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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 188-191

A “Grey Swan” malignant melanoma: Implantation metastasis on the skin graft donor site


1 Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Medical School, Adana, Turkey
2 Department of Pathology, Cukurova University Medical School, Adana, Turkey

Date of Submission29-Jun-2019
Date of Acceptance15-Oct-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Ahmet Umut Yuvaci
Cukurova University Faculty of Medicine Plastic, Reconstructive and Aesthetic Surgery Clinic, 01380 Saricam, Adana
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_60_19

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  Abstract 


We report a 67-year-old male presented with recently evolved malignant melanoma (MM). This MM was interestingly located on the split-thickness skin graft donor site which was harvested 3 months ago for repairing previous frontoparietal MM excision area. This case was presented and literature was reviewed.

Keywords: Implantation, malignant melanoma, metastasis, skin graft


How to cite this article:
Tabakan I, Yuvaci AU, Gencel E, Acikalin A. A “Grey Swan” malignant melanoma: Implantation metastasis on the skin graft donor site. Turk J Plast Surg 2020;28:188-91

How to cite this URL:
Tabakan I, Yuvaci AU, Gencel E, Acikalin A. A “Grey Swan” malignant melanoma: Implantation metastasis on the skin graft donor site. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 22];28:188-91. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/188/284962




  Introduction Top


Malignant melanoma (MM) is a malignancy of melanocytes, which are located primarily in the skin, but also found in the gastrointestinal tract, oral and genital mucosa, eyes, and leptomeninges, and occurs after DNA mutation most often secondary to excess sun exposure (ultraviolet A and ultraviolet B). MM is the third most common skin cancer (1%) and highest mortality of any type of skin cancer (75%). The incidence of MM is increasing rapidly. MM is a multifactorial disease; host factors affecting metastasis include Fitzpatrick I and II skin types, blue/green eyes, numerous congenital nevi, atypical nevi, and giant nevi. MM is capable of spreading by local invasion, as well as through hematogenous and lymphatic invasion. Tumor implantation is uncommon. The treatment of MM is excision with wide margins according to the tumor depth and width. Sometimes, flap or skin grafting is required after wide excision. Split-thickness skin grafts may be taken from any area of the body and can be harvested by dermatome devices. The donor site is covered with wound dressing materials. Here, we present a new evolving tumor on the split-thickness skin graft donor site that may be a possible implantation or a distant metastasis.


  Case Report Top


A 67-year-old male presented with a 2 cm × 2 cm diameter hyperpigmented tumor on the right frontoparietal area [Figure 1]. He had a history of four sessions of cryotherapy in another center. The biopsy revealed MM. Positron emission tomography showed a hypermetabolic skin lesion on the right frontoparietal area and hypermetabolic lymph nodes in the right cervical region.
Figure 1: Preoperative image of malignant melanoma on the right frontoparietal area

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The operation was performed under general anesthesia and the tumor was excised with a 2-cm margin and repaired with split-thickness skin graft taken from the left anterior thigh using the Integra® Padgett® Electric Slimline Dermatome (Plainsboro, NJ, USA) taken from the left anterior thigh. The sentinel lymph node which was preoperatively marked with technetium-99 and active blue injection was dissected [Figure 2].
Figure 2: Postoperative 1 month, defect area repaired with split-thickness skin graft

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The pathologic examination showed nodular MM, Clark level V, and Breslow level 7 mm. There was no lymphovascular invasion or lymph node metastasis, satellite nodes were absent, and the surgical margins were intact. The BRAF gene mutation pV600K variant was detected 23% positive in genetic analysis [Figure 3].
Figure 3: Hematoxylin and eosin of the nodular melanoma in the frontoparietal site. Spindled atypical melanocytes (gray arrow) infiltrating the dermis with foci of necrosis (black arrows) (Magnification × 40)

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The patient consulted with the department of medical oncology, and interferon alpha was administered with an adjuvant aim. However, 2 months later, a 7 mm × 7 mm lesion occurred on the split-thickness skin graft donor site [Figure 4].
Figure 4: A 7 mm × 7 mm lesion occurring on the split-thickness skin graft donor site

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The biopsy showed that MM and the tumor was excised with 1-cm margins [Figure 5]. The pathology report revealed nodular MM, Clark level IV, Breslow level 3.5 mm, no satellite nodes, and no lymphovascular invasion [Figure 6]. Surgical margins were intact. The BRAF mutation was again found Exon 15, P V600K variant, 22% positive. After excision, positron emission tomography computed tomography scan repeated and showed increased metabolic activity in the right cervical lymph nodes and increased metabolic activity in the hilar lymph nodes and mediastinum as well as cerebral metastasis. Cranial irradiation was performed and he consulted with the department of medical oncology for further evaluation.
Figure 5: Intraoperative image of new lesion, after being excised with a large margin

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Figure 6: Nodular melanoma on the cruris. This lesion displayed similar histomorphology to the previous tumor, showing spindled atypical melanocytes (gray arrow) infiltrating the dermis (hematoxylin and eosin, ×40)

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  Discussion Top


MM is an aggressive tumor with high metastatic potential, with metastasis occurring through different paths and different locations: 10% of cases show regional metastasis and 5% show distant metastasis including the soft tissues, bone, visceral, and cranial sites. However, in our case, the metastatic lesion occurred on the skin graft site. There are four possible mechanisms for the formation of a new lesion at this site: (1) distant skin metastasis, (2) the presence of a tumor at the skin graft donor site preoperatively, (3) coincidental new tumor development at the skin graft donor site, and (4) implantation of the tumor at the skin graft donor site.

This case had several characteristics that allowed us to exclude some of these mechanisms. None of the tumors in our patient histopathologically showed lymphovascular invasion and the two regions have different lymphoid drainage. Because of the locations of the two tumors, we concluded that the second tumor was not a satellite lesion or distant skin metastasis. There was no nevi or hyperpigmented lesion on the split-thickness skin graft donor site before harvesting the graft. Histopathological examination showed that both tumors were the same type of MM, and BRAF analysis between the two tumors showed a similar mutation. There was no association between the specific BRAF-mutant genotype and the histogenetic subtype of the primary cutaneous melanoma. However, V600K-mutant melanoma is more common in the head and neck region.[1] Although there is a slight chance for a coincidental tumor, all these facts led us to consider that the tumor resulted from an implantation.

There are only a few case reports showing MM skin implantation. Zangana reported MM implantation from the upper anterior thigh to the abdominal wall caused by direct prolonged contact with unhealthy skin far from the primary lesion.[2] Koller reported a case of the right foot lateral MM, repaired with a split-thickness skin graft from the upper left thigh, wherein a new tumor occurred on the skin graft donor site.[3] Gairola et al. also reported a case of MM implantation on the split-thickness skin graft donor site.[4] Our case adds to these previous findings, stressing the role of the surgical team in tumor prevention.

Implantation of a malignant tumor is an important problem and surgeons must change tumor-contaminated tools, gloves and scrubs if necessary in order to rule out the possibilty.


  Conclusion Top


Tumor implantation is a rare complication; nevertheless, each member of the surgical team should be aware of the risks and take strict precautions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Menzies AM, Haydu LE, Visintin L, Carlino MS, Howle JR, Thompson JF, et al. Distinguishing clinicopathologic features of patients with V600E and V600K BRAF-mutant metastatic melanoma. Clin Cancer Res 2012;18:3242-9.  Back to cited text no. 1
    
2.
Zangana AM. Satellite implantation of the skin with malignant melanoma. Saudi Med J 2006;27:1404-6.  Back to cited text no. 2
    
3.
Koller J, Kaserer C. “Implantation metastasis” of malignant melanoma. Am J Dermatopathol 1994;16:104.  Back to cited text no. 3
    
4.
Gairola M, Sriram V, Sharma DN, Mohanti BK, Rath G. Tumour implantation on a donor site from malignant melanoma of the right arm: A rare clinical entity. Indian J Dermatol Venereol Leprol 1999;65:298-300.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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