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Case Reports

Abstract

A 78-year-old male presented with an enlarging right shoulder mass and diffuse lymphadenopathy. The mass progressed in a span of 6 months from a small, irregular, and dark-colored lesion to a flesh-colored, fungating and ulcerated mass measuring approximately 10cm in diameter. In addition, CT-scan demonstrated enlarged lymph nodes involving the submental, cervical, supraclavicular, jugular, and subpectoral chains suspicious for metastatic involvement. A shave biopsy demonstrated focal junctional enlarged and atypical melanocytes arranged in variably sized nests with upward migration and confluence, epidermal necrosis, and atypical dermal melanocytes arranged in large, expansile nests and sheets with impaired maturation. Extending from radial aspect of the lesion to uninvolved dermis, were aggregates of small monotonous lymphocytes with clumped chromatin and basophilic cytoplasm arranged in a perivascular distribution. Immunohistochemical studies demonstrated expression of NRAS and SOX10 in the atypical melanocytes whereas the lymphoid aggregates were positive for CD20, CD5, LEF1, CD200, while negative for CD3, cyclin D1, and SOX11. Interestingly, LEF1 also demonstrated nuclear staining of the atypical melanocytes. Synchronous occurrence of melanoma and cutaneous involvement by CLL/SLL is a rarely documented event, and the abnormal lymphoid population should be distinguished from the more commonly found population of tumor infiltrating lymphocytes. The absence of tumor disruption, the monotonous nature of lymphocytes, and the distribution of the aggregates extending beyond the limits of the melanoma are diagnostic clues that should prompt its immunophenotypical characterization. The predominance of B-lymphocytes and its abnormal expression of CD5 and LEF1 argues in favor of CLL/SLL.