Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

The Risk Of Concomitant Chronic Lymphocytic Leukemia and Malignant Melanoma Molly Boyko, OMS-III, Dr. Peter Neidenbach, M.D. Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina.

Introduction

Clinical Presentation & Pathology

Discussion

• Sentinel lymph node biopsies for malignant melanoma (MM), an integumentary malignancy, are positive 30-40% of the time (Somerset et al. 2021). • A malignancy of B cells, called chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is largely found upon blood tests. • The incidence of discovering CLL in an otherwise healthy individual when performing a sentinel lymph node biopsy for metastasis of melanoma has not been well studied because the CLLusually presents clinically first.

Conclusion References • The risk factors for melanoma are ultraviolet (UV) light exposure, dysplastic nevi, fair skin, freckling, light hair, family or personal history of melanoma, male gender, age, and a weakened immune system (American Cancer Society, 2023). • Some of the same risk factors also predispose people to CLL, like age, male gender, race/ethnicity, and a weakened immune system. • The patient has skin phototype 1 with a long history of sun exposure, along with numerous other risk factors for both melanoma and CLL. • It is possible that some overlap in risk factors predispose people to both cancers. It is also possible that research has yet to find an explanation for this cooccurrence. • Physicians should acknowledge that a grossly enlarged lymph node in amelanoma patient does not always constitute melanoma. • Melanoma and CLL evade the body’s tumor surveillance system to induce immunosuppression (Kubica & Brewer, 2012). • The literature reveals that there is some association between CLL and melanoma, but there is limited investigation as to why. (Farma et al. 2012). • Patients with both CLL and melanoma could benefit from regular screening for each disease if diagnosed with one or the other due to the reduced overall survival of the collision of the two diseases (Gero et al. 2014). • Patients with CLL are more likely to develop skin cancers, like melanoma. • The inverse may have occurred, as the patient presented with melanoma twice before CLL was diagnosed. • Multiple risk factors were present for both diagnoses like age, race, and immunosuppression. • This unique presentation of concomitant melanoma and CLL could be of paramount importance in caring for patients with either disease. • Further research is necessary to discover the clinical significance of the relationship between CLL and melanoma. • Understanding underlying etiologies of the disease will assist providers to be better equipped to screen and care for their patients.

Figure 1. a Hematoxylin and Eosin stain (H&E) (x10): positive for malignant melanoma. Confluent nests of markedly atypical melanocytes present at the dermal/epidermal junction with pagetoid growth. b Melanoma-associated antigen recognized by T cells (MART-1) (x10): positive in residual neoplasm.

Case Description

A 74-year-old male with a past medical history of completely resected melanoma in situ 15 years prior was diagnosed with a second primary melanoma. The second melanoma, located on the left mid-back, was a tan, gray lesion with a variegated macular surface. A shave biopsy revealed aninvasive malignant melanoma with a Clarks level of at least IV, Breslow depth of at least 1.0mm to the lateral and deep margins, and no ulceration. The histopathological examination revealed atypical melanocytes (Fig. 1).The area was resected and a keystone flap was performed to close the wound (Fig. 2). The left axillary sentinel lymph nodes were also excised and biopsied. The nodes were negative for metastatic melanoma but showed small mature lymphocytes with occasional mitoses positive for CLL (Fig 3).The CLL was occult as the patient was not experiencing any fatigue, infections, bruising, fever, weight loss, night sweats, or swollen lymph nodes. The patient's oncologist decided clinical observation of the CLL as the treatment of choice, since the cancer grows slowly and treatment in the early stages does not offer much benefit.

Figure 2. The patient's upper back following complete resection of the melanoma.

References

1. Somerset AE, Jameson MJ. Sentinel Lymph Node Biopsy in Patients with Melanoma. Medscape. 2021 Oct 14. 2. Risk Factors for Melanoma Skin Cancer. American Cancer Society. 2019 Aug 14. 3. Kubica AW, Brewer JD. Melanoma in Immunosuppressed Patients. Mayo Clinic Proceedings. 2012 Oct; 87(10). 4. Farma JM, Zager JS, Barnica-elvir V, et al. A Collision of Diseases: Chronic Lymphocytic Leukemia Discovered During Lymph Node Biopsy for Melanoma. Annals of Surgical Oncology. 2012 Nov 20. 5. Gero D, Queiros da Mota V, Boubaker A. Accuracy of Sentinel Lymph Node Dissection for Melanoma Staging in the Presence of a Collision Tumor with a Lymphoproliferative Disease. Lippincott Williams and Wilkins. 2014 Aug; 24(4).

Figure 3. a Sentinel lymph node CD5 stain (10x): positive in neoplastic B cells. b Sentinel lymph node CD23 stain (10x): positive in neoplastic B cells.

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2024 Research Recognition Day