PMC2904832_01
This figure demonstrates the patient's scalp melanoma that initially progressed in size between February 2006 (Fig. 1A) and May 2006 (Fig. 1B). During this time, various treatments had been attempted, including high dose interleukin-2, Temozolamide, and a melanoma peptide vaccine trial (UVA MEL-41). With the initiation of Aldara between May 2006 and November 2006, clinical evidence of regression is evident. The regression is evident in that the multipapular melanoma shown in Fig. 1B was replaced by the flatter black discoloration of Fig. 1C. Comparison of Fig. 1C to 1B also shows arrest of radial extension of the dermal disease, which had been rapid prior to May 2006.
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F1
Unfortunately, the patient progressed regionally at the scalp (Fig. 1A,B). After 6 months of treatment, her multipapular dermal scalp melanoma metastases changed, and were replaced by a flat black discoloration where the tumor had been (Fig. 1C). She did, however, develop a palpable nodule 16 x 12 mm deep to the dermis on the right forehead, clinically suspicious for a new subcutaneous metastasis (Fig. 1C). We cannot completely exclude the possibility that some foci of viable melanoma may have persisted in the dermis, as only a representative area was biopsied, however, the rapid radial growth of the dermal melanoma, shown in the comparison of Fig. 1B to Fig. 1A, did not continue once imiquimod was applied, (Fig. 1C), and there was notable flattening of the dermal melanoma throughout the lesion, which is typical for regressions of dark pigmented melanoma.
This figure shows an MRI image demonstrating the subcutaneous location of the low T1, bright T2 metastatic melanoma nodule.
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F2
The subcutaneous location of the low T1, bright T2 enhancing nodule is especially apparent on MRI (Fig. 2).
(A) Total magnification (40x, H&E stained) shows a skin biopsy taken prior to beginning Aldara treatment. (B) The atypical melanocytes are readily apparent in nests, (total magnification 200x, H&E stained). (C) (total magnification 20x, H&E stained) shows significant fibrosis and a focus of tumoral melanosis, or residual pigment within macrophages in a treated focus, in the more superficial portion of the treated dermis, consistent with Aldara therapy. (D) (total magnification 100x, H&E stained) shows in higher magnification tumoral melanosis also indicating treatment-associated changes whereas (E) (total magnification 100x, H&E stained) shows dyscohesive melanocytes in the deep subcutis, suggesting persistent subcutaneous tumor.
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F3
A skin biopsy taken prior to imiquimod therapy is shown in Fig. 3A,B, which may be compared to a tissue section taken after imiquimod therapy (Fig. 3C,D,E).
Total magnification (20x, H&E stained) reveals a low power (scanning) magnification of metastatic melanoma in the deep subcutis. Note that the metastasis lies deep to the layer of skeletal muscle.
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F4
Figure 4 further shows a scanning magnification of subcutaneous metastasis located in the deep subcutis that persisted in spite of treatment.