Case Letter
Primary melanoma of leptomeninge in a patient with giant congenital melanocytic nevus
Adriana Kamilly Leitão Pitman Machado
, Débora Bacellar Cruz Nunes, Francisca Regina Oliveira Carneiro, Alena Margareth Darwich Mendes
Corresponding author
Service of Dermatology, Universidade do Estado do Pará, Belém, PA, Brazil
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0 ] "pt" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta – Caso clínico</span>" "titulo" => "Melanoma primário de leptomeninge em paciente com nevo melanocítico congênito gigante" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "404" "paginaFinal" => "406" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1188 "Ancho" => 1583 "Tamanyo" => 476513 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Neoplasia formada pela proliferação de células atípicas com pigmento, infiltrava preferencialmente a meninge, em meio a 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"<span class="elsevierStyleTextfn">Case Letter</span>" "titulo" => "Primary melanoma of leptomeninge in a patient with giant congenital melanocytic nevus" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "404" "paginaFinal" => "406" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Adriana Kamilly Leitão Pitman Machado, Débora Bacellar Cruz Nunes, Francisca Regina Oliveira Carneiro, Alena Margareth Darwich Mendes" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Adriana Kamilly Leitão Pitman" "apellidos" => "Machado" "email" => array:1 [ 0 => "adriana_kamilly@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Débora Bacellar Cruz" "apellidos" => "Nunes" ] 2 => array:2 [ "nombre" => "Francisca Regina Oliveira" "apellidos" => "Carneiro" ] 3 => array:2 [ "nombre" => "Alena Margareth Darwich" "apellidos" => "Mendes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Service of Dermatology, Universidade do Estado do Pará, Belém, PA, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2141 "Ancho" => 1417 "Tamanyo" => 259547 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Giant congenital melanocytic nevus in garment with multiple satellite lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital Melanocytic Nevus (CMN) is characterized by pigmented lesions present at birth or in the first weeks of life. The Giant Congenital Melanocytic Nevus (GCMN) form presents a minimum extension of 20<span class="elsevierStyleHsp" style=""></span>cm in adult life and is rare (1:20,000 newborns). In addition to being an unsightly condition, giant CMN presents additional risks of extracutaneous morbidities such as neurological complications. A complicating factor is the presence of melanocytic cells in the Central Nervous System (CNS), a comorbidity called Neurocutaneous Melanosis (NCM).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of female patient, accompanied since the age of 2 years with GCMN in garment. In clinical follow-up, no neurological symptoms or changes in psychomotor development were detected. A brain Magnetic Resonance Imaging (MRI) confirmed the presence of T1-Weighted (W) images in the left parietal region, corresponding to neurocutaneous melanosis. The diagnosis was made upon typical imaging and skin findings.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dermatological examination revealed a brownish-black plaque, with evident hypertrichosis, extending from the cervical region to the knees, garment-like, with multiple satellite lesions on the face, upper and lower limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient had nodules on the back corresponding to schawannoma. At 10 years old, after loss of clinical follow-up for 3 years, she started a sudden onset of seizures, right hemisphere paresis, headache and vomiting.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Brain MRI scan demonstrated the presence of a single solid expansive lesion measuring 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm in the left fronto-parietal region, associated with an intense vasogenic edema, promoting midline deviation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Histopathology showed a neoplasm formed by the proliferation of atypical cells, containing granular brown pigment similar to melanin and with hyperchromatic, enlarged central nuclei with evident nucleoli, frequent atypical mitoses, preferentially infiltrating the meningeal but also the adjacent brain parenchyma, amid areas of necrosis and hemorrhage (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The immunohistochemical examination showed strong reactivity to the panel of antibodies S100, HBM45 and Melan A. Additional imaging studies showed no metastasis. The final diagnosis was primary melanoma of leptomeningeal. The patient died from intracranial hemorrhage followed by cardiorespiratory arrest four months after diagnosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Primary CNS melanoma is a rare disease. It represents 1% of melanomas and approximately 0.05% of primary malignancies of cranial tumors. These can be divided into nodular intraparenchymal and diffuse leptomeningeal patterns.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Primary leptomeningel Malignant Melanoma (MM) is extremely rare, with an incidence of one case per 20 million individuals, generally showing aggressive progression and resistance to chemotherapy and radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The risk of estimated lifetime MM-all sites for individuals with CMN is around 5%, with increased risk to 12% in patients with neurocutaneous melanosis. This is characterized by the migration and erroneous proliferation of melanocytic cells in the CNS from neural crest melanoblasts.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">NCM involves several additional comorbidities which include hydrocephalus, convulsions, cranial nerve palsy, neuropsychiatric disorders and the risk of malignant degeneration of the cells. Mortality rate is close to 100% for CNS MM cases and 70% of patients with neurocutaneous melanosis will die before 10 years of age.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This aggressive entity found within the context of CMN is due to a different biological behavior with the presence of somatic mutations in 81% of cases in the NRAS gene of the melanocytes, in detriment of the mutations BRAF, demonstrating that they are genetically different from nevi developed after birth and an important risk factor for primary CNS and cutaneous melanoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">NRAS-mutant tumors tend to behave more aggressively particularly in early stages of the disease. In view of this differential genetic behavior, target therapies have been investigated for CNS melanoma in patients with CMN and the proven mutation of the protoncogene NRAS. Initial studies have demonstrated results of MEK inhibitors, Trametinib, in symptom control and improved quality of life, an important step in the discovery of treatment for this condition.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Evidence indicates a higher incidence of this neoplasm in patients presenting multiple satellite lesions, such as the pattern in garment-like, and/or paravertebral or axial location.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">CNS melanoma currently emerges as the major limiting prognostic factor in children with CMN. In this scenario, cutaneous melanoma plays a less decisive role, influencing the decision toward prophylactic surgical excision. Brain MRI is important in this scenario, which should preferably be performed in the first year of life, since the incidence of CNS and cutaneous MM in the group with altered examination is 12%, as opposed to MM incidence of 1% in the group with normal CNS MRI at birth. The clinical follow-up of patients with altered MRI examinations should be annual.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Adriana Kamilly Leitão Pitman Machado: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Débora Bacellar Cruz Nunes: Elaboration and writing of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Francisca Regina Oliveira Carneiro: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Alena Margareth Darwich Mendes: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "xack473886" "titulo" => "Acknowledgment" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-09-19" "fechaAceptado" => "2019-11-05" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Machado AKLP, Nunes DBC, Carneiro FRO, Mendes AMD. Primary melanoma of leptomeninge in a patient with giant congenital melanocytic nevus. An Bras Dermatol. 2020;95:406–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Service of Dermatology, Universidade do Estado do Pará, Belém, PA, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2141 "Ancho" => 1417 "Tamanyo" => 259547 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Giant congenital melanocytic nevus in garment with multiple satellite lesions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1567 "Ancho" => 1336 "Tamanyo" => 129145 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presence of a single solid expansive lesion measuring 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm in the left fronto-parietal region, associated with an intense vasogenic edema, promoting midline deviation.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1188 "Ancho" => 1583 "Tamanyo" => 476513 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Neoplasm formed by the proliferation of atypical cells containing pigment preferentially infiltrating the meningeal but also the adjacent brain parenchyma, amid areas of necrosis and hemorrhage (Hematoxylin & eosin, ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective study of patients with large congenital melanocytic nevi and the risk of melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.C.L. Viana" 1 => "E.M.A. Goulart" 2 => "B. Gontijo" 3 => "F.V. Bittencourt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/abd1806-4841.20175176" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2017" "volumen" => "92" "paginaInicial" => "200" "paginaFinal" => "205" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28538879" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary central nervous system malignant melanoma with lep tomeningeal melanomatosis: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Fujimori" 1 => "K. Sakai" 2 => "F. Higashiyama" 3 => "F. Oya" 4 => "T. Maejima" 5 => "T. 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Rodriguez-Peralto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/DAD.0000000000001039" "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2018" "volumen" => "40" "paginaInicial" => "506" "paginaFinal" => "510" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29077579" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MEK inhibition appears to improve symptom control in primary NRAS-driven CNS melanoma in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "V.A. Kinsler" 1 => "P. O’Hare" 2 => "T. Jacques" 3 => "D. Hargrave" 4 => "O. Slater" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/bjc.2017.49" "Revista" => array:6 [ "tituloSerie" => "Br J Cancer" "fecha" => "2017" "volumen" => "116" "paginaInicial" => "990" "paginaFinal" => "993" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28253523" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack473886" "titulo" => "Acknowledgment" "texto" => "<p id="par0095" class="elsevierStylePara elsevierViewall">To Service of Dermatology/UEPA.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000003/v4_202007210853/S0365059620300714/v4_202007210853/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000003/v4_202007210853/S0365059620300714/v4_202007210853/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300714?idApp=UINPBA00008Z" ]
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| 2024 July | 141 | 127 | 268 |
| 2024 June | 130 | 72 | 202 |
| 2024 May | 91 | 52 | 143 |
| 2024 April | 95 | 80 | 175 |
| 2024 March | 78 | 53 | 131 |
| 2024 February | 84 | 74 | 158 |
| 2024 January | 62 | 48 | 110 |
| 2023 December | 53 | 55 | 108 |
| 2023 November | 84 | 68 | 152 |
| 2023 October | 66 | 65 | 131 |
| 2023 September | 77 | 64 | 141 |
| 2023 August | 62 | 38 | 100 |
| 2023 July | 62 | 35 | 97 |
| 2023 June | 80 | 34 | 114 |
| 2023 May | 67 | 21 | 88 |
| 2023 April | 62 | 22 | 84 |
| 2023 March | 69 | 47 | 116 |
| 2023 February | 77 | 36 | 113 |
| 2023 January | 57 | 43 | 100 |
| 2022 December | 78 | 33 | 111 |
| 2022 November | 99 | 47 | 146 |
| 2022 October | 94 | 63 | 157 |
| 2022 September | 102 | 53 | 155 |
| 2022 August | 86 | 55 | 141 |
| 2022 July | 71 | 43 | 114 |
| 2022 June | 71 | 54 | 125 |
| 2022 May | 50 | 45 | 95 |
| 2022 April | 71 | 59 | 130 |
| 2022 March | 68 | 76 | 144 |
| 2022 February | 53 | 40 | 93 |
| 2022 January | 61 | 78 | 139 |
| 2021 December | 38 | 50 | 88 |
| 2021 November | 66 | 55 | 121 |
| 2021 October | 63 | 77 | 140 |
| 2021 September | 58 | 50 | 108 |
| 2021 August | 61 | 58 | 119 |
| 2021 July | 38 | 34 | 72 |
| 2021 June | 34 | 44 | 78 |
| 2021 May | 50 | 78 | 128 |
| 2021 April | 106 | 181 | 287 |
| 2021 March | 65 | 55 | 120 |
| 2021 February | 19 | 17 | 36 |
| 2021 January | 36 | 17 | 53 |
| 2020 December | 32 | 14 | 46 |
| 2020 November | 36 | 15 | 51 |
| 2020 October | 55 | 8 | 63 |
| 2020 September | 31 | 13 | 44 |
| 2020 August | 12 | 6 | 18 |
| 2020 July | 33 | 12 | 45 |
| 2020 June | 13 | 10 | 23 |
| 2020 May | 17 | 9 | 26 |
| 2020 April | 0 | 4 | 4 |
Show all
