This document summarizes the pathology findings of a 67-year-old male with malignant melanoma on his left foot. Biopsies and lymph node dissections were performed. Microscopic examination found infiltrating malignant melanoma extending to the subcutaneous fat. Three of 23 superficial lymph nodes and one of four deep lymph nodes showed tumor metastasis. Prognostic factors like tumor stage, level of invasion, shape, sex, age, location, mitotic rate, and ulceration were discussed. Differentiating melanoma from nevi and other pigmented lesions can be challenging and requires examination of architectural and cytological features along with clinical context.

1. Tumor Board
24/04/2018

2. PATIENT DETAILS
• Age/Sex : 67 / Male
• Hospital OP/ IP No: A18011748
• FNAC No: 55/18
• Date Of Aspiration : 26/02/2018
• Clinical Diagnosis : Malignant Melanoma plantar aspect of
left foot.
• Site of FNAC : Left inguinal lymph nodes.
• Mode of FNAC : USG Guided FNAC
.

3. Microscopy
• Cellular smears showed reactive spectrum of
lymphoid cells with lymphoglandular bodies seen in
the background.
• No malignant cells were seen in the present smears
studied.

4. Impression
USG Guided FNAC of left inguinal lymph nodes revealed
• Features suggestive of reactive lymphadenitis.
• No malignant cells were identified.

5. PATIENT DETAILS
• Age/Sex : 67/Male
• Hospital OP/ IP No: A18011748
• Biopsy No: 484/18
• Date Of Receiving Specimen : 27/02/18
• Clinical Diagnosis :
• Nature of Specimen : Full thickness and edge biopsy of
the swelling from left foot.
.

6. Gross Examination
• Received 4 grey white to grey black soft tissue bits,
largest measures 1x0.5cm and smallest measures
0.2x0.2cm. All embedded in one block.

7. Microscopy
Superficial strips of epidermis with surface hyperkeratosis and ulcerated
epidermis with the tumor cells infiltrating into the underlying dermis.
4x

8. Microscopy
Tumor cells are arranged in the form of nests, groups and trabeculae with cleft like spaces.
4x 10x

9. Microscopy
Tumor cells are arranged in the form of nests, groups and trabeculae with cleft like spaces.

10. Microscopy
Section studied shows
Superficial strips of epidermis with surface
hyperkeratosis and ulcerated epidermis with the
tumor cells infiltrating into the underlying dermis.
Tumor cells are arranged in the form of nests, groups
and trabeculae with the cleft like spaces.

11. Impression
Biopsy from growth over the left side of foot -
Infiltrating Malignant Melanoma – Nodular ulcerative
type.

12. PATIENT DETAILS
• Age/Sex : 67/Male
• Hospital OP/ IP No: A18011748
• Biopsy No: 561/18 to 563/18
• Date Of Receiving Specimen : 08/03/2018
• Clinical Diagnosis : Malignant Melanoma – Left Foot
• Nature of Specimen :
• Wide local excision of lesion with underlying
skin from plantar aspect of left foot.
• Superficial inguinal block dissection specimen.
• Deep inguinal and iliac nodes specimen.
.

13. Gross Examination
Received a skin flap measuring
9.5x6.5x1.5cm with a nodulo-
ulcerative hyperpigmented
lesion measuring 3.2 x 3cm.

14. Gross Examination
Cut section - The lesion is
round to oval with irregular
borders and is
• 1.2 cm from the closest
surgical margin,
• 4.2 cm from the farthest
margin
• 1 mm away from the deep
resected margin.

15. Gross Examination
Another hyperpigmented area is
seen 1.7 cm away from the
primary lesion and 2 cm away
from the farthest resected
margin.

16. Gross Examination
Also separately received a fatty
soft tissue portion measuring
4.5x3.5x1cm. External surface is
partly congested. No lymph
nodes identified.

17. Gross Examination
Received a container labelled superficial inguinal block
dissection specimen.
• Received a single fibrofatty tissue fragment
measuring 20x10x3cm. 23 lymph nodes were
identified with the largest lymph node measuring
2x1.5x1cm.

18. Gross Examination
Received a container labelled deep inguinal block
dissection specimen.
• Received four grey yellow fibrofatty tissue
fragments, largest fragment measuring 5.5x3.5x1cm
and the smallest fragment measuring 2x2x0.5cm.
Four lymph nodes were identified in which the
largest lymph node measures 2.5 x 1.3 x 1 cm.

19. Microscopy
4x
4x
Tumor cells seen upto
ulcerated epidermis

20. Microscopy
10x 40x
Large round to polygonal cells arranged in sheets, having amphophilic to clear cytoplasm
with enlarged vesicular nuclei having prominent nucleoli seen.

21. Microscopy
10x 40x
Spindle cells arranged in fascicles and bundles with nuclear pleomorphism seen.

22. Microscopy
10x 40x
Lymphovascular invasion seen.

23. Microscopy
10x 10x
Neurotropism seen

24. Microscopy
4x 10x
Tumor cells with abundant melanin pigment is seen in most of the areas.

25. Microscopy
4x 10x
40x
Tumor cells infiltrate
upto the subcutaneous
fat – Clarke Level V

26. Microscopy
4x 4x
Tumor cells on H & E Tumor cells after melanin bleach

27. Microscopy
10x 10x
Tumor cells on H & E Tumor cells after melanin bleach

28. Microscopy
40x 40x
Tumor cells on H & E Tumor cells after melanin bleach

29. Microscopy
4x 10x
40x
3 out of 23 superficial group
of lymph nodes are
infiltrated by tumor.

30. Microscopy
4x 10x
40x
1 out of 4 deep inguinal
group of lymph nodes
show extranodal fat
metastasis.

31. Microscopy
Section from tumor and tumor adjacent areas shows
tumor tissue lined by epidermis with large areas of
ulceration and covered with serofibrinous exudate.
Tumor cells are seen upto epidermis.

32. Microscopy
• Biphasic pattern of tumor cells are seen.
Large round to polygonal cells arranged in sheets,
having amphophilic to clear cytoplasm with
enlarged vesicular nuclei having prominent
nucleoli seen.
 Spindle cells arranged in fascicles and bundles
with nuclear pleomorphism seen.
Abundant melanin pigment is seen in most of the
areas. Tumor cells infiltrate upto the subcutaneous
fat.
• Neurotropism seen.
• Lymphovascular invasion seen.

33. Microscopy
Deep resected margin does not show tumor invasion
however lies in the same low power field of adjacent
tumor.
All resected margins and the closest resected margin
are all free of tumor.
Melanoma in situ component not seen in the
sections studied.
Associated melanocytic lesion not seen.
Sections studied from the hyperpigmentated lesion
away from the mass/growth are unremarkable.

34. Microscopy
3 out of 23 superficial inguinal group of lymph nodes
are infiltrated by tumor. One of them show perinodal
fat infiltration by tumor cells.
1 out of 4 deep inguinal group of lymph nodes show
extranodal fat metastasis.

35. Impression
• Malignant melanoma nodulo-ulcerative type. Clark
level – V.
• Neurotropism and lymphovascular invasion seen.
• Deep resected margin is very close and lies
in the same low power field of tumor.
• All the resected margins are free of tumor.
• Melanoma in situ component not seen.
• Associated melanocytic lesion not seen.

36. Impression
• 3 out of 23 superficial group of lymph nodes show
tumor metastasis.
• 1 out of 4 deep inguinal group of lymph nodes show
tumor metastasis.
• Totally, 4 out of 27 lymph nodes are positive for
tumor.

37. DISCUSSION

38. Differential Diagnosis
● Differentiation from melanocytic nevi is best achieved
using histologic criteria based on architectural and
cytologic features in concert with clinical features;
molecular methods hold some promise for the future.
● Spitz nevus versus spitzoid melanoma can be a challenge
to differentiate and perhaps impossible at times;
all Spitz and Spitz-like lesions require complete excision

39. Differential Diagnosis
• Malignant blue nevus
The architectural and cytologic features of nevi are
distinct from those of melanoma and include small
size, symmetry, circumscription, and evenly spaced
junctional nests.
Maturation of dermal nests is a helpful histologic
feature associated with nevi.

40. Special Stains and
Immunohistochemistry
• When a malignant neoplasm is poorly differentiated,
melanocytic markers such as S-100 protein and
HMB-45 may be useful in confirming the diagnosis of
melanoma

41. Prognostic Factors
Tumor stage
• The simpler staging system for melanoma divides it
into three stages (10 year survival rate):
I. localized disease (70 %)
II. regional cutaneous (satellite or in-transit)
metastasis or regional lymph node metastasis (less
than 20% )
III. distant metastasis. (less than 20% )

42. Prognostic Factors
Level of invasion

43. Prognostic Factors
Level of invasion
• In Clark’s system, melanomas are divided into five
levels of invasion along with the 5-year disease-free
survival after surgery
I. Intraepidermal (in situ).
II. In the papillary dermis. (100%).
III. Filling the papillary dermis and stopping at the
interphase between the papillary and reticular
dermis. (88%)
IV. In the reticular dermis (66%).
V. In the subcutaneous fat. (15%).

44. Prognostic Factors
Shape of the lesion
• Thus prognosis is related to the maximum tumor
elevation.
• worse for polypoid than for dome-shaped lesions.
Sex
• In one large series, the 5-year survival rate was
50.5% for males.
70.5% for females.

45. Prognostic Factors
Age
• younger age is associated with a more favorable
prognosis in males but not in females.

46. Prognostic Factors
Anatomic location
• high-risk sites: scalp, mandibular area, midline of
trunk, upper medial thighs, hands, feet, popliteal
fossae, and genitalia.
Clinicopathologic type
• better prognosis for melanoma arising in
Hutchinson freckle.
• intermediate prognosis for superficially spreading
melanoma
• worse prognosis for nodular melanoma.

47. Prognostic Factors
Cytologic features
• Whether the melanoma cells are spindle,
epithelioid, or any other shape seems to bear
no direct relationship to the prognosis.
Degree of pigmentation
• This feature does not seem to influence prognosis.

48. Prognostic Factors
Mitotic activity
– Tumor mitotic rate is a more powerful prognostic
indicator than ulceration.
Cell proliferative activity
– Melanomas have been stained for cell
proliferation markers such as MIB-1 (Ki-67) and
PCNA.
– Doubtful about its independent prognostic
information.

49. Prognostic Factors
Dermal inflammatory infiltrate
– a dense lymphocytic infiltrate around the melanoma is
associated with a better prognosis, particularly if the
lymphocytes are closely intermingled with the
neoplastic melanocytes (’tumor-infiltrating
lymphocytes’)
Ulceration
– The presence of ulceration however minimal has
emerged as one of the most important prognostic
determinators of the primary tumors.

50. Prognostic Factors
Regression
• presence of focal areas of regression in a
malignant melanoma may modify the significance
of the level or thickness of the residual tumor.
Staining pattern
• No consistent relationships have been detected
between any histochemical or
immunohistochemical staining patterns in
melanoma and prognosis.

51. Prognostic Factors
Angiotropism
– growth of melanoma cells along the external
surface of blood vessels.
– a predictor of local recurrence and in-transit
metastases.
Microscopic satellite
– tumor nests over 50 μm in diameter separate
from the main tumor mass.
– high association with regional lymph node
metastases and, therefore, with prognosis.

52. Prognostic Factors
Metastases to sentinel node
– Among cases with positive sentinel nodes, the
prognosis is related to the tumor burden and to
the presence of extranodal extension.
– metastases and micrometastases affect prognosis
adversely, whereas isolated HMB-45 or Melan-A-
positive cells apparently do not.
Preexisting benign nevus
– the prognosis of melanoma is significantly better
when the tumor had histologic evidence of a
coexisting acquired melanocytic nevus.