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Multiple haemorrhagic-like cutaneous metastasis of malignant melanoma

European Journal of Dermatology. Volume 15, Number 5, 409-10, September-October 2005, Clinical report

Summary

Author(s) : Olivier Dereure, Véronique Blatiere, Bernard Guillot , Department of dermatology, University Hospital of Montpellier, Hôpital Saint-Eloi, 80 avenue A. Fliche, 34295 Montpellier Cedex 5 France.

Summary : Ctaneous metastasis of malignant melanoma usually presents as pigmented or non-pigmented, sometimes angiomatous nodules of various sizes. However, we recently observed a further example of haemorrhagic-like cutaneous metastasis, a quite infrequent clinical pattern, remarkable for the multiplicity of lesions.

Keywords : cutaneous metastasis, haemorrhagic, melanoma

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ARTICLE

Auteur(s) : Olivier Dereure, Véronique Blatiere, Bernard Guillot

Department of dermatology, University Hospital of Montpellier, Hôpital Saint-Eloi, 80 avenue A. Fliche, 34295 Montpellier Cedex 5 France

accepté le 27 Novembre 2004

A 32-year-old white woman was diagnosed with a superficial spreading melanoma of the right buttock in 1998 (Breslow 1.57 mm; Clark III; no sentinel node biopsy performed at the time of primary lesion excision), followed by complete inguinal lymph node dissection in 2001 because of regional recurrence. Two months after this surgery, numerous well-limited hematoma-like areas spontaneously appeared on the left breast, chest, abdominal wall and upper limbs quickly followed by local swelling and pain. Clinical examination then revealed more than 10 cutaneous lumps ranging in size from 5mm to more than 4 cm in diameter, all of them painful and displaying a superficial, sometimes annular, haemorrhagic-like pattern at different stages of local biligenia ( (figure 1) ). Surgical removal of one of these haemorrhagic lesions confirmed the diagnosis of cutaneous metastasis, but without any significant histological pattern of haemorrhage or vascular proliferation, in spite of the clinical features, and the surrounding tissues were otherwise unremarkable; haemosiderin deposits were notably absent in histological samples. Standard haemostasis tests (platelet count, fibrinogen, activated cephalin time, prothrombin time) were normal. Chemotherapy with dacarbazine was then initiated with a significant size reduction of the larger lesions and a complete disappearance of the smallest ones. The outcome was unfortunately marked by brain, lung and liver metastasis and further recurrence of subcutaneous secondary lesions displaying a similar haemorrhagic pattern in most cases.

Discussion

A haemorrhagic-like pattern in cutaneous metastasis of malignant melanoma seems to be a very infrequent event since it has only been reported once in the international literature [1] although its real frequency might be higher and underestimated by a lack of systematic reports. Our patient differs slightly from Török’s observation by the multiplicity of the cutaneous haemorrhagic lesions and by the lack of a triggering factor such as physical exercise. The mechanisms underlying the occurrence of this unusual clinical picture are unknown. It might be related to an anarchical and particularly fragile neo-vascularization of some metastasis leading to spontaneous bleeding for minor physical exercise or traumatisms such as gentle rubbing of these lesions due to their lump-like pattern. However, this hypothesis raised by Török was not supported by our patient’s history, since haemorrhagic lesions occurred spontaneously (whereas it followed minor physical exercise in Török’s case) nor by histological features, in both Török’s case and our observation. No haemostasis impairment was present in our patient according to standard tests and she did not experience any other haemorrhagic complication. A rapid increase in the size of metastasis might instead favour the development of superficial haemorrhages as in our patient, who experienced a quick occurrence of cutaneous secondary lesions. Finally it is of interest to point out that a similar target-like, haemorrhagic-like pattern has already been reported in cutaneous metastasis of other malignancies [2]. Such reports make it all the more important to thoroughly investigate any spontaneous cutaneous haemorrhagic, hematoma-like lesions occurring in patients with malignancies, to rule out the possibility of an atypical secondary lesion, even in the absence of significant skin infiltration which can appear later.

References

1 Török L, Kirschner A, Ocsay H, Olasz K. Hematoma-like metastasis in melanoma. J Am Acad Dermatol 2003; 49: 912-3.

2 Dereure O, Guilhou JJ, Guillot B. A new clinical pattern of cutaneous metastasis: target-like lesions. Br J Dermatol 2003; 148: 361.