Portal de Periódicos da CAPES

To the Editor

2006; Lippincott Williams & Wilkins; Volume: 28; Issue: 5 Linguagem: Inglês

10.1097/01.dad.0000210390.36724.0b

1533-0311

Harleen Sidhu, Jagmohan S. Sidhu,

Sarcoma Diagnosis and Treatment

To the Editor: We have read with great interest the article from A. S. Boyd, H. Wu, and Y. Shyr1 on: Monster cells in malignant melanoma. Around the time this article was published, we came across a case of ileal malignant melanoma with a very high content of "monster" cells in an HIV-positive 48-year-old man with an absolute CD4 count of 196/mL (reference range: 430 to 1760/mL). The melanoma was detected as a lead point in the intussusception of distal ileum, and was located at a distance of about 63 cm from the ileocecal valve. There was only one lesion in the resected specimen of distal ileum, appendix, and proximal colon with numerous involved regional lymph nodes. Histologic examination showed malignant cells with a high content of monster cells (Fig. 1) and melanin in the malignant cells. Immunohistochemical positivity for S-100 protein (Fig. 2), HMB-45 (Fig. 3), and vimentin in the tumor cells supported the diagnosis of malignant melanoma. There was no previous history of cutaneous, oral, subungual, anal canal, or ocular melanoma. A very thorough physical examination revealed only one cutaneous lesion. This was present on the right, lower leg and was completely excised. It turned out to be a dermatofibroma on histologic and immunohistochemical examination (factor XIIIA positivity and CD34 negativity). No ocular, oral, subungual, or anal canal lesions were seen. A PET scan helped detection of multiple enlarged lymph nodes in both axillae and in the retroperitoneum. An excised axillary lymph node also showed malignant melanoma with a high content of monster cells. Dermatofibromas with monster cells have also been described in the literature.2 In our case, the dermatofibroma did not show any monster cells or large cells.FIGURE 1: Monster cells (H & E; x 400).FIGURE 2: Monster cells (S-100; x 400).FIGURE 3: Monster cells (HMB 45; x 400).We propose naming a melanoma with monster cells as monstrocellular melanoma because this morphology could indicate a very aggressive variant. A. S. Boyd, H. Wu, and Y. Shyr have also suggested the association of this morphology with aggressive behavior.1 We would also like to make a brief comment about the ileal location of our melanoma. Is this melanoma in the ileum a primary ileal melanoma or a metastatic melanoma to the ileum? Absence of any other primary and the location of this lesion about 63 cm away from the ileocecal valve does support this tumor being a primary melanoma, most probably arising from the melanoblastic cells of the neural crest which migrate to the ileum (or to the Meckel diverticulum) through the omphalomesenteric canal.3 No elements of Meckel diverticulum were identified in our case. Harleen K. Sidhu, MS4* Jagmohan S. Sidhu, MD† *Royal College of Surgeons in Ireland 123 St Stephen's Green Dublin 2, Ireland †Department of Pathology United Health Services Hospitals 33-57 Harrison Street Johnson City, NY 13790