Progress of multiple cutaneous and subcutaneous melanoma metastases of the face during imiquimod treatment

A 68‐year‐old man developed a local recurrence with multiple cutaneous and subcutaneous nodules three months after excision of a primary malignant melanoma of the temple. Despite extensive surgery and adjuvant irradiation, another local recurrence occurred. Following further local progression during dacarbazine chemotherapy, topical treatment with imiquimod was begun and the chemotherapy was changed to fotemustine. During this treatment further local progression occurred and two months later regional lymph node and distant metastasis were detected. The patient died from his tumor disease eighteen months after the first diagnosis of malignant melanoma.     

Management of regional metastases

Treatment of regional melanoma metastases aims not only at local remission of the primary tumour but also at prevention or delay of distant metastases. Regional metastases can occur as satellite, in-transit and regional lymph node metastases. This is an overview of the current therapeutic modalities for regional metastatic melanoma: surgical management of relapse, satellite and in-transit metastases; therapeutic lymphadenectomy; development from elective lymph node dissection to sentinel lymph node dissection (SLND); radiotherapy and isolated limb perfusion. Instead of elective lymph node dissection the new microstaging technique by means of SLND is gaining particular importance. For this method prognostic relevance is expected and thus it is supposed to be an important staging parameter for adjuvant treatment planning.     

Erfahrungen mit der neuen American Joint Committee on Cancer (AJCC)‐Klassifikation des kutanen malignen Melanoms

A new AJCC/UICC staging classification of malignant melanoma was published in 2001 and has been in use since then. Compared to the TNM classification used for the previous 15 years, the new classification contains fundamental changes. The classification of the primary tumor is now based on newly defined classes for Breslow's tumor thickness (0 – 1.0 mm; 1.01 – 2.0 mm, 2.01 – 4.0 mm; > 4.0 mm). Histopathologically diagnosed ulceration is the second prognostic factor in primary melanoma and its presence leads to upstaging into the next higher T category. Clark level of invasion is now only relevant for tumors up to 1 mm thick; levels IV and V are also reasons for upstaging. Classification of regional lymph node metastasis distinguishes between microscopic metastasis only as detected with sentinel lymph node biopsy and clinically detectable macroscopic metastasis. Additionally, the number of metastatic nodes and the presence of satellite and in‐transit metastasis are prognostic factors for classification of regional lymph node metastasis. In distant metastasis, the kind of organ involvement has a role for classification (only skin and lymph nodes vs. lung vs. other organs) and an elevated LDH value leads to upstaging. A critical analysis of data of the German Central Malignant Melanoma Registry did not confirm the strong role of histopathological ulceration of the primary tumor in all T‐ and N‐stages. Furthermore, there is an inconsistency of the classification as stage IIC displays a significantly worse prognosis as compared to stage IIIA. In spite of these drawbacks the new staging classification should used particularly in clinical trials in order to make data internationally comparable.     

Descriptive analysis of cutaneous recurrence patterns in patients with melanoma

Background and objectivesFew studies have addressed cutaneous recurrence of melanoma. The aim of this retrospective study was to analyze the characteristics and prognostic significance of the different patterns of cutaneous recurrence.Material and methodsPatients diagnosed with melanoma between 1988 and 2008 at Hospital de Bellvitge, Barcelona, Spain and for whom data were available for at least 2 years of follow-up were included in the study. Local recurrence was defined as melanoma invasion of the skin adjacent to the scar left by excision of the primary tumor, regional metastasis or recurrence as metastasis restricted to the area drained by a regional lymph node station, and distant cutaneous metastasis as metastasis occurring outside this area. The relationship between cutaneous recurrence pattern and age, sex, primary tumor site, tumor subtype, Breslow depth, and ulceration was assessed.ResultsEighty-five out of 1,080 patients (7.87%) had cutaneous recurrence. In 71 of those patients (83.53%; 27 men and 44 women; mean age, 60.68 years), this was the first indication of melanoma recurrence. Thirty-two patients had local recurrence, 32 regional metastasis, and 7 distant metastasis. Significant differences were observed in survival time from diagnosis of the primary tumor (P = .044) and from diagnosis of cutaneous recurrence (P < .001) according to the type of recurrence.ConclusionsOur results suggest that the pattern of cutaneous recurrence is prognostically significant and related to the site of the primary tumor given that the majority of local and regional recurrences occurred in primary tumors located on the lower limbs and head.     

Risk factors for in-transit metastasis in patients with cutaneous melanoma

BackgroundIn-transit metastases have been associated with the presence of various negative prognostic factors in patients with cutaneous melanoma. It has recently been suggested that sentinel lymph node biopsy (SLNB) may lead to an increase in the incidence of this particular type of metastasis. In this study, we analyzed risk factors for the appearance of in-transit metastasis and its potential association with the use of SLNB.Material and methodsA prospective study was undertaken in a cohort of 404 patients with cutaneous melanoma seen in the melanoma unit of Hospital San Cecilio in Granada, Spain. Statistical analysis was performed with SPSS 15.0 and Epidat 3.1 using the χ² and Fisher exact tests.ResultsOut of 93 (23%) patients with recurrence at any time, 28 (6.9%) had in-transit metastases. The occurrence of in-transit metastasis was associated with age greater than 50 years, greater Breslow depth and Clark level, the presence of ulceration, positive SLNB, and the presence of other types of recurrence (local recurrence, lymph node metastasis, or distant metastasis). There was no relationship between surgical treatment or performing SLNB and the presence of in-transit metastasis.ConclusionsThe risk factors for in-transit metastasis are the same as those for any type of recurrence and coincide with factors linked to poor prognosis. Given that in-transit metastases are much more common in patients with positive SLNB, while the technique itself is not linked to their occurrence, these findings suggest that the appearance of in-transit metastasis is linked to biological characteristics of the tumor cells rather than an influence of the surgical technique.     

Should adjuvant radiotherapy be recommended following resection of regional lymph node metastases of malignant melanomas?

BACKGROUND: Several authors have recommended adjuvant radiotherapy following resection of regional lymph node metastases in cutaneous malignant melanoma. There is, however, little evidence from controlled trials that patients benefit from this treatment. OBJECTIVES: To evaluate the usefulness of adjuvant radiotherapy following resection of lymph node metastases in cutaneous malignant melanoma. METHODS: We performed a retrospective study comparing 58 patients who underwent radiotherapy following resection of regional lymph node metastases with 58 controls from another centre who exclusively underwent regional lymphadenectomy. Patients and their controls were matched with respect to the number of tumour-bearing lymph nodes (1 vs. > 1) and to gender, although the proportion of thick tumours was greater in the irradiation group. RESULTS: The overall survival curves were almost identical in the two groups. There were nine disease recurrences in the study group and 12 in the control group (not significant). Regional recurrences in the irradiated patients were usually accompanied by metastases at other sites. CONCLUSIONS: The present study does not support the recommendation of adjuvant radiotherapy following resection of regional lymph node metastases in patients with malignant melanoma.     

Lack of survival benefit in sentinel lymph node‐positive melanoma with immediate complete lymphadenectomy – a review

For decades, melanoma surgery has been guided by the Halstedian concept of stepwise metastasis, first into the lymph nodes and subsequently to distant sites. Early complete lymph node dissection (CLND) was therefore recommended in order to improve survival. Four large prospective randomized trials failed to show any survival benefit of CLND in comparison to observation alone. Sentinel lymph node biopsy was introduced in the 1990's, and CLND was limited to patients with positive sentinel nodes. Based on lymphoscintigraphy, it was pointed out that draining lymph nodes can now be detected more accurately. In one large trial, sentinel lymph node‐guided CLND was compared to observation alone, and no advantage for melanoma‐specific survival was detected. More recently, two prospective randomized studies tested whether CLND improved melanoma‐specific survival or overall survival in patients with positive sentinel nodes. Neither study found a better survival rate for patients with CLND than with observation alone. The reason for the failure of CLND to improve survival is clearly parallel development and not stepwise development of lymph node metastasis and distant metastasis. Immediate CLND in melanoma surgery is therefore called into question.     

Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma

BackgroundSentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure.ObjectiveTo evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma.Methods:Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm², ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05.Results:Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome.Study limitations:The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization.Conclusions:In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.     

Disease progression in patients with thin cutaneous melanomas (tumour thickness < or = 0.75 mm): clinical and epidemiological data from the Tumour Center Munich 1977-98

BACKGROUND: Although survival in patients with thin melanomas (tumour thickness < or = 0.75 mm) is usually excellent, thin melanomas have the potential to metastasize. OBJECTIVES: To determine risk factors for the development of disease progression in patients with thin cutaneous melanomas. METHODS: A retrospective study was performed between 1977 and 1998 to identify risk factors for the development of disease progression in 2302 patients with cutaneous melanoma with tumour thickness < or = 0.75 mm, diagnosed and treated at the Department of Dermatology and Allergology, Ludwig-Maximilians University, Munich, Germany. The Kaplan-Meier method was used to estimate the influence of different clinical characteristics for the occurrence of first progression during 10 years of follow-up. RESULTS: An analysis of the data from 6298 patients with cutaneous melanoma identified 2302 patients (37%) who presented with cutaneous melanoma with a tumour thickness < or = 0.75 mm, without clinical signs of metastasis at initial diagnosis (clinical stage Ia). A small subgroup of our patients (77 of 2302) developed metastatic disease during the follow-up period. The estimated rate of occurrence of metastasis after 10 years of follow-up was 4.7%. The mean follow-up time was 62 months (median 46). Of these 77 patients, 16 experienced progression at the primary tumour site and 32 presented with regional lymph node metastases. Twenty-eight patients primarily developed systemic metastases (seven patients with and 20 without regional lymph node metastases, one patient with regional lymph node metastases and local recurrence). In one patient the primary site of metastatic disease was not reported. Clinical characteristics included age, sex of the patient and different subtypes of cutaneous melanoma: superficial spreading melanoma, nodular melanoma, acrolentiginous melanoma (ALM) and lentigo maligna melanoma (LMM). Male patients and patients with LMM or ALM were significantly over-represented (P = 0.02 and P = 0.002). In the group of 77 patients with thin melanomas (< or = 0.75 mm), local recurrence was over-represented as compared with those with melanomas > 0.75 mm. No difference in group was found for overall survival after the occurrence of lymph node metastasis as the first manifestation of disease progression. CONCLUSIONS: Thorough follow-up and skin examination is recommended for a subgroup of patients with thin tumours, which consists of male patients with LMM or ALM located in the head and neck region.     

Late recurrence (10 years or more) of malignant melanoma in south‐east Germany (Saxony) A single‐centre analysis of 1881 patients with a follow‐up of 10 years or more

Background Late recurrent melanoma (MM) is rare. Objective In the present study, we analysed the frequency of late recurrent MM in south‐eastern Germany. Patients and methods In our centre, 2314 MM patients were documented (1972–2001). A total of 1881 patients in stage I or II (AJCC) with a follow‐up of ≥10 years were selected and screened for late recurrence (≥10 years after diagnosis). Results Twenty patients were identified (1.1%), 13 women and 7 men, median age 44 years (age range 30–74 years). Nineteen suffered from cutaneous MM and one had a uveal MM (excluded from further analysis). The primary cutaneous MM occurred on the trunk (6), on the upper limb/shoulder (4), or on the lower limb (9). MM type was superficial spreading (13), nodular (2), acrolentiginous (1), lentigo maligna‐type (1) or unclassified (2). Tumour thickness varied from 0.33 mm to 9.5 mm (median 2.0 mm). Ulceration was seen in four, and spontaneous regression in two MM patients. Invasiveness into blood or lymphatic vessels occurred in seven MM patients. The largest period from primary diagnosis to recurrence was 25.1 years with a median of 13.9 years. Metastatic spread was loco‐regional (12 patients) or distant (7). Four patients were survivors and three of these had in‐transit metastases only. Overall survival was 14.7 ± 6.6 years. Statistical analysis could not identify factors significantly associated with late recurrence. Conclusions Late recurrence is a clinical sign of melanoma dormancy. We conclude that late recurrences argue for a lifelong follow‐up of melanoma patients.     

Molecular diagnostics in melanoma

Molecular pathology is rapidly evolving, featuring continuous technologic improvements that offer novel clinical opportunities for the recognition of disease predisposition, for identifying sub-clinical disease, for more accurate diagnosis, for selecting efficacious and non-toxic therapy, and for monitoring of disease outcome. Currently, the identification and prognosis of primary cutaneous melanoma is based on histologic factors (tumor depth and ulceration) and clinical factors (number of lymph node and/or distant metastases). However, metastasis can occur in patients with thin melanomas, and sentinel lymph node biopsy does not identify all patients at risk for distant metastasis. New markers exist that correlate with melanoma progression, which may aid in melanoma identification, prognostication, and detection of minimal residual disease/early recurrence. Moreover, not many therapeutic options exist for melanoma as no regimen prolongs survival. Emerging data with investigational therapies suggest that certain markers might play a crucial role in identifying patients who will respond to therapy or show utility in the monitoring the response to therapy. Herein, molecular diagnostics that can potentially benefit the individual melanoma patient will be discussed.     

Malignes Melanom der Uvula und des weichen Gaumens

Malignant melanoma of the uvula and soft palate is very rare. We describe a case demonstrating the typical aggressive behavior of mucosal melanoma in contrast to cutaneous melanoma. Regional lymph node and distant metastases often develop rapidly in this type of melanoma. Despite aggressive surgical approaches, other treatment options are often limited and usually palliative. Therefore, early diagnosis is critical in patients with mucosal melanoma.     

Immunohistochemical detection of lymphovascular invasion with D2-40 in melanoma correlates with sentinel lymph node status, metastasis and survival

Using immunohistochemistry with anti-D2-40 for the detection of lymphovascular invasion (LVI-IHC) in 74 cases of invasive melanoma, we found LVI in 23% (16/74) of the tumors. Data on sentinel lymph node (SLN) biopsy were available for 36 patients. Sixty-seven percent (6/9) of patients with LVI-IHC and 19% (5/27) without LVI-IHC had positive SLN. Follow-up data were available for 60 patients. Data on recurrence/metastasis were available for 60 patients. Twenty-five percent (15/60) had LVI with immunohistochemistry. Fifty-three percent (8/15) of these patients had "distant" metastasis or regional recurrence compared with 11% (5/45) in those without LVI-IHC. Overall and disease-specific survival was shorter for patients with LVI. In both the univariate and multivariate Cox proportional hazards regression models, LVI-IHC in addition to ulceration was statistically significant with respect to overall survival. Specifically, in the reduced multivariate model, compared with patients with no LVI, patients with intratumoral LVI had a hazard ratio (HR) of 5.4 (95% CI 1.6–18.4), while patients with peritumoral LVI had a HR of 3.8 (95% CI 0.7–20.9). In addition, patients with ulceration had an increased hazard of 4.4 (95% CI 1.2–16.8).
For the first time, we herein show a positive correlation with LVI in melanoma detected with immunohistochemistry and distant metastasis, overall survival and disease-free survival.     

Metastatic pathways and time courses in the orderly progression of cutaneous melanoma

BACKGROUND: It is known that two-thirds of patients who develop clinical metastases following treatment of a primary cutaneous melanoma initially present with locoregional metastases and one-third initially present with distant metastases. However, few reports in the literature give detailed figures on different metastatic pathways in cutaneous melanoma. OBJECTIVES: The aim of the present study was to perform a detailed analysis of the different metastatic pathways, the time course of the development of metastases and the factors influencing them. METHODS: In a series of 3001 patients with primary cutaneous melanoma at first presentation, 466 subsequently developed metastasis and were followed-up over the long term at the University of Tuebingen, Germany between 1976 and 1996. Different pathways of metastatic spread were traced. Associated risk factors for the different pathways were assessed. Differences in survival probabilities were calculated by the Kaplan-Meier method and evaluated by the log-rank test. RESULTS: In 50.2% of the patients the first metastasis after treatment of the primary tumour developed in the regional lymph nodes. In the remaining half of the patient sample the first metastasis developed in the lymphatic drainage area in front of the regional lymph nodes, as satellite or in-transit metastases (21.7%) or as direct distant metastases (28.1%). Anatomical location, sex and tumour thickness were significant risk factors for the development of metastasis by different pathways. The most important risk factor appeared to be the location of the primary tumour. The median intervals elapsing before the first metastasis differed significantly between the different metastatic pathways. The direct distant metastases became manifest after a median period of 25 months, thus later than the direct regional lymph node metastases (median latency period, 16 months) and the direct satellite and in-transit metastases (median latency period, 17 months). In patients who developed distant metastases the period of development was independent of the metastatic route. The time at which the distant metastases developed was roughly the same (between 24 and 30 months after the detection of the primary tumour), irrespective of whether satellite or in-transit metastases, lymph node metastases or distant metastases were the first to occur. CONCLUSIONS: The time course of the development of distant metastasis was more or less the same irrespective of the metastatic pathway; this suggests that in patients with in-transit or satellite metastasis or regional lymph node metastasis, haematogenic metastatic spread had already taken place. Thus, the diagnostic value of sentinel lymph node biopsy and the therapeutic benefit of elective lymph node dissection may be limited, as satellite and in-transit metastases or direct distant metastases will not be detected and haematogenous spread may already have taken place when the intervention is performed.     

Histologic correlates of metastasis in primary invasive squamous cell carcinoma of the lip

Clinical and histologic features of 44 invasive squamous cell carcinomas of the lip treated by surgical excsion were correlated with metastases and survival. Age, diameter, ulceration, grade, depth of invasion, muscle invasion, mitotic rate, lymphatic-vascular invasion, and tumor infiltrating lymphocytes were evaluated. Two (4.5%) patients had local recurrence, 10 (23%) had metastases to cervical lymph nodes, and 2 (4.5%) died from complications of extensive spread in the neck. One patient with local recurrence had regional node metastases. Regional metastases were discovered at the lime of (3 patients) or up to 21 (median 8) months after initial diagnosis, correlating with ulceration (P − 0.003), depth of invasion (P − 0.0001), and mitotic rate (P − 0.05) of the primary tumor. Depth exceeding 2.0 mm. was associated with metastasis (P − 0.028), and all carcinomas deeper than 6.0 mm. metastasized. Eight of the 10 patients with regional metastases had no farther disease after treatment through the follow-up period (median 64 months). Both fatalities were older (median 81 years) men. These results underscore the metastatic potential of invasive squamous cell carcinoma of the lip. Histologic analysis of the primary lesion can be used to identify individuals at risk.     

Merkel-Zell-Karzinom

Merkel cell carcinoma is a rare aggressive malignant neuroendocrine skin tumor, which can metastasize to lymph nodes early and often shows local recurrence. The prognosis depends on tumor size and disease stage. The majority of recurrences appear during the first 2 years after the primary diagnosis. The 5-year survival rate for primary tumor ?2 cm is 50–60?%. With lymph node metastases the 5-year survival rate is 42–52?%, while with distant metastases it drops to 17–18?%. Extensive staging inclusive sentinel lymph node biopsy is essential to assess the risk for distant metastasis and to allow the best recommendations for therapy. After surgical treatment with adequate safety margin, subsequent adjuvant radiation therapy of the tumor region and lymphatic draining basin is recommended to reduce the risk of local recurrence and lymphatic spread.     

Efficacy of positron emission tomography and computed tomography in clinical staging of cutaneous malignant melanoma

Accurate staging is very important for determining the prognosis and appropriate treatment for malignant melanoma (MM). The aim of this study is to determine the effectiveness of positron emission tomography and computed tomography (PET/CT) imaging in staging MM. Patients diagnosed with MM who then underwent PET/CT metastasis before treatment were assessed retrospectively. For each patient, the following variables were recorded: Breslow thickness, Clark's level, number of mitoses, the presence of ulceration detected in the pathology report, and the presence of lymph nodes and/or distant metastases detected by PET/CT. The pathology and PET/CT reports of 139 patients (79 female and 60 male) were retrospectively evaluated for staging after MM diagnosis. Patients with a Breslow thickness greater than 3.4 mm and Clark's level of 4 to 5 were found to be statistically significantly higher with regional lymph node metastasis after PET/CT scans. Patients with Breslow thickness greater than 2.85 mm and Clark's level of 4 to 5 were found to be statistically significantly higher with distant metastasis after PET/CT scan. The results of our study suggest that PET/CT imaging for metastasis scanning, starting with T2 patients, may be used in MM staging to reduce the need for sentinel lymph node (SLN) biopsy and lymph node dissection.     

Sentinel‐Lymphonodektomie beim malignen Melanom – ein Update

Ten years after the introduction of the sentinel lymph node biopsy technique in the management of malignant melanoma, it is time to take stock. The complex method has proved itself sufficiently sensitive, although a certain percentage of false‐negative histological results have to be taken into account. Presently, it is still a point at issue whether sentinel lymph node biopsy should be regarded as the standard of care in high‐risk patients. Three prospective multicentre trials have failed to demonstrate a survival benefit resulting from elective lymph node dissection. In contrast, a retrospective multicentre study has recently shown that patients with node metastases diagnosed by the sentinel procedure benefit from early excision of their nodal disease in terms of overall survival, as compared to patients with delayed dissection of palpable nodes. Studies worldwide have established the pathologic status of the sentinel lymph node biopsy as the most important prognostic factor for recurrence and survival after the excision of primary melanoma. As with any invasive staging procedure, sentinel lymph node biopsy should have demonstrated therapeutic consequences. Unfortunately, an unequivocally acknowledged adjuvant therapy is lacking. Moreover, the impact of complete lymph node dissection after positive sentinel biopsy on survival or local disease control has not yet been clarified.     

Routine FDG PET-CT in patients with a high-risk localized melanoma has a high predictive positive value for nodal disease and high negative predictive value for the presence of distant metastases

Background FDG PET‐CT is the superior imaging modality for the detection of visceral metastases (M+) in patients with melanoma. Conflicting evidence exists regarding its role for the initial staging of patients with high risk localized melanoma (large Breslow Thickness (BT) and/or ulceration). Objective To assess the role of routine staging with FDG PET‐CT in melanoma patients with localized high risk melanoma. Methods Forty‐eight consecutive patients with 1 < BT < 4 mm with ulceration and with BT ≥ 4 mm were staged with PET‐CT. PET‐CT procedures were performed on a GE Discovery ST® scanner. PET‐CT findings for regional nodal status and presence of distant metastatic disease were collected. The gold standard for nodal assessment was pathological examination. The gold standard for M+ was conventional imaging and clinical follow‐up, confirmed by biopsy whenever feasible. Results No patient had a positive PET‐CT for M+. Six patients (13%) had a non‐conclusive PET‐CT; none of them presented with M+ within 6 months. Forty‐three patients (90%) had a negative PET‐CT, amongst them only one patient (2.5%) presented with M+ within a year. Six patients had FDG‐avid lymph nodes in the drainage territory of the primary melanoma, either SLNB or lymph node dissection confirmed metastatic nodal involvement. The predictive positive value of PET for regional node involvement was 100%. Comments FDG PET‐CT does not seem to be effective at detecting M+ at baseline staging in patients with high risk localized melanoma. However, it has a high negative predictive value for the presence of M+ at 6 months and a high positive predictive value for nodal involvement.     

Composite haemangioendothelioma with lymph‐node metastasis: an unusual presentation at an uncommon site

A 48‐year‐old woman presented with red papules on the thigh. Histopathological examination indicated pyogenic granuloma, and the patient was treated with total excision in 2003 and electrocauterization in 2005. Three months later, upon recurrence of the lesions, a diagnosis of composite haemangioendothelioma (CHE) was made. The patient was treated by total excision and lymph‐node dissection, which revealed inguinal lymph‐node metastasis. Despite the surgery, a further local recurrence occurred, subsequently treated by wide excision en bloc, with adjuvant radiotherapy and chemotherapy. Although CHE is defined as a vascular tumour with low‐grade malignancy, the local recurrences and lymph‐node metastases resulted in treatment difficulties in this case. Unlike earlier cases, the tumour in our patient presented as localized numerous small papulonodules, and lymph‐node metastasis was detected within a relatively short time. Dermatologists and pathologists should be aware of this rare condition and include it in the differential diagnosis of vascular lesions.