The umbilicus: a rare site for melanoma. Clinical considerations in two cases. Case reports

SPECT/CT-Guided Surgical Removal of a Positive External Iliac Sentinel Node in Primary Umbilical Melanoma: Report of a Case, and Up-to-Date Review of the Literature

Primary umbilical melanoma is rare tumor, representing about 5% of all umbilical malignancies.The lymphatic drainage from the tumor is challenging and can be to inguinal, axillary and retroperitoneal nodes. Dynamic and static lymphoscintigraphy with single-photon emission tomography/computed tomography (SPECT/CT) and sentinel lymph node biopsy (SLNB) is a widely validated technique in patients with clinically localized melanoma to search for and quantify nodal spread of cutaneous melanoma. Moreover, it offers the surgeon the preoperative information about the number and location of the sentinel lymph nodes (SLNs), which makes SLNB easier and quicker. This is the first report of an ulcerated thick melanoma of the umbilicus metastasizing only to an external iliac lymph-node without involvement of superficial inguinal SLNs. The preoperative high-resolution ultrasound (HR-US) examination of the regional lymph node field had been normal. This case-report shows how addition of SPECT/CT to planar imaging in a patient with clinically localized umbilical melanoma can help avoid incomplete SLNB when a deep SLN is not removed. A literature review of umbilical melanoma is also provided.

Primary Cutaneous Umbilical Melanoma: The Michigan Experience

BACKGROUND

Primary cutaneous umbilical melanoma is rare. Thorough information regarding its characteristics and treatment, including use of sentinel lymph node biopsy (SLNB) staging, is difficult to obtain. The unique anatomy of the umbilicus adds to the complexity of diagnosing and treating melanoma at this site.

OBJECTIVE

To improve understanding of diagnosis and treatment of primary cutaneous umbilical melanoma through presenting 7 new cases and reviewing 39 cases in the literature.

MATERIALS AND METHODS

The University of Michigan melanoma database query and review of the literature regarding reported cases of primary umbilical melanoma.

RESULTS

In 7 new and 39 previously reported cases of primary cutaneous umbilical melanoma, we describe signs and symptoms, histopathologic features, differential diagnosis, relevant anatomical considerations, and definitive treatment including SLNB when applicable.

CONCLUSION

Our series, combined with a thorough literature review and compilation of findings, provides a better understanding and appreciation of melanoma in the unique anatomical site of the umbilicus, with a reminder to carefully examine the umbilicus during a full skin examination in patients at risk of melanoma. Primary umbilical melanoma presents and can be appropriately treated similarly to cutaneous melanoma in other sites, with attention to relevant anatomy.

Clinicopathologic features and surgical management of primary umbilical melanoma: a case series

Background

Primary umbilical melanoma is an uncommon tumor that is poorly described in the medical literature. The umbilical region is a particular anatomic site owing to the presence of embryonal remnants, which can be a potential metastatic pathway, as well as the braided lymphatic network drainage. Hence, primary malignant neoplasms affecting the umbilicus require a different and more radical surgical approach compared with other melanomas.

Case presentation

In this report, we describe a series of three patients of Caucasian ethnicity who presented with primary umbilical melanoma at the National Cancer Institute of Naples, Italy. All patients underwent wide excision of the tumor including the underlying peritoneum. No surgical complications, either immediate or delayed, were observed in any of the patients. Sentinel lymph node biopsy was negative in two cases. Two of the patients developed metastatic disease and died after systemic medical therapy. The other patient is currently in follow-up, and remains disease-free after 21 months.

Conclusions

The umbilicus has vascular and embryological connections with the underlying peritoneum, so that early visceral involvement is more likely to occur with primary umbilical melanomas. As such, tumor resection including the underlying peritoneum is required to avoid local relapse, whilst sentinel lymph node biopsy appears to be of poor diagnostic value.

Diagnosis and management of primary umbilical melanoma with omphalitis features

We report on a 62-year-old Chinese male patient who presented with a pigmented lesion in the umbilical area and who was treated for omphalitis in a local hospital for 1 month. Biopsy pathological examination revealed that the lesion was a melanoma. The Breslow depth was estimated at 3 mm, and Clark's level was IV. Ultrasonography showed no suspicious pathological lymph nodes, and no metastases were detected in the lung, liver or brain through CT scans. Reexcision was performed with lateral marginsd >2 cm from the original scar down to the peritoneum, including the umbilicus, round ligament of the liver and urachus. No adjuvant therapy was suggested, and the patient was still alive without recurrences or metastases after 36 months.

Cutaneous endometriosis: non-invasive analysis by epiluminescence microscopy

The clinical appearance of cutaneous endometriosis can share some features with malignant melanoma, thus representing a possible cause for concern in both patient and clinician. In recent years, the use of epiluminescence microscopy (ELM, dermoscopy) has proved useful in improving the accuracy of diagnosis of pigmented skin lesions. The purpose of this study was to analyse the dermoscopic features of cutaneous endometriosis with histopathological correlation. We studied a case which showed homogeneous reddish pigmentation, regularly distributed. Within this typical pigmentation there were small red globular structures, but more defined and of a deeper hue, which we called 'red atolls'. ELM thus revealed a distinctive pattern in cutaneous endometriosis.

Primary melanoma of the umbilicus: report of a case and review of the relevant anatomy

BACKGROUND

Malignant melanoma presenting on the umbilicus is rare. Treatment of melanoma on the umbilicus is difficult because of the unusual anatomy of the umbilicus.

OBJECTIVE

To present the case of a patient with a primary malignant melanoma of the umbilicus and to discuss treatment concerns that are relevant to the umbilical anatomy.

METHODS

This is a case report as well as a review of the pertinent anatomy.

RESULTS

The initial excision was read as having clear deep and lateral margins on histopathologic examination. Postoperative complications led to a re-excision down to and including the umbilical attachment to the peritoneum. The re-excision revealed residual primary cutaneous malignant melanoma in a remnant umbilical cyst.

CONCLUSION

When a malignant melanoma is located on the vertical sidewall or bottom of the umbilicus, one should consider surgical excision down to peritoneum, including the umbilical attachment to the peritoneum. Because this is beyond the scope of training for most dermatologic surgeons, it would be appropriate to refer these patients to a surgical oncologist or a plastic surgeon.