Page 135 - TD-4-1

Tumor Discovery An ominous and rare variant of melanoma

through vascular and lymphatic invasion, making it one of protocol. Targeted therapies, such as BRAF and mitogen-
the most lethal forms of melanomas. While PM can affect activated protein kinase inhibitors, may become relevant
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younger patients and mucosal areas such as the vagina, in certain stages of the disease. In addition, systemic
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rectum, esophagus, and airway, skin involvement occurs therapy using programmed cell death protein 1 inhibitors
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in less than a third of patients, mostly commonly on the like pembrolizumab has shown promise for surgically
1
back. 2,4,6 Many definitions have been used to describe resected stage IIB or IIC melanoma, irrespective of
PM, but they generally converge on a set of common histopathological features such as subtype, ulceration, or
characteristics. Essentially, PM is characterized by an tumor thickness. 10
exophytic growth caused by an aggregation of melanoma Follow-up is mandatory for PM due to the tumor’s
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cells above the skin surface. More than 50% of the tumor ability to develop early local recurrence within 5 cm of
3,5
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is typically located on the cutaneous surface and is often the surgical scar. Although specific follow-up protocols
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accompanied by ulceration. If an endophytic component for PM are lacking, active surveillance criteria used for
2,6
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is present, it accounts for <50% of the total tumor depth. other melanoma types are often applied. This surveillance
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Notably, PM can be either pedunculated or sessile, with or includes follow-up visits every 3 months during the first
3
without pigmentation, and it usually lacks radial growth. 3 years and every 6 months thereafter. Early detection of
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2,4
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Instead, it typically demonstrates rapid vertical growth, metastases or local recurrence is facilitated through lymph
which is responsible for vascular embolism. 2
node ultrasonography, CT scans, and PET scans. 11
The diagnosis of PM is challenging due to its atypical The 5-year survival rate for PM ranges from 32%
presentation, which often does not follow the asymmetry, to 42%, significantly lower than the 57% observed in
border, color, diameter, and evolving rule but aligns non-PM cases. Given this poor prognosis, prevention and
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more with elevated, firm, and progressive growth (EFG ). early detection are paramount. A high index of suspicion is
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Its ability to mimic benign conditions such as pyogenic necessary when evaluating atypical presentations, such as
granuloma, intradermal nevus, fibroepithelial polyp, polypoid and amelanotic lesions, to ensure timely diagnosis
3,5
3,5
3
cutaneous metastasis, infectious disorders, other and treatment. Raising awareness among dermatologists
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5
benign lesions, skin cancers, and skin sarcomas makes and surgical oncologists is equally important. Moreover,
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its detection particularly difficult. Moreover, PM may educating patients about their diagnosis and risk factors
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appear either pigmented or non-pigmented, sessile enables practitioners to identify and address small, non-
or pedunculated, and its tendency to ulcerate further life-threatening lesions before they progress. Preventive
complicates diagnosis. These overlapping characteristics strategies, such as the use of regular sunscreen and
8
with benign or malignant conditions emphasize the need appropriate clothing for physical protection, are strongly
for heightened diagnostic suspicion to ensure timely recommended to prevent deoxyribonucleic acid (DNA)
identification.
damage associated with ultraviolet radiation. These
11
Histopathological analysis is essential for diagnosing measures contribute significantly to reducing melanoma
PM, revealing a higher degree of cellular atypia, cellular risk and improving patient outcomes.
and nuclear pleomorphism, a high mitotic index, and 9
significant Breslow depth. These factors, along with the rate Several challenges to PM diagnosis have been
of ulceration and presence of lymphovascular invasion, identified, including the lack of pigmentation in some
4
contribute to the poor prognosis of PM 2,5,6 compared lesions, the tumor’s similarity to benign and malignant
to other melanoma subtypes, as they are linked to the entities, limited awareness of this condition, and its
development of hidden metastases. 6 atypical clinical presentation, which often fails to meet the
ABCD or EFG criteria. These factors delay diagnosis and
Imaging, including positron emission tomography treatment, resulting in missed opportunities for timely
(PET) scans, computed tomography (CT) scans, and MRI intervention.
of the head, chest, abdomen, and pelvis, is crucial for
staging and detecting distant metastases in soft tissues, the 4. Conclusion
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brain, lungs, liver, and skin. PM represents a distinct risk factor in the evolving
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The cornerstone of treatment for PM is wide local landscape of melanoma management. A high level
resection, with a recommended 2 cm margin for lesions of clinical suspicion and a comprehensive diagnostic
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with a Breslow thickness of 2 mm or greater. This approach are essential for timely and effective treatment.
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procedure is typically combined with sentinel lymph Educating both practitioners and patients about atypical
node assessment to improve staging accuracy. Adjuvant melanoma presentations is vital for improving outcomes
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chemotherapy is also part of the standard treatment and minimizing diagnostic delays. Preventive measures,
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Volume 4 Issue 1 (2025) 127 doi: 10.36922/td.5105