BRIEF REPORTS
Fine-Needle Aspiration Cytology
of Desmoplastic Malignant
Melanoma Metastatic
to the Parotid Gland:
Case Report and Review of the Literature
David C. Chhieng, M.D., Joan F. Cangiarella, M.D.,
Jerry Waisman, M.D., and Jean-Marc Cohen, M.D.*
We report a case of desmoplastic malignant melanoma metastatic
to the parotid gland initially evaluated by fine-needle aspiration.
The cytologic findings consisted of scattered spindle cells in a
background of heterogeneous lymphoid cells. The spindle cells
were scant and displayed mild cytologic atypia. In addition, rare
stromal fragments were also present. Cytoplasmic pigment and
intranuclear cytoplasmic inclusions were not seen. The initial
impression was that of a reactive lymph node with fibrosis. In
retrospect, rare spindle cells displayed moderate atypia. In addi-
tion, the stromal fragments were cellular and contained spindle
cells with mild atypia. These cytologic findings along with a known
history of malignant melanoma should provide clues to the correct
diagnosis of desmoplastic malignant melanoma. Diagn. Cytopa-
thol. 2000;22:97–100. r 2000 Wiley-Liss, Inc.
Key Words: malignant melanoma; desmoplasia; metastasis; parotid
gland; needle biopsy
Desmoplastic malignant melanoma (DMM) was first de-
scribed by Conley et al. in 1971.1 It is a rare subtype of
malignant melanoma that is characterized by a proliferation
of spindle neoplastic cells with a variable stromal re-
sponse.1–3 The majority of these tumors arise in the sun-
damaged skin of the head and neck region and have a high
propensity to spread along nerve fascicles.4–7 The cytologic
features of malignant melanoma have been well de-
scribed.8–12 However, there is only one case report on the
cytologic findings of DMM.13 We report a case of DMM
involving the parotid gland initially evaluated by fine-needle
aspiration (FNA) biopsy. The cytologic findings are de-
scribed along with a discussion of the differential diagnosis.
Department of Pathology, New York University of Medical Center, New
York, New York
*Correspondence to: Jean-Marc Cohen, M.D., Department of Pathology,
Beth Israel Medical Center, First Avenue at 16th Street, New York NY
10003.
Received 2 March 1999; Accepted 24 June 1999
r 2000 WILEY-LISS, INC.
Case Report
A 45-year old Caucasian male first presented with a pig-
mented lesion of the forehead 2 years ago. A wide excision
was performed. The histology revealed a malignant mela-
noma, Clark level IV with a thickness of 3.8 mm. The lesion
was composed of both epithelioid and spindle-shaped mela-
nocytes. The melanoma recurred in the forehead 1 year later
and was again completely excised. Six months later, the
patient presented with a 2-week history of a left parotid
mass. Physical examination revealed a 2-cm firm, movable
mass of the left parotid gland. The overlying skin was
unremarkable. An FNA biopsy was performed and the
aspiration smears were interpreted as a reactive intraparotid
lymph node. The parotid swelling became smaller after a
course of antibiotic treatment but never completely resolved.
An FNA was repeated 6 months later. A cytologic diagnosis
of reactive lymphoid hyperplasia with fibrosis was made.
Because of persistence of the parotid swelling despite
conservative treatment, a left parotidectomy was performed.
Materials and Methods
The FNAs were performed by cytopathologists using 25-
gauge needles. The smears were either air-dried or fixed in
95% ethanol and then stained with a modified Giemsa or the
Papanicolaou stain, respectively. The surgical specimen was
fixed in 10% buffered formalin and embedded in semisyn-
thetic paraffin. Five µm sections were cut and stained with
hematoxylin and eosin. Additional sections were obtained
for immunohistochemical study. After deparaffinization, the
sections were placed in a citrate buffer and treated in a
microwave oven for 10 min. The immunostaining was
performed with antibodies to S-100 protein and HMB-45
antigen. Appropriate positive and negative controls were
performed. Additional material of the surgical specimen was
Diagnostic Cytopathology, Vol 22, No 2 97
CHHIENG ET AL.

Fig. 1. The aspiration smear was cellular and consisted of numerous

lymphocytes and rare benign salivary gland acinar cells (open arrow). In Fig. 2. Rare spindle cells with moderate nuclear enlargement and pleomor-
addition, there were scattered spindle cells with elongated and slender phism were noted (arrow). The cytoplasm was delicate and devoid of
nucleus and fine chromatin (solid arrow) (Papanicolaou stain x600). pigment (Diff-Quikt stain x600).

also fixed in glutaldehyde for ultrastructural examination.

Ultrathin sections were cut, stained with uranyl acetate and
lead citrate, and examined under a transmission electron
microscope.

Results
Cytologic Findings
Both aspiration smears were cellular and consisted of a
heterogeneous population of lymphocytes. Rare fragments
of dense fibrous stroma and benign salivary gland tissue
were also noted. In addition, there were scattered spindle
cells in the second aspiration smears (Fig 1). The majority of
the spindle cells appeared as naked nuclei. The cytoplasm,
when present, was scanty, delicate, and devoid of pigment.
The nuclei were elongated and slender with fine chromatin.
The spindle cells were initially interpreted as consistent with
fibroblasts. In retrospect, rare spindle cells displayed moder-
ate atypia with nuclear enlargement, irregular nuclear con-
tours, and prominent nucleoli (Fig. 2). Furthermore, the
stromal fragments were cellular and contained atypical
spindle cells. Similar spindle-shaped cells were also noted in
the first aspiration smears, but they were scantier and less
conspicuous than those in the second aspiration smears.
Immunostaining for S-100 protein performed on a destained
slide was noncontributory.
Gross and Histologic Findings
The surgical specimen consisted of a parotidectomy speci-
men with overlying skin and subcutaneous tissue. The skin
appeared unremarkable. On serial sectioning of the parotid
gland, the glandular parenchyma was partly replaced by a
poorly circumscribed, firm, white mass, measuring 5 ⫻
3.5 cm.
Microscopically, a fibrous-appearing tumor diffusely infil-
trated the parotid gland, the adjacent soft tissue, and the deep
dermis of the overlying skin. The tumor was highly variable
Fig. 3. Histologic section revealed an infiltrating tumor composed of
spindle cells arranged in fascicles. There was extensive intercellular
collagenous deposition. A prominent lymphoid infiltrate was noted. (Insert)
The neoplastic cells displayed mild to moderate atypia. Mitotic figures were
frequent. Cytoplasmic pigmentation was absent (hematoxylin and eosin
x40, insert: x400).
in cellularity and composed of spindle cells arranged in
fascicles and whorls (Fig. 3). The neoplastic cells displayed
mild to moderate atypia. Mitotic figures were frequent.
Cytoplasmic pigmentation was absent. There was extensive
intercellular collagenous deposition. A prominent lymphoid
infiltrate, particularly in the perivascular areas, was noted.
Perineural invasion was frequent. The histologic findings
were consistent with the diagnosis of DMM. Two intrapa-
rotid lymph nodes were also involved by DMM.
The tumor cells were immunoreactive with S-100 protein
but negative for HMB-45 antigen. Ultrastructural examina-
tion revealed bundles of spindle cells with irregular nuclear
contours, prominent cytoplasmic processes, and occasional
cell junctions. Basement membrane material was focally
present. Rare structures consistent with premelanosomes

98 Diagnostic Cytopathology, Vol 22, No 2


were also seen. These findings supported the diagnosis of
DMM.
Discussion
Malignant melanoma can manifest itself in various morpho-
logic patterns and cell types, thus mimicking benign as well
as malignant neoplasms. Desmoplastic malignant melanoma
(DMM) is an uncommon subtype and is associated with
higher frequency of local recurrence.4 The histology has
been well described and is characterized by a spindle cell
proliferation with variable cellularity.1–4,6 The neoplastic
cells arrange themselves in interlacing fascicles or whorls
and exhibit mild to marked polymorphism. Melanin pigment-
containing neoplastic cells as well as melanophages may be
found but are usually absent. A desmoplastic response, in the
form of collagenization of the intercellular stroma, is almost
invariably present. Therefore, some areas, in which there is
an abundant collagen deposition along with relatively bland
appearing spindle cells, may be mistaken as a benign
process.14 Neurotropism is found in many but not all DMMs.
Perivascular lymphoid infiltrates are often noted and in some
tumors can be prominent and misinterpreted as inflamma-
tory skin lesions or malignant lymphoma.15 Histologic
patterns resembling a malignant fibrous histiocytoma (MFH),
a peripheral nerve sheath tumor (PNST), and a smooth
muscle tumor have also been described.4,6 There is much
controversy about the origin of the neoplastic cells. Most
workers believe that the neoplastic cells are melanocytic in
origin and undergo progressive metaplasia towards fibro-
blasts, myofibroblasts, or schwannian cells.1,3–5
The cytologic findings of DMM have rarely been de-
scribed in the literature. Egbert et al.16 mentioned the use of
FNA in the diagnosis of a metastatic lesion in one of their 25
cases of DMM; they did not describe the cytologic features.
Nance et al.13 described the cytologic findings of DMM from
a recurrent chest wall lesion and a metastatic lesion to the
adrenal gland from the same patient. They reported the
presence of microtissue fragments of spindle cells with
hyperchromatic nuclei and prominent nucleoli. On the
contrary, we observed predominantly isolated spindle cells
in a background of a heterogeneous population of lymphoid
cells. The latter could represent the prominent lymphoid
infiltrate often seen in DMM or could be secondary to the
sampling of the intraparotid lymph node. As the neoplastic
cells could undergo fibroblastic differentiation and appear
bland, they may be overlooked or be difficult to differentiate
from reactive fibroblasts. In retrospect, rare spindle cells
with moderate atypia were identified. Intracytoplasmic pig-
ment and intranuclear cytoplasmic inclusions were not seen
in our case as well as others.13
The cytologic differential diagnosis of DMM is broad and
includes a variety of benign and malignant spindle cell
processes. Benign processes that should be considered
include dermatofibroma, schwannoma, neurofibroma, leio-
DESMOPLASTIC MALIGNANT MELANOMA
myoma, and fibromatosis. It is important to differentiate a
reparative process with scarring from a locally recurrent
DMM.13 The presence of significant cytologic atypia favors
a diagnosis of DMM over a benign process. Malignant
lesions that should be distinguished from DMM include
sarcomatoid carcinoma, MFH, MPNST, leiomyosarcoma,
and fibrosarcoma. If cytologic evidence of specific differen-
tiation is not apparent, these lesions may be difficult to
separate from DMM since the latter often lack cytoplasmic
pigments and other characteristic features of malignant
melanoma. The use of ancillary studies such as immunocyto-
chemical staining may be helpful in the differential diagno-
sis. The majority of DMMs will be positive for vimentin,
S-100 protein, and neuron specific enolase.4 HMB-45 anti-
gen, a marker for malignant melanoma, is usually negative
in DMMs.17 Electron microscopy may also be helpful if
premelanosomes and/or melanomas are identified.16
The differentiation of DMM from MPNST may be
difficult or even impossible because both tumors have many
overlapping features. DMM often demonstrates evidence of
schwannian differentiation at both light and electron micro-
scopic levels.2,6,18,19 Both tumors are immunoreactive for
S-100 protein and negative for HMB-45 antigen.6,15 Clinical
information such as a known history of a melanocytic lesion,
the presence of lymph node metastases, or a history of
neurofibromatosis may be useful in their differentiation.5,7,20
Since both entities are of neural crest origin and are
aggressive, some authors consider the distinction between
DMM and MPNST irrelevant.2,5
DMM often arise in the sun-damaged skin of the head and
neck region of elderly patients.1,2,5–7,13,15,16 There is a slight
male predominance.4,6,14 They can arise as a complication of
many types of malignant melanoma but most frequently
with lentigo maligna.1,5 Although malignant melanoma
frequently involves the parotid gland, only rare examples of
DMM involving the parotid gland have been reported. Three
cases of recurrent DMMs involving salivary gland were
reported by Reed and Leonard.5 Auclair et al.21 reported one
neurotropic melanoma in their report of 67 cases of sarcoma-
toid neoplasms of the parotid gland. Labrecque et al.22
mentioned a case of parotid gland involvement by recurrent
DMM. Jennings et al.,23 in their report of five additional
cases of parotid involvement by DMM, suggested that the
mode of spread of DMM to the parotid gland could also be
along nerve fibers in addition to via lymphatic and by direct
extension. Superficial parotidectomy and wide local exci-
sion with or without radiation therapy have resulted in
effective local control.5,23
In summary, we report the cytologic findings of a case of
DMM metastatic to the parotid gland. It is important to
consider DMM in the differential diagnosis of a spindle cell
lesion, especially in patients with a history of cutaneous
Diagnostic Cytopathology, Vol 22, No 2 99
CHHIENG ET AL.
malignant melanoma. The use of ancillary studies may be
helpful in making the diagnosis.
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