24 January 2008 – Case of the Week #109
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We thank Drs. Angela Bohlke and Matthew Stark, Tulane University School of Medicine, Louisiana (USA), for contributing this case. To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and microscopic images in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) for your time after we send out the case. Please only send cases with a definitive diagnosis, and preferably cases that are out of the ordinary.
Case of the Week #109
A 58 year old Asian female presented with a 6 month history of post-menopausal bleeding. She denied any other complaints and was not on any medications. Physical exam was unremarkable. Ultrasound demonstrated a grossly abnormal uterus with an area of centrally increased echogenicity suspicious for endometrial cancer. She had an endometrial biopsy.
What is your diagnosis?
Undifferentiated malignant neoplasm suggestive of melanoma
The specimen shows markedly pleomorphic cells with abundant eosinophilic cytoplasm and frequent large eosinophilic nucleoli. There is a high mitotic rate and multiple areas of necrosis. No residual endometrial or cervical tissue is identified.
Immunohistochemistry confirmed the diagnosis of melanoma. The tumor cells were immunoreactive for MART1 and HMB45. There was moderate staining for S100. The tumor cells were essentially negative for keratins CAM5.2, CK7 and CK20, with only rare focal staining.
Melanoma of the uterus is very rare, either as a primary or metastatic tumor. Uterine metastases have been described from known primaries in the skin (Gynecol Oncol 2004;93:252), uvea (Pathol Oncol Res 2006;12:184) and hard palate (Can J Surg 2002;45:461). Melanoma has even been reported to metastasize to uterine polyps, including adenomyomas (Int J Surg Pathol 2005;13:223).
Some uterine melanomas may originate in the cervix, where they are also rare (see Cervix chapter). At both sites, prognosis is poor, whether the tumor is primary or secondary. Primary tumors may arise from lentigo or blue nevus, which have been reported at these sites (Diagn Gynecol Obstet 1981;3:269).
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