Primary dermal melanoma

Louise Photiou, The Victorian Melanoma Service, The Alfred Hospital, Vic, Melbourne, Australia; Nikki R Adler, St Vincent’s Hospital, Melbourne, Vic, Australia; Andrew Haydon, Department of Medical Oncology, Alfred Hospital, Melbourne, Vic, Australia; Catriona A. McLean, Department of Anatomical Pathology, Alfred Hospital, Melbourne, Vic, Australia; John W. Kelly, The Victorian Melanoma Service, The Alfred Hospital, Vic, Melbourne, Australia; Victoria J. Mar, The Victorian Melanoma Service, The Alfred Hospital, Vic, Melbourne, Australia. DermNet NZ Editor-in-Chief A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. November 2018.


What is primary dermal melanoma?

Primary dermal melanoma, also known as solitary dermal melanoma, represents melanoma confined to the dermis without an epidermal (junctional) component. It can sometimes be difficult to differentiate from a cutaneous melanoma metastasis [1].

Primary dermal melanoma has been proposed as a distinct subtype of melanoma due to the observation that these patients have a much better prognosis than those with a true cutaneous melanoma metastasis [2,3].

Who gets primary dermal melanoma?

Both men and women are at equal risk of developing a primary dermal melanoma. The average age at diagnosis is 51.2 years, within a range of 8–83 years [3]. No ethnicity data has been reported for primary dermal melanoma.

What are the clinical features of primary dermal melanoma?

Primary dermal melanoma may not be recognised as a melanoma and the classic ABCD rules for melanoma may not apply. It is usually the same colour as the skin and presents as an elevated, firm, growing nodule.

What are the complications of primary dermal melanoma?

The complications of primary dermal melanoma include recurrence and metastasis.

The incidence of recurrence and melanoma metastasis is low in published case series of patients with a presumed primary dermal melanoma [1–5].

How is primary dermal melanoma diagnosed?

The diagnosis of primary dermal melanoma is a difficult one and requires clinicopathological correlation. It is often difficult and sometimes impossible to distinguish between primary dermal melanoma and cutaneous metastasis histologically. A detailed medical history should be taken to exclude a previous melanoma that may have produced a cutaneous melanoma metastasis.

The pathologist will usually report a nodular melanoma without an in-situ or junctional component, and that it is contained entirely within the dermis. Regression and ulceration may be seen and can be attributed to prior trauma.

What is the differential diagnosis for primary dermal melanoma?

The differentiation mostly relies on the thorough clinical history of a growing lesion, examination findings, and clinicopathological correlation, and is very important as it confers significant prognostic and therapeutic implications. The most important differential for primary dermal melanoma is a cutaneous melanoma metastasis.

Most primary dermal melanomas do not look like typical melanomas and are usually excised with the provisional diagnosis of a basal cell carcinoma, squamous cell carcinoma, scar, dermatofibroma, cyst, blue naevus, or haemangioma [1–3].

What is the treatment for primary dermal melanoma?

As primary dermal melanoma is a cutaneous melanoma, the treatment should be as for any other cutaneous melanoma following the most current American Joint Committee on Cancer (AJCC) guidelines [4].

Patients with primary dermal melanoma should be given the opportunity to have a sentinel lymph node biopsy and be investigated appropriately for suspected distant disease with careful follow up.

It is also important to perform a full skin examination to exclude another primary cutaneous melanoma.

What is the outcome for primary dermal melanoma?

The importance of a correct diagnosis of primary dermal melanoma is linked directly to the observation that patients with primary dermal melanoma do well compared with other patients with melanoma. The current literature cites survival rates of 73–100% at 3–5 years [1,5], compared to a survival rate of 52% at 5 years for patients with a cutaneous melanoma metastasis [7].

Primary dermal melanoma may sometimes progress to metastatic melanoma.

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References

  1. Swetter SM, Ecker PM, Johnson DL, Harvell JD. Primary dermal melanoma: a distinct subtype of melanoma. Arch Dermatol 2004; 140(1): 99–103. PubMed
  2. Sidiropoulos M, Obregon R, Cooper C, Sholl LM, Guitart J, Gerami P. Primary dermal melanoma: a unique subtype of melanoma to be distinguished from cutaneous metastatic melanoma: a clinical, histologic, and gene expression-profiling study. J Am Acad Dermatol 2014; 71(6): 1083–92. PubMed
  3. Teow J, Chin O, Hanikeri M, Wood BA. Primary dermal melanoma: a West Australian cohort. ANZ J Surg 2015; 85(9): 664–7. PubMed
  4. Gershenwald JE, Scolyer RA, Hess KR, et al.Melanoma of the Skin.Amin M, Edge SB, Greene FL, et al. eds. AJCC Cancer Staging Manual. 8th ed. Switzerland: Springer; 2017:563–585.
  5. Lee CC, Faries MB, Ye X, Morton DL. Solitary dermal melanoma: beginning or end of the metastatic process? Ann Surg Oncol 2009; 16(3): 578–84. PubMed
  6. Bowen GM, Chang AE, Lowe L, Hamilton T, Patel R, Johnson TM. Solitary melanoma confined to the dermal and/or subcutaneous tissue: evidence for revisiting the staging classification. Arch Dermatol 2000; 136(11): 1397–9. PubMed
  7. Pan Y, Haydon AM, McLean CA, McDonald PB, Kelly JW. Prognosis associated with cutaneous melanoma metastases. Australas J Dermatol 2015; 56(1): 25–8. PubMed

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