154 J I M D C 2 0 1 8 154
Op e n Ac c e ss
C a s e R e p o r t
Primary Malignant Melanoma of Adrenal Gland
Usman Hassan1, Mudassar Hussain2, Hamna Salahudin3, Sheeba Ishtiaq4, Noreen Akhtar5
1,2,5 Consultant Histopathologist, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore
3 Resident Histopathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore
4 Assistant professor of histopathology and Consultant Histopathologist Gulab Devi Hospital, Lahore
A B S T R A C T
A 49 years old male presented with abdominal pain for two months. Abdominal examination revealed slight tenderness
in the right lumbar region. On radiological examination an abnormal lesion, measuring 5.5cm x 4.5cm, involving the right
adrenal gland was found. It was biopsied and histological and immunohistochemical features were consistent with
malignant melanoma. After meticulous physical examination, the patient did not have ocular or muco-cutaneous
melanoma and he did not have any past significant medical or surgical history. We labelled this case as primary
malignant melanoma of adrenal gland. Unfortunately, the patient died two months after the detection of tumor and before
the start of treatment.
Key Words: Abdominal pain, Adrenal mass, Malignant melanoma
Address of Correspondence
Usman Hassan
Email: drusmanhassan256@gmail.com
Article info.
Received: March 24, 2018
Accepted: May 12, 2018
Cite this case Report: Hassan U, Hussain M, Salahudin H, Ishtiaq S, Akhtar N. Primary Malignant
Melanoma of Adrenal Gland. 2018; 7(2):154-156.
Funding Source: Nil
Conflict of Interest: Nil
I n t r o d u c t i o n
Malignant melanoma is a neoplasm of skin. Apart from
the skin and choroid plexus, primary malignant
melanoma at other sites is a rare entity.1 Documented
sites where malignant melanoma can occur are lung2,
genitourinary tract3, and GIT4. It is very rare in adrenal
gland. Only 12 well-documented cases of primary
malignant melanoma of adrenal gland have been
reported.5 In the adrenal gland it originates from neural
crest cells present in adrenal medulla.6 It is difficult to
differentiate between primary and metastatic malignant
melanoma in adrenal gland. Histological and
immunohistochemical studies are not helpful in
differentiating between primary and metastatic malignant
melanomas.6 Therefore meticulous physical examinations
is necessary to rule out the possibilities of primary ocular
or mucocutaneous melanomas. Up till now, primary
malignant melanoma of adrenal gland has not been
reported from Pakistan.
C a s e R e p o r t
A 49 years old male presented with the complaints of
abdominal pain, anorexia and weight loss for two months.
He did not have any significant past medical or surgical
history. On general physical examination patient was
emaciated and pale. Abdominal examination only
revealed slight tenderness in right lumbar region.
Laboratory investigations showed haemoglobin of 10.0
g/dl with MCV and MCHC 78.6 fl and 30.6g/dl
respectively. Renal function tests, liver function tests, and
electrolytes were normal. Abdominal ultrasound showed a
solid hypoechoic mass of 5.5cm x 4.5cm, above the upper
pole of right kidney. It did not show increased flow on
Doppler. Left kidney, liver, gall bladder, bile duct, spleen
and pancreas were normal. No pleural effusion, ascites or
para aortic lymphadenopathy was noted. 3D CT abdomen
with IV contrast revealed a dense abnormal lesion,
measuring 5.5cmx4.5cm, involving the right adrenal
gland. Both kidneys showed multiple cysts with no solid
mass or obstructive changes. Liver, gall bladder, spleen,
C A S E R E P O R T
155 J I M D C 2 0 1 8 155
pancreas, aorta and IVC were normal. No ascites was
seen.
Patient underwent diagnostic laparoscopy and an
incisional biopsy was taken from right adrenal mass. On
gross examination, we found multiple fragments
measuring 2.0cm x 1.0cm x 1.0cm in aggregate.
Specimen weighed 8 grams. Cut surface revealed
hemorrhagic and necrotic areas. Microscopic examination
revealed a malignant neoplasm, comprising of polygonal
cells arranged in diffuse sheets. The cells showed marked
pleomorphism, atypia, atypical mitoses (11/10 HPF) and
few cells showed intracytoplasmic melanin pigment (Fig
1). Few areas showed necrosis.
Figure 1(A): Low power view shows sheets and
clusters of medium to large sized atypical polygonal
cells with focal areas of pigmentation (arrow) [H&E
10X100].
Figure 1(B): High power view shows atypical tumor
cells with rounded vesicular nuclei, prominent
nucleoli, intra cytoplasmic melanin pigment [H&E
40X100].
Tumour cells revealed positive expression for Melan A,
S100, HMB-45 (Fig 3\2) and negative staining for
synaptophysin, calretinin, inhibin, Cytokeratin, LCA.
Figure 2: Positive immunohistochemical staining for
MELAN A ,HMB-45 AND S100.
Based on above-mentioned results, an initial diagnosis of
malignant melanoma was made and patient was
evaluated for any possible primary site of malignant
melanoma. On meticulous evaluation, physicians did not
find any ocular or mucocutaneous melanoma. Patient was
diagnosed as case of primary malignant melanoma of
adrenal gland. He was referred to oncologist for further
management. However, patient died before the start of
treatment, two months after diagnosis of adrenal
malignant melanoma. Autopsy was not performed due to
lack of attendant’s consent.
D i s c u s s i o n
Malignant melanoma comprises of 2% of all body
tumours.7 Primary and metastatic melanomas of the
adrenal gland are rare and are incidental findings. Pain is
the most common manifestation along with
gastrointestinal symptoms caused by the compression of
the structures adjacent to the tumour.8 Primary melanoma
of the adrenal gland is usually a voluminous, non-
functional tumor showing heterogeneous contrast
enhancement on the computed tomographic (CT) scan
and diagnosis is made on the basis of
immunohistochemical studies and criteria led by
Carstens et al.2 Adrenal glands can be the sites of
metastatic deposits from cutaneous or visceral
melanomas in up to 50% of cases.9,10 The presence of
melanoma in both adrenal glands favors metastatic
melanoma over a primary adrenal melanoma.11
156 J I M D C 2 0 1 8 156
Histopathological and immunohistochemical studies
cannot usually differentiate between primary and
metastatic malignant melanomas. Primary melanoma of
adrenal gland is a very rare entity.12 Only 12 cases have
been reported to date.13 It is important to rule out
possibilities of adrenocortical carcinoma,
pheochromocytoma and metastatic melanoma before a
diagnosis of primary malignant melanoma of adrenal
gland is made.
The patients presented by Parker and Vincent et al,12
Kinseley and Baggentons et al,14 Dick et al 15 Sasidharam
et al,16 Granero et a 17 and Luis González-Sáez et al had
more than 50years of age while our patient was 49 years
old similar to the cases presented by Dao et al,
Liatsikos et al, and Zalatnai et al respectively. 6,18,19 The
previously reported cases as well as our case had a
tumor size of more than 5 cm. The largest reported
adrenal tumor measured 17cm x 12cm x 10cm. The
cases presented by Kniseley and Baggentoss et al,14
Parker and Vincent et al,12 Dao et al 6 and Zalatnai et al,19
died shortly after detection of disease. Our patient also
died after two months of detection. This indicates poor
prognosis of the disease.
In one study of 31 patients who underwent adrenal
surgery for metastasis at a single institution over 10 years’
period (1999-2008), the primary tumor diagnosis was non-
small cell lung carcinoma in 20, colorectal carcinoma in 5,
renal cell carcinoma in 2 and malignant melanoma and
breast carcinoma in one case each.20 In our case there
was a unilateral adrenal involvement. There was no
ocular or muco-cutaneous melanoma. This highly favors
primary malignant melanoma of adrenal gland. Out of
279929 samples processed at our institute for various
diseases during last five years, 429 cases were
diagnosed as malignant melanoma. Only one out of these
429 cases was adrenal malignant melanoma.
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