Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(3):e2022103 1 Dermatology Practical & Conceptual Cutaneous Spitzoid Melanoma in Childhood After Acute Lymphocytic Leukemia Beatriz Ferreira do Prado Bassetti1, Sergio Albertini Daiuto1, Gilles Landman2, Francisco Macedo Paschoal3 1 Medical Student, Centro Universitário FMABC, Santo André, Brazil. 2 Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil 3 Discipline of Dermatology, Centro Universitário FMABC, Santo André, Brazil. Keywords: melanoma, Acute Lymphocytic Leukemia, Spitz Nevus, Skin Cancer Citation: Bassetti BFP, Daiuto SA, Landman G, Paschoal FM. Cutaneous spitzoid melanoma in childhood after acute lymphocytic leukemia. Dermatol Pract Concept. 2022;12(3):e2022103. DOI: https://doi.org/10.5826/dpc.1203a103 Accepted: November 4, 2021; Published: July 2022 Copyright: ©2022 Ferreira do Prado Bassetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/ which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Sergio Albertini Daiuto, Discipline of Dermatology at Centro Universitário FMABC, Avenida Lauro Gomes, 2000 - Vila Sacadura Cabral, CEP: 09060-870, Santo André - São Paulo, Brazil E-mail: s.daiuto@gmail.com Introduction Acute lymphocytic leukemia (ALL) is the most common childhood malignancy. It has a good prognosis but one-third of all childhood ALL deaths are due to toxicity or secondary malignancies. We report the case of a patient with a personal history of ALL who had cutaneous spitzoid melanoma at the beginning of puberty. Case presentation A 13-year-old female patient from São Paulo, Brazil, pre- sented, in 2015, a well-defined, erythematous, ulcerated brown nodule in the left temporal region, with a 1-year evo- lution (Figure 1A). She presents a personal history of ALL diagnosed in 2013, treated with chemotherapy. Dermoscopy shows polymorphic vessels, exulceration, hematic crusts, and chrysalis (Figure 1B). No specific finding of the melanocytic lesion was present. The initial hypotheses were keratinocytic or vascular neoplasms being performed incisional biopsy for diagnosis. A histopathological analysis showed a neoplasm with cells arranged in nests, ample and eosinophilic cytoplasm, with oval or rounded nuclei and prominent nucleoli, whose diag- nosis was infiltration by primary melanoma. Excisional bi- opsy confirmed the diagnosis of nodular, ulcerated, spitzoid, Clark V melanoma with tumor thickness (Breslow) of 4.7 mm (Figures 2). Surgical treatment with wide excision was performed, followed by adjuvant treatment with interferon alpha 2b at a dose of 6350,000 IU, subcutaneously, 3 times a week for 2 years, the only adjuvant treatment available at the time of diagnosis. The patient remained in oncological follow-up for 5 years and in remission of both neoplasms. Conclusions This case report shows a remarkable clinical similarity with what was reported by Goldes et al. in 1984, whose initial 2 Research Letter | Dermatol Pract Concept. 2022;12(3):e2022103 Figure 1. (A) Well-delimited, ulcerated brown nodule on the left temporal skin. (B) Dermoscopy showing polymorphic vessels, exulceration, hematic crusts and chrysalis streaks. Figure 2. Melanocytic neoplasm characterized by proliferation of cells that are either epithelioid or fusiform with eosinophilic cytoplasm, whose nuclei have a moderate degree of polymorphism and promi- nent nucleoli, forming an extensive dermal lesion (H&Eeosin, 100x). diagnosis, however, was Spitz nevus, but the patient died of metastatic melanoma [1]. The differential diagnosis be- tween spitz nevus in its atypical presentation, such as ag- gressive spitz tumor of undetermined biological significance, and spitzoid melanoma is a major challenge [2]. Both may share findings such as fusiform melanocytes, prominent nu- cleoli, junctional nests, diameter greater than 10 mm, and high-grade nuclear atypia. The characteristics that favor the diagnosis of melanoma are greater depth of the lesion, in- volvement of reticular and subcutaneous dermis, mitosis in the deep dermis, nuclear and cellular pleomorphism, asym- metry and ill-defined limits, all of them present in our report. Nevertheless, in certain situations only the development of metastasis will define the diagnosis. We can assume that the approach presented in the face of the diagnosis of spitzoid melanoma (wide excision and adjuvant immunotherapy) may have influenced the outcome of the present report. The most common secondary malignant neoplasms after ALL are lymphoreticular (acute myelocytic leukemia and Hod- gkin disease), followed by endocrine, keratinocytic, and renal tumors. Immunosuppression by chemotherapy and radiotherapy is related to an increased risk of developing a subsequent neoplasm but not necessarily related to their causes. In addition to being rare in childhood, the occurrence of cutaneous melanoma as a secondary neoplasm after ALL, is even more uncommon, and this case in our knowledge is the second case reported in the literature. However, it should be considered mainly in the presence of a pigmented nodule on the face. References 1. Goldes J, Holmes S, Satz M, Cich J, Dehner L. Melanoma masquerading as Spitz nevus following acute lymphoblastic leukemia. Pediatr Dermatol. 1984;1(4):295-298. DOI: 10.1111/ j.1525-1470.1984.tb01132.x. PMID: 6593699.2. Harms KL, Lowe L, Fullen DR, Harms PW. Atypical Spitz Tumors: A Diagnostic Challenge. Arch Pathol Lab Med. 2015;139(10):1263- 1270. DOI: 10.5858/arpa.2015-0207-RA. PMID: 26414472.