93-Year-Old Woman Misdiagnosed with Sarcoma Before Nipple Melanoma Discovery
A rare case of nipple melanoma underscores the need for accurate diagnosis to avoid unnecessary surgeries.
A 93-year-old woman was initially misdiagnosed with sarcoma before invasive melanoma was confirmed.
Histopathological analysis revealed significant diagnostic challenges due to limited tissue sampling.
The case highlights the importance of considering melanoma in persistent nipple lesions, regardless of patient gender.
A rare case involving a 93-year-old woman has brought to light the diagnostic challenges associated with nipple melanoma. Initially, the patient presented with an ulcerated lesion on her left nipple, which had been bleeding for eight months. Misdiagnosed as undifferentiated sarcoma, the true nature of the condition was only revealed post-surgery when invasive melanoma was identified. The lesion measured approximately 3–4 cm and was characterized by its firm, violaceous appearance.
The diagnostic process began with breast imaging that indicated a suspicious mass measuring 44 × 35 mm and enlarged axillary lymph nodes. Despite fine-needle aspiration yielding no malignant cells, a core biopsy suggested undifferentiated sarcoma. This led to a modified radical mastectomy and axillary lymph node dissection, which were performed based on the initial misdiagnosis.
Further examination through immunohistochemistry revealed that the lesion was actually an ulcerated invasive superficial spreading melanoma of the nipple-areolar complex, with a Breslow thickness of at least 60 mm. The tumor showed significant cellular variability and a heterogeneous expression of melanocytic markers. Although the initial biopsy was negative for S100, subsequent tests indicated patchy positivity for several markers, underscoring the limitations of the initial tissue sampling in diagnosing poorly differentiated malignancies.
All 15 dissected axillary lymph nodes were found to be negative, confirming the diagnosis of Stage IIC melanoma with clear surgical margins. Following a multidisciplinary review, the medical team opted against adjuvant therapy due to the patient’s advanced age. Remarkably, 26 months after the diagnosis, she remains disease-free. This case raises critical questions regarding the surgical management of nipple melanoma, suggesting that wide local excision may be more appropriate than mastectomy, which has not shown a survival benefit.
The rarity of primary nipple-areolar complex melanoma, which can mimic other conditions like Paget disease or benign pigmented lesions, emphasizes the necessity of including melanoma in the differential diagnosis for persistent nipple abnormalities. Enhanced histopathological assessments and appropriate biopsy techniques are essential to prevent diagnostic errors and facilitate less invasive surgical options.
