11/21/2016IntroductionMUCOSAL MELANOMA AND PIGMENTED LESIONS OFMUCOSAL SURFACESAdriano Piris, M.D.Co-Director – Mihm Cutaneous PathologyConsultative Service (MCPCS)Brigham and Women’s Hospital, HarvardMedical School Mucosal melanoma as different biological entitythan cutaneous melanomag of diagnosisg Rarityy of disease and timingprecludes significant studies to standardizestaging and managementStewart Rahr-MRA Young Investigator:Melanoma Research Alliance, Washington,DCMucosal melanoma diagnosisDiagnosis: Invasive mucosal melanoma Mucosal lentigo (melanosis) Benign mucosal melanocytic proliferation:junctional or compound nevusnevus, blue nevus Atypical melanocytic hyperplasia Melanoma in situ Invasive Melanoma Malignant “pigmented” nodule Rule out metastatic disease: Clinical history andpidentification of an in situ component Small samples: no obvious in situ component Examination of adjacent uninvolved mucosa iscrucialDiagnosis: Invasive mucosal melanomaMucosal melanoma: in situ component Amelanotic nodule: Undifferentiated or sarcomatoid proliferation First: establish the melanocytic nature of thetumor (Immunohistochemistry)- S100, HMB45,Melan-A, Mart-1, and MitF Second: Identify in situ component Confluent growth of lentiginous and nestedintraepidermal melanocytes with atypicalfeatures Emphasisp as s oof lentiginouse g ous ggrowthowith insidiouss d ousand multifocal pattern, extending alongunderlying native glandular units These “precursor” lesions may be subtle and notreadily visualized with H&E only. Melanocytic markers are crucial to identify insitu/precursor lesions and extent of disease1

11/21/2016Pathological Evaluation of the Tumor Tumor thickness correlates with survival 2.0 mm or less better prognosis Due to late diagnosis most lesions are usuallythicker than 2.0 mm AJCC histomorphological criteria (fromcutaneous melanoma) have not been validatedEvaluation of Local Disease A: Established primary mucosal melanoma B: Extent of local disease: CT or MRI C: Basic metastatic workup: serum lactatedehydrogenase, chest x-ray, combined PET/CTscanning of chest, abdomen, and pelvisSites of origin(Clinical) Evaluation of Extent of Disease Clinical staging system for cutaneous diseaseapplied to mucosal melanomas Stage I: Localized disease Stage II: Regional lymph node disease Stage III: Disseminated diseasePrimary mucosal melanoma of the sinonasal tract: a clinicopathologicand immunohistochemicalstudy of thirty-two cases.Mark C. Mochel, MD, Lyn M. Duncan, MD, Adriano Piris, MD, andStefan Kraft, MD*Pathology Service, Massachusetts General Hospital, Harvard MedicalSchool, Boston, MA,USA 02114,USA,02114 *now at Institute of Pathology, University Medical Center HamburgEppendorf,Hamburg, Germany Respiratory mucosaOral cavityEsophagusGenital mucosal surfacesGastrointestinal mucosaUrinary tractAuditory canalConjunctivaSinonasal mucosal melanoma Rare disease with poor survival Poorly characterized early/precursor lesions Retrospective analysis found 31 of 32 patientswith associated intraepidermal melanocyticproliferationsHead and Neck Pathology, in print2

11/21/2016Sinonasal mucosal melanoma Age: 30-90 years (median 71)M-F ratio 3:2Follow upp ((31 ppts):) 5 to 211 months ((mean 42))58% died of melanoma associated conditions19% died of unknown causes6% alive with metastatic disease19% alive without melanomaSinonasal mucosal melanoma MMIS (confluent intraepithelial proliferation ofcytologically atypical melanocytes): 67% ofcases, confirmed by MITF Melanocytic hyperplasia (intraepithelialmelanocytic proliferation without confluentgrowth or atypia): 16% (5 cases) Overall incidence of associated intraepidermalmelanocytic proliferations: 83%Characteristics of the invasive component Determination of accurate tumor thickness wasnot possible in the majority of cases due tofragmentation of the specimen In 7 specimens: 0.3 to 15.0 mm Morphology: epithelioid, spindled, and small cellmorphology Presence of 3 mitoses/mm2 and necrosiscorrelated with tumor progression and overallsurvivalSingle atypical melanocytesH&EAtypical melanocytichyperplasia3

11/21/2016Hyperplasia and atypia, notMMISMochel et al: Melanocytes within sinonasalmucosa Negative control: sinonasal mucosaremoved for rhinosinusitis No intraepithelial melanocytes found inthese negative controls Identification of melanocytic hyperplasiawithin the context of “melanosis” insinonasal mucosa should raise theconcern of a precursor lesion.MMIS, resp. epitheliumEasy to miss MMIS4

11/21/2016MITF extensive MMISMMIS in resp epitheliumMITFExtensive gland involvementInvasive componentEpithelioid cell with central necrosis5

11/21/2016Small round cellSpindle cell fascicularMelanomamimics in themucosalsurfaceFreckles Lentigines and MelanosesFreckles,6

11/21/2016The Freckles, lentigines, and melanoses Not classified as a form of precancerousmelanocytic proliferation Their recognition is important because :Peutz-Jeghers Syndrome:macules on lips buccalmucosa– clinicalli i l appearance resembesb melanomal– Multiple lentigines/ melanoses may be asign of a systemic disease associated withnon-melanocytic cancers.Labial melanotic macule CLINICAL FEATURES– Classically lower lip on or just off midline– Similar lesions anywhere in oropharynx– Identical lesions in the genital mucosae are termed vulvar andpenile melanosis HISTOLOGY– Slight epithelial hyperplasia; parakeratosis– Increased numbers of banal melanocytes with dendriticmorphology; basilar hyperpigmentation– Melanophages in stroma7

11/21/2016Atypical melanocytes in squamousmucosa: NOT melanosisThe genital melanocytic proliferations: mainforms Mucosal lentigoVulvar melanosisCommon acquired nevusDysplastic nevusMalignant melanomaVulvar Melanosis Clinically presents as a solitary (up to or severalcentimeters in size) or multiple intenselypigmented macule(s); similar phenomenon onpenis is called penile melanosismelanosis. Clinical differential diagnosis: radial growthphase mucosal LMM, patch type bowenoidpapulosis, and pigmented Bowen’s disease8

11/21/2016Vulvar Melanosis :Histomorphology HypermelanosisMild increase in number of basilar melanocytesAcanthosisNo melanocytic atypiaDifferential diagnosis: atypical lentiginousmelanocytic hyperplasia (precursor lesion tomelanoma)Mucosal Lentigo From Simulators of Malignant MelanomaDrs. Kerl and Cerroni, University of GrazAtypical melanocytes in squamousmucosa: NOT melanosisCervico-vaginal invasivemelanoma: Case 19


11/21/2016Vulvo-urethral invasive melanoma:Case 2Malignant melanoma of anorectal region: a clinicopathologic study of61 casesMuhammad Usman Tariq, Nasir Ud Din, Nausheen Feroz Ud Din, Saira Fatima, and Zubair AhmadAnnals of Diagnostic Pathology, 2014‐10‐01, Volume 18, Issue 5, Pages 275‐281Copyright 2014 Elsevier Inc.11

11/21/2016Ano-rectal Mucosal MelanomaAno-rectal Mucosal MelanomaCutaneous Malignant MelanomaAnorectal melanoma Superficial Spreading Melanoma Expression of vimentin, S-100, HMB-45,and Melan A in 100%, 100%, 94.4%, and93.3% cases, respectively. Cytokeratins were positive in 9% andCD117 (c-kit) in 20% of cases in whichthey were performed. All cases were BRAF negativeBRAF/NRAS Acral Lentiginous MelanomaCKIT Lentigo Maligna MelanomaCKITChronic Sun Damage (CSD) Nodular Melanoma?BRAF/NRASMucosal Malignant Melanoma: CKITPigmented Lesions of the ConjunctivaTypes of Non-MelanocyticOcular PigmentationScleral Diseases Blue ScleraStaphylomaScleromalaciaSenile hyaline plaqueMetabolic Disorders Ochronosis Gaucher’s disease Jaundice12

11/21/2016Benign EpithelialPigmented Tumors Pigmented seborrheic keratosisBenign squamous papillomaVerruca vulgarisPigmented eccrine poromaOphthalmic Pathology Describes MelanocyticLesions to Arise from 3 Types of Melanocytes1. Intraepithelial melanocytes that lie among the basal epithelial cells andmay show dendritic processes between keratinocytes2. Nevus cells- oval cells that form nests and sheets at the epidermaldermal or epithelial-subepithelial junction3. Fusiform dendritic melanocytes that lie in the deeper mesenchymalor subepithelial tissueCongenital Melanosis BenignEpithelial Melanosis - Clinical1. Patchy flat brown pigmentation of conjunctival epithelium2. Associated with skin color3 U3.Usuallyll bilbilateralt l non-inflamedi fld non-vascularizedl i d andd stationaryt ti4. Most common in limbal area and may advance to caruncle5. May advance onto cornea after surgery or trauma- streaks and swirls6. Usually congenital may be acquired in african-americansConjunctival NeviGGenerall ClinicalCli i l ConsiderationsCid ti Single most common site- juxta-limbal followed byepibulbar, the plica, and caruncle May be focal or diffuse but not multifocal13

11/21/2016Pigmented Lesions of the ConjunctivaNevi most unusual in palpebral orforniceal conjunctiva, suspect melanomaAll bulbar nevi freely movable with Q tiptraction unless hinged at limbus-if hinged and immovable, suspectmelanomaCommon Acquired NeviAll palpebral nevus-like lesions should bebiopsiedConjunctival nevi do not extend onto thecornea-if observed probably melanoma1. Junctional- Type A cells in nests2. Compound –Intraepithelial and substantia propria proliferation- subepithelial cells have a “lymphocytoid” appearance and are notmelanized in deeper component3. Subepithelial – May show type C cell proliferation4. Blue nevi– Characteristic dendritic cells.5. 40% of conjunctival nevi have a combined element, often very focalCommon Acquired Nevi6. Downward protrusion of small solid pegs of epithelium is typical forsub epithelial nevi7. Epithelium- lined cysts multiple and diffuse are characteristic forbenign sub epithelial nevi8. Balloon cells and spindle cells may be found in conjunctival nevi9. Blue neviCharacteristic dendritic cells.14

11/21/2016Junctional Nevus in a 7 year old boyCourtesy of Dr. Frederick A. Jakobiec. 201415

11/21/2016Combined Nevi 40% of a series of 95 conjunctival nevi hada combined element (personal series) The combined component varied from ablue nevus to a deep penetrating nevus In most instances, the combined aspectwas very small but rarely accounted formost of the nevus These lesions are benign16

11/21/2016COMPOUND NEVUS OF SPITZSub-epithelial Melanocytes andAssociated Lesions-Scleral Dendritic1. Blue nevus2. Cellular blue nevus3. Occulodermal melanocytosisBlue Nevus17

11/21/2016Oculodermal Melanocytes (Ota)Clinical1. Ipsilateral pigmentation of periocular skin along withmelanosis oculi2. Periorbital skin may be brown, slate or bluish3 Pigment3.Pitddeep tto conjunctivajti anddddoesn’t’t move withith Q titiptraction in contrast to benign epithelial melanosis4. Most common in Blacks and Asians5. Low risk of uveal or orbital melanomaAcquired Melanosis of theConjunctiva1. Benign epithelial melanosis of conjunctiva- congenital2 P2.Primaryiacquiredi d melanosisli offconjunctiva3. Secondary acquired melanosis ofconjunctivaJakobiec, F.A et al. Clinicopathologic Characteristics of Premalignant and Malignant Melanocytic Lesions of the Conjunctiva.Ophthalmology 96:147-166; 198918

11/21/2016PRIMARY ACQUIREDMELANOSISDefinition accepted by World Health Organization (WHO)1. Lesion is primary because not the result of racial, metabolic or localt i l ffactorstopicalt2. Acquired – not congenital3. Melanosis – due to melanin productionPrimary Acquired MelanosisClinical FlatBrown (golden brown to chocolate)May involve corneay involve anyy aspectpof conjunctivajincludingg tarsal conjunctiva,j,Mayfornix and caruncleMay be multipleAlmost always unilateral.May extend across lid margin into epidermis.May “shrink”, progress or remain stable for prolonged periods.Occurs in middle-aged or elderly, usually white patients (rare inblacks).19

11/21/2016PAM HistologyNormal ConjunctivaPAM 1without atypia (overproduction of Melanin with hyperplasia)Hyperplasia of benign melanocytes confined tobasilar epithelium( not considered premalignant)PAM 2with atypiaExamine for epithelioid cells and pattern of growthCourtesy of Dr. Frederick A. Jakobiec. 2014Primary Acquired Melanosis with Mild AtypiaPAM without atypia – there is an increased number of melanocytesCourtesy of Dr. Frederick A. Jakobiec. 2014Primary Acquired Melanosis with Moderate AtypiaPAM with mild atypia – there is an increased number of basal melanocytes andsome scattered higher level dendritic melanocytesCourtesy of Dr. Frederick A. Jakobiec. 2014Primary Acquired Melanosis with Severe AtypiaPAM with severe atypia – there are numerous large dendritic melanocytesPAM with moderate-to-severe atypia – there are large dendritic melanocytesCourtesy of Dr. Frederick A. Jakobiec. 2014Courtesy of Dr. Frederick A. Jakobiec. 201420

11/21/2016Malignant melanoma of theConjunctiva1. Melanoma with PAM (75%)2. Melanoma without PAM (25%)Note: 25% of all lesions have evidence of preexisting nevus3. Overall mortality – 25% of all typesMalignant Melanoma of theConjunctiva Risk Factors– Predominantly caucasians– Older age (average age 52-53 years)– PrePre-existingexisting Primary Acquired Melanosis (PAM) give riseto 60% of conjunctival melanoma– Rarely associated with a pre-existing nevus– History of extensive sunlight exposureJovanovic P. et al. Int J Clin Exp Pathol. 2013Malignant Melanoma of theConjunctiva Symptoms and Clinical Features––––5-10% of all ocular melanomasAverage age 52-53 yearsEqual sex incidenceM t common complaintMostl i t iis a pigmentedit d spott or nodule;d lirritation and pain less common– Location: Bulbar conjunctiva (92%) Temporal quadrant (63%) Touching limbus (61%)– Pigmented lesion in the palpebral, forniceal conjunctiva,plica semilunaris, and caruncula are prima facie melanomaFarber M. et al. JAAD. 1998Griewank KG et al. Clin Cancer Res. 2013Jovanovic P. et al. Int J Clin Exp Pathol . 2013Malignant Melanoma of theConjunctiva Symptoms and Clinical Features– Melanoma without PAM is solitary nodule– Early invasion in PAM may be associated with a plaque– Anyy pigmentedpglesion surrounded byy numerous vessels shouldbe biopsied– Rarely the lesion is non-pigmented and the multiple vessels area clue– Multiple lesions common 33%– Local recurrence 26% at five years; 51% at 10 years– Mortality 38% at 10 yearsGriewank KG et al. Clin Cancer Res. 2013Jovanovic P. et al. Int J Clin Exp Pathol . 201321

11/21/2016Malignant Melanoma of theConjunctiva Histopathology– Most lesions exhibit radial growth extending beyond the invasivecomponent.– Pattern most commonly pagetoid but lentiginous variants occur(lentigo maligna can extend into the epithelium)– Invasive component can be spindled, small cell, epithelioid ormixed.– Mitoses frequent; greater than 5 per 10 hpf associated with highrisk of metastases.– Thickness 2mm. High risk of metastasis.– Lymphatic invasion. High risk of metastases.– Tils: absence retlated to high risk of metasases.Zembowicz,A et al. Arch Pathol Lab Med. 2010Griewank KG et al. Clin Cancer Res. 2013Jovanovic P. et al. Int J Clin Exp Pathol . 2013Clinical PathologicCorrelations of MutationsMalignant Melanoma of theConjunctiva Prognosis Location:– Palpebral conjunctiva, fornices, plica, caruncula, and lid margins:– Caruncle – BRAF 66% ; NRAS 0% ; Wild Type 33% Higher mortality than epibulbar Higher risk for local recurrence Higher risk for distant metastases Pathology:– Pre-existing nevus – BRAF 65% ; NRAS 27% ; WildType 8% No other clinical pathologic correlations found,including relationship to mitoses, metastases,and disease free or overall survival.Griewank KG et al. Clin Cancer Res. 2013Jovanovic P. et al. Int J Clin Exp Pathol. 2013– Thickness 2 mm. associated with high risk of metastasis anddeath– Cell type: Mixed type 3x higher mortality than spindle cells Pure spindle cells excellent survival––––Positive margins predict higher risk of recurrenceLymphatic invasion: 4x higher mortalityDe novo melanoma 35% mortality at 10 yearsMelanoma in PAM 9% mortality at 10 yearsJovanovic P. et al. Int J Clin Exp Pathol . 201322

11/21/2016Activating Mutations inConjunctival Melanoma BRAF - 29% (V600E 21%)NRAS - 18%Wild Type - 53%c-KitKi - 0% (15%(1 % showedhd non-activatingi i mutations)i) PTEN (Chromosome 10) loss commonly found inassociation with BRAF and usually with NRAS –Activation of AKT pathwayTreatment of ConjunctivalMelanoma Griewank KG et al. Clin Cancer Res. 2013Melanoma with PAM easily confused with nevus. Any lesion that changesshould be removedAny pigmented lesion extending on to the cornea should be excisedPrimary: Wide local excision– Adjuvant Therapy: Brachytherapy, cryotherapy, mitomysinMultiple lesions and/or multiple recurrences:– Mitomysin or brachytherapy primarilyExenteration: Reserved for extensive wide-spread recurrences or invasionof scleraSentinel Lymph Node Biopsy: (Preliminary Results)– Performed for tumors 2mm. In thickness or with ulceration or mitoses 5 per 10 hpfGriewank KG et al. Clin Cancer Res. 2013Jovanovic P. et al. Int J Clin Exp Pathol. 2013Cohen VML. Br J OphthalmolAcknowledgmentsMartin C. Mihm Jr., MDFrederick A. Jakobiec, MDCynthia Magro, MD23

Pathology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 02114USA, 02114, * now at Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Head and Neck Pathology, in print Sinonasal mucosal melanoma Rare disease with poor survival Poorly characterized early/precursor lesions