma subtypes, the expansion of the well--knownknownacronym to ABCDE has been advocated in order to aidacronym to ABCDE has been advocated in order to aidearlier identification and removal of potentially curableearlier identification and removal of potentially curablemalignancies [malignancies [11].].


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Pyogenic granulomas are common, acquired, benignPyogenic granulomas are common, acquired, benignlesions resulting from capillary proliferation. Whereas thelesions resulting from capillary proliferation. Whereas theexact pathophysiology remains unknown, lowexact pathophysiology remains unknown, low--grade localgrade localinflammation, trauma, hormonal factors, drugs,inflammation, trauma, hormonal factors, drugs,microscopic arteriovenous malformations, viralmicroscopic arteriovenous malformations, viraloncogenes, and the production of angiogenetic growthoncogenes, and the production of angiogenetic growthfactors may play a role in development of these lesionsfactors may play a role in development of these lesions[[22,, 33].].

Pyogenic granulomas usually develop painlessly over thePyogenic granulomas usually develop painlessly over thecourse of a few weeks. They most commonly present ascourse of a few weeks. They most commonly present assolitary, erythematous, papules or nodules ranging insolitary, erythematous, papules or nodules ranging insize from a few millimeters to several centimeters. Thesize from a few millimeters to several centimeters. Themost frequent location is on the head and neck,most frequent location is on the head and neck,specifically the cheek, lips, and gingival and nasalspecifically the cheek, lips, and gingival and nasalmucosa. Pyogenic granulomas often bleedmucosa. Pyogenic granulomas often bleedspontaneously or after minor trauma, and may erode orspontaneously or after minor trauma, and may erode orulcerate.ulcerate.


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Removal of a pyogenic granuloma is mostRemoval of a pyogenic granuloma is mostcommonly performed by excision orcommonly performed by excision or

curettage with cauterization. Because thecurettage with cauterization. Because theliterature contains some reported cases ofliterature contains some reported cases ofmelanoma mimicking the presentation ofmelanoma mimicking the presentation of

pyogenic granulomas [pyogenic granulomas [44,, 55], biopsy and], biopsy andhistopathologic examination of all suchhistopathologic examination of all suchcases should be undertaken.cases should be undertaken.


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ConclusionConclusion This report details a case of nodular melanoma thatThis report details a case of nodular melanoma that

strongly resembled a pyogenic granuloma. Because thestrongly resembled a pyogenic granuloma. Because theliterature contains reports of nodular melanomaliterature contains reports of nodular melanomamimicking the presentation of a pyogenic granuloma,mimicking the presentation of a pyogenic granuloma,all such lesions should be biopsied for histopathologicall such lesions should be biopsied for histopathologicdiagnosis. Whereas the ABCD criteria are bothdiagnosis. Whereas the ABCD criteria are bothsensitive and specific clinical indicators of melanomasensitive and specific clinical indicators of melanoma

when a lesion satisfies multiple criteria [when a lesion satisfies multiple criteria [11], our patient], our patientpresented with only one (diameter greater than 6 mm).presented with only one (diameter greater than 6 mm).If evolution is considered in the context of ourIf evolution is considered in the context of ourpatients presenting lesion, our suspicion for melanomapatients presenting lesion, our suspicion for melanomais increased because the lesion rapidly changed in sizeis increased because the lesion rapidly changed in sizeand surface characteristics, manifested by ulcerationand surface characteristics, manifested by ulceration

and bleeding. Early biopsy of changing lesions may leadand bleeding. Early biopsy of changing lesions may leadto a better prognosis for atypically presentingto a better prognosis for atypically presentingmalignancies; the prognosis of melanoma is largelymalignancies; the prognosis of melanoma is largelybased on the stage, including depth and location of thebased on the stage, including depth and location of theprimary tumor, as well as presence and extent of nodalprimary tumor, as well as presence and extent of nodaland metastatic disease [and metastatic disease [66].].


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melanoma: revisiting the ABCD criteria. JAMA. Dec 8 2004; 292(22):2771melanoma: revisiting the ABCD criteria. JAMA. Dec 8 2004; 292(22):2771--6. [6. [PubMedPubMed]]

2. Requena L, Sangueza OP, Cutaneous vascular proliferation. Part II.2. Requena L, Sangueza OP, Cutaneous vascular proliferation. Part II.Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997; 37: 887Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997; 37: 887--919. [919. [PubMedPubMed]]

3. Mussalli NG, Hopps RM, Johnson NW (1976) Oral Pyogenic Granuloma3. Mussalli NG, Hopps RM, Johnson NW (1976) Oral Pyogenic Granulomaas a complication of Pregnancy and the use of Hormonal Contraceptives.as a complication of Pregnancy and the use of Hormonal Contraceptives.

Int J Gynaecol Obstet 14, 187Int J Gynaecol Obstet 14, 187--191. [191. [PubMedPubMed]]4. Elmets CA, Ceilley RI. Amelanotic melanoma as a pyogenic granuloma.4. Elmets CA, Ceilley RI. Amelanotic melanoma as a pyogenic granuloma.Cutis 1980; 25: 164Cutis 1980; 25: 164--7. [7. [PubMedPubMed]]

5. Harrington P, O'Kelly A, Trail IA, FreemontAJ. Amelanotic subungual5. Harrington P, O'Kelly A, Trail IA, FreemontAJ. Amelanotic subungualmelanoma mimicking pyogenic granuloma in the hand. J R Coll Surgmelanoma mimicking pyogenic granuloma in the hand. J R Coll SurgEdinb. 2002; 47:638Edinb. 2002; 47:638640. [640. [PubMedPubMed]]

6. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC6. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCCmelanoma staging and classification. J Clin Oncol 2009; 27:6199.melanoma staging and classification. J Clin Oncol 2009; 27:6199.[[PubMedPubMed]]


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Junck M, Huerter CJ,Junck M, Huerter CJ, Sarma DP.Sarma DP.(2011(2011). Unknown: Rapidly growing). Unknown: Rapidly growinghemorrhagic papule on the cheek of ahemorrhagic papule on the cheek of a

5454--yearyear--old man. Dermatology Onlineold man. Dermatology OnlineJournal 17(1): 11. [PubmedJournal 17(1): 11. [Pubmed--indexed inindexed inMEDLINE].MEDLINE].

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Unknown: Rapidly growing hemorrhagic papule on the cheek of a 54-year-old man