Pigmented tumors

Tumeurs pigmentées (mélanome)

The main fear of the patient and the practitioner to a pigmented tumor is that of a melanoma.

Black tumors can be of origin:

– Non-melanocytic: thrombosed angiomas, basal cell carcinoma, histiocytofibroma, actinic keratosis;

– Melanocytic: nevi, melanoma, lentigo, freckles.

If in doubt, do not hesitate to seek expert advice.

Best melanoma screening examination is the examination of the skin covering on a patient undressed during the medical consultation.


Next the clinical aspect, there are mainly the thrombosed hemangioma, pigmented basal cell carcinoma, the histiocytofibroma, actinic keratosis and seborrheic.

Angioma thrombosed:

Clinically, this is a very black knot surrounded by a reddish halo, playing in a few days, most frequently in young adults. It can take a disturbing nature to the patient.

Do not hesitate to biopsy in order not to miss a nodular melanoma.

The lesion disappears by itself thereafter.

Pigmented basal cell carcinoma:

Basal cell carcinoma is recognized by his seat on exposed skin (face ++) on an old subject to prolonged sun exposure history (fisherman, farmer, recreation or outdoor work). The elementary lesion orienting the diagnosis is the presence of small beads on the periphery.

Do not burn injury to fresh nitrogen practice but, if possible, an excisional biopsy or skin biopsy. If we did not used such gestures and the lesion is large or delicate seat is best left the patient to the specialist.


The histiocytofibroma is a characteristic feature in the clinical lesion. The complaint is aesthetic. Located mostly on the legs of women, he made a brownish lens, firm, hard palpable on deep plans, although limited and not painful.The lesion gives the impression of a pellet on palpation due to its intussusception in the skin.

Therapeutic abstention is the rule, wound excision in case of being unsatisfactory.

Spots and actinic keratosis:

The spots and actinic keratoses are caused by cumulative sun exposure on skin aging.

Actinic tasks:

Actinic perform tasks pigmented macules (“age spots”) that the damage is not aesthetic.

We can offer treatment by application of topical depigmentation (Mela-D, for example).

Sun protection is important.


Actinic keratoses occur on the same field, but may be the bed of basal cell carcinoma. They realize erythematous lesions, yellow, brown, slightly scaly, slightly keratotic, rough to the touch.

It must burn with liquid nitrogen. Sun protection is important.

Seborrheic keratoses:

Seborrheic keratoses are not related to sun exposure, but appear in the majority of cases during aging (from 30 years for some).

It affects the face, chest, realizing flat lesions, or warty, and vary in pigmentation (coffee, black). They seem to put on the skin and is easily raised when applying the curette or tongue depressor.

An efflorescence of seborrheic keratoses was described in the evolution of certain cancers (sign of Leser-Trelat).The value of this sign has been questioned.

Treatment is not always necessary. If aesthetic inconvenience, applying liquid nitrogen or electrocautery can be proposed.

Pigmented tumors (melanoma)
Pigmented tumors (melanoma)


Freckles or freckles:

Freckles are extremely commonplace in the general population, in clear complexion subjects. They increase in number and size after sun exposure.

Rarely, they appear early in life and are axillary available, they can be integrated as part of neurofibromatosis type 1 or Von Recklinghausen disease (Crowe sign).

Photoprotection measures are explained in these populations, because of the increased risk of neoplastic lesions associated with sun exposure.


Extremely commonplace too, lentigo carries a brownish blotch, dark brown, a few millimeters in diameter. The land is also that of the elderly with significant sun exposure.

They are due to increase of melanin.

The presence of lentigines on mucous membranes (lips) evokes a Peutz-Jeughers syndrome, combining mucocutaneous lentigines and colonic polyps.

The depigmenting topical photoprotection and can be proposed.


The nevi are making limited well pigmented lesions, homogeneous, roughly symmetrical, small (<1 cm diameter), non-progressive. They are asymptomatic. Their appearance is roughly the same. The diagnosis is usually obvious.

They mostly appear during the first part of life and are absent in the newborn.

An efflorescence of nevi may be observed during pregnancy. These can then change and take a worrying aspect. Their appearance in the elderly is very suspicious and an excisional biopsy is often necessary.

Large congenital nevi (> 5 cm) are entrusted to specialist and, most often, for resection.

The trauma does not promote degeneration.

An ulcerated melanoma may bleed. The patient then reported himself bleeding to a banal trauma.

Events can occur in the life of the nevus.


Bleeding or thrombosis:

A sudden darkening of the lesion with varying inflammatory halo, is in favor of bleeding or thrombosis.

Folliculitis sub-nævique:

A hair nevus becoming sensitive, edematous, inflammatory folliculitis evokes sub-nævique.

The abstention is the rule.

Halonævus Sutton:

Nevus surrounding himself with a whitish halo, disappearing gradually, is a halonævus Sutton. It’s the attack of the immune system nevus. This is a common occurrence during adolescence. If halonævus is inhomogeneous, appeared in a subject over fifty years we should fear melanoma and realize an excisional biopsy.

The halonævi may also occur on previously normal nevi during the evolution of melanoma.

Syndrome of atypical nevi:

The syndrome of atypical nevi corresponds to the presence in an individual many nevi (> 50), large size, occurring in areas not exposed. Their appearance may be atypical because it does not meet all the reassuring characters (symmetry, regular edges, uniform color).

However, they all have a similar appearance.

Excision of all lesions is useless.

Dermatological supervision is necessary, however, because the ground is the same as that of melanoma.

Blue nevi:

The blue nevus is a nevus with homogenous blue pigmentation due to the deep localization of the pigment.

If melanoma is suspected, it will not hesitate to entrust the patient to a specialist for dermoscopy and possibly biopsieexérèse.

Nevus of Ota:

The nevus of Ota nevus matches involving the two branches of the trigeminal.


Conventionally, the nevi are more numerous when the immune challenge cit.

Mongolian blue spot:

The Mongolian blue spot is a blue nevus congenital, more common among black and Asian subjects and populations of the Mediterranean.

This is a lumbar slate spot, disappearing spontaneously later in childhood.


There is no specific treatment for nevi.

Photoprotection is required. Self-monitoring is needed. Resection is proposed

in case of occurrence of a nevus de novo and a change in its appearance. Nevus ulcerated saignotant traumatized and must be removed.

Whenever possible, you should also practice excision of nevi disturbing the patient. Large congenital nevi (> 20 cm) are removed by the specialist.


Melanoma, malignant tumors developed at the expense of melanocytes in the basal layer of the epidermis, should remain haunted practitioner before any pigmented lesion. Indeed, metastatic melanoma have fast power through blood and lymphatic system, and are not very sensitive to chemotherapy. Early surgical removal is imperative. The evolution is typically:

Or – an initially horizontal extension, intraepithelial, or longer, followed later by a vertical extension in the dermis (superficial spreading melanoma);

– Either by extending the outset vertical (nodular melanomas).

Can then occur metastasis, skin

between the lesion and the draining nodes,

or lymph node or visceral.


Melanoma is suspected by the clinic before the morphological analysis of the lesion and confirmed by histological analysis of the piece of excisional biopsy. Contrary to popular belief, melanomas occur most often in healthy skin, and rarely on injury (nevi) preexisting.


The questioning is important, he said:

– New or recent modification of a pigmented lesion;

– Regression or disappearance of a pigmented lesion;

– Patient age: exceptional in children;

– Ethnic group: more common in the white matter, rarer in people with black or yellow skin;

– Personal or family history: in particular pigmented lesions, any notion of resection and results of histological analysis;

– Sunburn in childhood;

– Quality of tanning: not easily or bronze;

– Profession and Recreation: sun exposure;

– Potential exposure under tanning lamps.

Clinical examination:

Melanoma is suspected by the clinic before the morphological analysis of the lesion. Clinical examination should focus on search for other suspicious lesions, the presence of lymph nodes in the drainage area of ​​the lesion and distance and organomegaly. The contrast between the suspicious lesion and the patient’s other nevi, which do not resemble moles, is also important (rule of “Ugly Duckling”). Do not forget to examine the feet, toes, ears and ear canals, genitals and anal margin.

Analysis by dermoscopy is the responsibility of specialist who have received specific training.

Melanoma preferentially seat on the trunk of men and women’s legs.

* Morphological analysis:

Morphological analysis is conventionally based on the rule of Primer (Box 1).

Box 1. Rule Primer
Irregular edges, often notched, polycyclic, poorly limited, casting ink
Inhomogeneous color with browner areas darker, bluish, discolored, red, pink, infl ammatory
Diameter greater than 6 mm
Scalability after the interrogation of the patient or previous photographs, with increase in size, modifi cation of the lesion, color change, or relief appearance saignotage

* Black tumor:

In the presence of a black tumor, a number of subjects at increased risk of developing melanoma:

– The sun is the major environmental factor.

Intermittent sun exposure, repeated, preferentially occurring in childhood (especially that there was sunburn) are particularly at risk. Sun exposure during recreational, intermittent, and is more at risk than the preferential continuous exposure. However, melanose Dubreuilh elderly patients is more related to chronic and cumulative sun exposure, and certain subtypes (acral melanoma, mucosal melanoma) are not related to sun exposure. Note that artificial exposure under ultraviolet lamps also increases the risk;

– Family history is important and should be systematically sought by the examination (10% of patients with melanoma have a family history of melanoma 2 of 3 generations). If melanoma proven, children and the patient’s siblings are systematically examined;

– Subjects to light phototype (fair skin, blond or red hair, light eyes, freckles, blushing before sunbathing difficult) have a higher risk;

– Subjects with multiple nevi large, suspicious look (atypical nevus syndrome);

– Subjects with a personal history of melanoma (the same causes, same effects);

– Carriers of congenital nevus large (note the size);

– The subjects with the DNA repair defect (Xeroderma pigmentosum, especially in the subject from the Maghreb).

Further examination:

If melanoma is suspected, the golden rule is: any suspicious lesion should be excisional biopsy for histopathological examination.

The room is best entrusted to a specialized pathologist in dermatopathology, with the maximum of clinical information.

The lesion is removed completely, with clear margins, and at best oriented. It must not be destroyed in the liquid nitrogen in case of suspicion of melanoma. If large lesion excision decaying, a simple biopsy can be done initially until surgical excision.

The excisional biopsy is preferably carried out by a dermatologist, practicing minor surgery, or a surgeon.

Diagnosis is suspected in front the clinical aspect, is confirmed by histological analysis. It shows a tumor composed of melanoma cells with a home often epidermal and dermal components.


Table I. Five-year survival according to Breslow
Table I. Five-year survival according to Breslow

The main criterion is histological prognosis.

This is the Breslow, representing the measurement of tumor height on histological examination.

The five-year survival is directly dependent on this index (Table I).

Thus, the prognosis is good for lesions with Breslow index of less than 0.75 mm, bad if the index is greater than 3 mm, intermediate and often unpredictable between.

The prognosis depends on other elements (the presence or absence of ulceration, histologic regression area, advanced age, male, acral or mucosal topography).

Table II. Features of melanomas according to their subtype
Table II. Characteristics of melanomas according to their subtype

The clinical and histological confrontations used to classify melanoma in six different groups, with variable prognosis (Table II).


The balance varies with the clinical severity:

– Melanoma thickness less than 1.5 mm, without remote location: clinical, chest x-ray and optionally échoabdominale (starting points);

– Adverse clinical lymph node, visceral or clinical Breslow thickness greater than 1.5 mm: computed tomography (CT) chest and brain.


Metastases may occur when tumor cells have invaded the dermis. They are first, for years, in the territory of nodal drainage. Later, they become palpable tumor. In situ metastasis may appear on the initial tumor site;cutaneous metastases in transit between the original injury and lymphatic drainage area. After lymph node invasion, there is a risk of visceral involvement (lung, brain, liver, etc.), with a poor prognosis.

The development of melanoma is capricious, with a large interindividual variability.

A specialized monitoring is necessary for life, metastases may occur long after the initial injury, and a second melanoma still remaining to fear.


The only curative treatment is surgical. Treatment and monitoring are initially the responsibility of a specialized environment. Melanoma is supported 100%.

The initial excisional biopsy should be performed as soon as possible. After confirming the diagnosis, surgical revision is performed at best by a surgeon in a center used to treat this type of pathology, whose margins depend on Breslow.

If extensive resection or decaying, skin grafting or flaps can be made. Melanomas of the ends are processed by a resection often to three centimeters of the tumor.

If clinically node involvement, lymph node dissection should be performed with histology and immunohistochemistry glands in search of micrometastases.

If more than 1.5 mm thick melanoma, sentinel lymph node biopsy may be proposed by some (vital staining research or scan the first node drainage, excision and frozen section of it, so reaching the dissection ganglion detected the final extemporaneous or histological examinations).

Adjuvant therapies (interferon) are the responsibility of specialist and specialized protocols.

Chemotherapy (Déticène®, Muphoran®) provides only low response rate. It is indicated in patients with metastatic visceral involvement.

Radiation therapy, very effective, is only palliative.

Vaccination is still in its infancy.


A specialized monitoring is necessary for life. For thick melanomas more than 1.5 mm, a check-up every three months is required for the first year. Between the third and fifth years, surveillance is biennial. She then became annual.

All clinical examination involves the complete skin examination.