Appearances may be deceiving

A 64-year-old white female presented with an asymptomatic brown-to-black nodular lesion located on her back in proximity (about 1.7 cm) to a surgical scar; indeed, the patient had developed a melanoma in situ on her back in 2010. She reported that the lesion had been present for two years (Figure 1). Family history of melanoma or other skin cancers were negative. On dermatoscopy, the lesion showed an atypical starburst pattern, characterized by a blue-white veil and blue globules in the center, and a peripheral polymorphous vascular pattern showing the presence of dotted, linear and irregular vessels (Figure 2). A milia-like cyst was also observed in the inferior part of the lesion. An excisional biopsy was performed with 2 mm margins. The diagnosis proposed to the pathologist was Spitz-Reed nevus or melanoma. Histology revealed interconnected small nests of basaloid cells attached to the epidermis, embedded in a fibrous stroma. Focally, melanin pigment was seen in tumor nests (Figure 3). Appearances may be deceiving