Head and Neck Mucosal Melanoma

Consensus for nonmelanoma skin cancer treatment: basal cell carcinoma, including a cost analysis of treatment methods

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer in the US population affecting approximately 2.8 million people per year. Basal cell carcinomas are usually slow-growing and rarely metastasize, but they do cause localized tissue destruction, compromised function, and cosmetic disfigurement.

OBJECTIVE

To provide clinicians with guidelines for the management of BCC based on evidence from a comprehensive literature review, and consensus among the authors.

MATERIALS AND METHODS

An extensive review of the medical literature was conducted to evaluate the optimal treatment methods for cutaneous BCC, taking into consideration cure rates, recurrence rates, aesthetic and functional outcomes, and cost-effectiveness of the procedures.

RESULTS

Surgical approaches provide the best outcomes for BCCs. Mohs micrographic surgery provides the highest cure rates while maximizing tissue preservation, maintenance of function, and cosmesis.

CONCLUSION

Mohs micrographic surgery is an efficient and cost-effective procedure and remains the treatment of choice for high-risk BCCs and for those in cosmetically sensitive locations. Nonsurgical modalities may be used for low-risk BCCs when surgery is contraindicated or impractical, but the cure rates are lower.

Update on primary head and neck mucosal melanoma

Primary mucosal melanomas (PMMs) of the head and neck are uncommon malignancies that arise mainly in the nasal cavity and paranasal sinuses, followed by the oral cavity. The mainstay of treatment is radical surgical resection followed by adjuvant radiotherapy in selected patients with high-risk features. Multimodality therapy has not been well studied and is not standardized. Adjuvant radiotherapy seems to improve locoregional control but does not improve overall survival (OS). Elective neck dissection is advocated in patients with oral PMM. Systemic therapy should be considered only for patients with metastatic or unresectable locoregional disease. Despite improvements in the field of surgery, radiotherapy, and systemic therapy, patients with PMM still face a very unfavorable prognosis (5-year disease-free survival [DFS] <20%) with high rates of locoregional recurrence and distant metastasis. The present review aims to summarize the current state of knowledge on the molecular biology, pathological diagnosis, and management of this disease.

Sinonasal malignancy: presentation and outcomes

OBJECTIVE

We wanted to identify the presentation, diagnostic work-up and treatment outcomes of patients with sinonasal malignancy at Derriford Hospital, Plymouth, UK and compare these with the European Position Paper on Endoscopic Management of Tumours of the Nose, Paranasal Sinuses and Skull Base.

MATERIALS AND METHODS

This was a retrospective audit of all patients diagnosed with sinonasal malignancy over a five-year period. The clinical records and picture archiving and communications system data of the patients were reviewed.

RESULTS

Thirty patients with sinonasal malignancy were identified out of 570 head and neck cancer patients. The nasal cavity was the most common site for presentation, followed by the maxillary sinuses. Fifty per cent of patients had a squamous cell carcinoma and 27 per cent had a malignant melanoma. Half of the patients presented at stage IV of the cancer and 20 per cent at stage III. Thirty-seven per cent of patients underwent surgical management and only 20 per cent of the total patient group underwent endoscopic surgery. The mortality in our series was 30 per cent over the studied period.

CONCLUSION

Late-stage presentation of sinonasal malignancy has resulted in increased patient mortality in our case series. Also, we found a high incidence of malignant melanoma with high recurrence and survival rates.

Complete response of huge buccal malignant melanoma in an octogenarian patient to arterial chemotherapy

BACKGROUND

Primary oral mucosal melanoma is uncommon. However, it is an aggressive entity, and the absence of a standardized treatment protocol makes for an extremely poor prognosis.

METHODS

We described the clinical course and treatment by arterial chemotherapy of an 87-year-old patient with nonresectable huge buccal malignant melanoma. Continuous intra-arterial infusion of fluorouracil (50 mg/24 hours) and 1 intermittent weekly 10-mg shot of cisplatin were given.

RESULTS

The patient with oral melanoma presented with a roughly 6- × 4-cm exophytic mass that was noticed on the right buccal mucosa. The buccal tumor regressed dramatically until complete disappearance of the tumor mass was achieved at 2.5 months after intra-arterial chemotherapy was initiated. In total, 2880 mg of fluorouracil and 80 mg of cisplatin were administrated. The side effects of intra-arterial chemotherapy were mild and tolerable.

CONCLUSION

Our data demonstrate that intra-arterial chemotherapy could be an alternative treatment for nonresectable buccal malignant melanoma.

Metabolic response by FDG-PET to imatinib correlates with exon 11 KIT mutation and predicts outcome in patients with mucosal melanoma

BACKGROUND

In patients with metastatic melanoma and KIT amplifications and/or mutations, therapy with imatinib mesylate may prolong survival. 18F-labeled 2-fluoro-2-deoxy-D-glucose (18F-FDG) PET/CT may be used to assess metabolic response. We investigated associations of metabolic response, mutational status, progression-free survival and overall survival in this population.

METHODS

Baseline and 4-week follow-up 18F-FDG-PET/CT were evaluated in 17 patients with metastatic melanoma and KIT amplifications and/or mutations treated with imatinib in a multicenter phase II clinical trial. The maximum standardized uptake values (SUVmax) were measured in up to 10 lesions on each scan. Metabolic response was classified using modified EORTC criteria. Each patient had a diagnostic CT or MR at baseline, after 6 weeks of therapy and then at intervals of 2 months and anatomic response was classified using RECIST 1.0. Median follow-up was 9.8 months.

RESULTS

Partial metabolic response (PMR), stable metabolic disease (SMD) and progressive metabolic disease (PMD) was seen in 5 (29%), 5 (29%), and 7 (41%) patients respectively. Five patients (29%) had a KIT mutation in exon 11, four of whom (80%) had PMR while 1 (20%) had SMD. Twelve patients (71%) did not have a KIT mutation in exon 11, and only 1 (8%) had PMR, 4 (33%) had SMD and 7 (58%) had PMD. There was agreement of metabolic and anatomic classification in 12 of 17 patients (71%). Four of 17 patients (24%) had PR on both metabolic and anatomic imaging and all had a KIT mutation in exon 11. Survival of patients with PMD was lower than with SMD or PMR.

CONCLUSIONS

Metabolic response by 18F-FDG-PET/CT is associated with mutational status in metastatic melanoma patients treated with imatinib. 18F-FDG-PET/CT may be a predictor of outcome, although a larger study is needed to verify this.

CLINICAL TRIAL REGISTRATION

NCT00424515.

Orbital complications:diagnosis of different rhinological causes

To evaluate the clinical course of orbital complication using a standardised diagnostic pathway. Seventy-three patients with orbital complications underwent a multimodal diagnostic pathway comprising ENT examination, leucocytes/CRP, CT-/MRI-scanning and disease-related data. Twenty-nine patients suffered from rhinosinusitis, 28 from mucoceles, 13 patients from neoplasms and three patients from rheumatic disorders. Clinical examination diagnosed 60 patients with eyelid swelling, 55 patients with ocular pain, 14 patients with diplopia, 4 patients with exophthalmus, 29 patients with visual field defect and 4 patients with visual loss. The diagnostic pathway identified acute rhinosinusitis with a sensitivity/specificity of 90 %/90 %, mucoceles with 79 %/100 %, neoplasms with 100 %/96 % and granulomatosis with polyangiitis with 100 %/100 %, respectively. All patients left the hospital in good general condition and with regular ocular motility; two patients suffered persistent visual loss. The standardised application of a widely accepted diagnostic pathway reliably distinguishes different causes of orbital complication.

High-dose proton beam therapy for sinonasal mucosal malignant melanoma

Background

The significance of definitive radiotherapy for sinonasal mucosal melanoma (SMM) is sill controvertial. This study was to evaluate the role of high-dose proton beam therapy (PBT) in patients with SMM.

Methods

The cases of 20 patients with SMM localized to the primary site who were treated by PBT between 2006 and 2012 were retrospectively analyzed. The patterns of overall survival and morbidity were assessed.

Results

The median follow-up time was 35 months (range, 6–77 months). The 5-year overall and disease-free survival rates were 51% and 38%, respectively. Four patients showed local failure, 2 showed regrowth of the primary tumor, and 2 showed new sinonasal tumors beyond the primary site. The 5-year local control rate after PBT was 62%. Nodal and distant failure was seen in 7 patients. Three grade 4 late toxicities were observed in tumor-involved optic nerve.

Conclusion

Our findings suggested that high-dose PBT is an effective local treatment that is less invasive than surgery but with comparable outcomes.

Multilocular sinonasal malignant melanoma: a poor prognostic subgroup?

Clinical observations show that two subtypes of sinonasal malignant melanoma exist: uni- and multilocular melanoma. The aim of this retrospective study was to determine the prevalence and outcome of multilocular sinonasal malignant melanoma. All patients with sinonasal malignant melanoma treated at our institution between 1992 and 2011 were included. Survival and recurrence data were analyzed related to the distribution pattern of the tumors and other factors. Twenty-five patients were identified and included in the analysis. Seven patients (28 %) suffered from multilocular, the remaining 18 patients (72 %) from unilocular sinonasal malignant melanoma. The first group showed a significantly worse disease-free survival, whereas disease-specific and overall survival did not differ between the two subtypes. Multilocular sinonasal malignant melanoma is associated with an unfavorable disease-free survival compared to its unilocular counterpart.

Fast neutron radiotherapy for primary mucosal melanomas of the head and neck

BACKGROUND

Primary head and neck mucosal melanomas (HNMMs) are rare tumors managed with surgery and/or radiotherapy and associated with poor outcomes. Given their radioresistance, high linear energy transfer radiotherapy with neutrons may improve local control.

METHODS

We conducted a retrospective review of 14 patients with HNMM treated with neutrons at the University of Washington from 1990 to 2012. Five patients had T3 disease, 9 had T4 disease, 3 had regional nodal disease, and 4 had distant metastases at diagnosis. Primary sites were sinonasal (n=10), lip (n=2), and palate (n=2). Ten patients had initial surgical resection/debulking.

RESULTS

Nine patients had gross residual disease, 6 had complete response, and 3 had partial response. Local control was achieved in 79% until death or last follow-up, and 50% developed distant metastases. Kaplan-Meier 5-year local control was 66% and overall survival was 21%.

CONCLUSION

High rates of locoregional control were achieved with neutrons, despite the presence of gross disease. Survival was limited by early distant metastases.

Malignant melanoma metastatic to the larynx: a case report

Malignant melanoma of the larynx is a rare cancer that can appear as a primary tumor or as a metastasis from a cutaneous head and neck primary. To the best of our knowledge, only 60 cases of primary laryngeal melanoma have been reported in the world literature. Melanomas metastatic to the larynx are even more rare, as only 24 cases have been previously reported. Survival is poor, and recurrence is uncommon. We describe a new case of a malignant melanoma metastatic to the larynx, which represents the first such case in Iran.

Pigmented lesions of the oral cavity: an update

Oral pigmentation may be focal, multifocal, or diffuse. The lesions may be blue, purple, brown, gray, or black. They may be macular or tumefactive. Some are localized harmless accumulations of melanin, hemosiderin, or exogenous metal; others are harbingers of systemic or genetic disease; and some can be associated with life-threatening medical conditions that require immediate intervention. The differential diagnosis for any pigmented lesion is extensive, and can include examples of endogenous and exogenous pigmentation. Although biopsy is a helpful and necessary aid in the diagnosis of focally pigmented lesions, with diffuse presentations lesions require a thorough history and laboratory studies to establish a definitive diagnosis.

Imatinib for melanomas harboring mutationally activated or amplified KIT arising on mucosal, acral, and chronically sun-damaged skin

PURPOSE

Amplifications and mutations in the KIT proto-oncogene in subsets of melanomas provide therapeutic opportunities.

PATIENTS AND METHODS

We conducted a multicenter phase II trial of imatinib in metastatic mucosal, acral, or chronically sun-damaged (CSD) melanoma with KIT amplifications and/or mutations. Patients received imatinib 400 mg once per day or 400 mg twice per day if there was no initial response. Dose reductions were permitted for treatment-related toxicities. Additional oncogene mutation screening was performed by mass spectroscopy.

RESULTS

Twenty-five patients were enrolled (24 evaluable). Eight patients (33%) had tumors with KIT mutations, 11 (46%) with KIT amplifications, and five (21%) with both. Median follow-up was 10.6 months (range, 3.7 to 27.1 months). Best overall response rate (BORR) was 29% (21% excluding nonconfirmed responses) with a two-stage 95% CI of 13% to 51%. BORR was significantly greater than the hypothesized null of 5% and statistically significantly different by mutation status (7 of 13 or 54% KIT mutated v 0% KIT amplified only). There were no statistical differences in rates of progression or survival by mutation status or by melanoma site. The overall disease control rate was 50% but varied significantly by KIT mutation status (77% mutated v 18% amplified). Four patients harbored pretreatment NRAS mutations, and one patient acquired increased KIT amplification after treatment.

CONCLUSION

Melanomas that arise on mucosal, acral, or CSD skin should be assessed for KIT mutations. Imatinib can be effective when tumors harbor KIT mutations, but not if KIT is amplified only. NRAS mutations and KIT copy number gain may be mechanisms of therapeutic resistance to imatinib.

BRAF and GNAQ mutations in melanocytic tumors of the oral cavity

OBJECTIVE

The genetic factors participating in oral melanoma evolution have not been studied extensively. We aimed to analyze the prevalence of BRAF and GNAQ mutations in a series of oral melanocytic tumors, nevi, and melanomas.

STUDY DESIGN

The study group consisted of 4 melanomas and 10 nevi (6 intramucosal, 4 blue nevi). DNA was extracted from paraffin-embedded tissue sections, and mutations in GNAQ and BRAF were analyzed with the use of mass spectrometery.

RESULTS

V600E point mutation was identified in the BRAF gene in 3 intramucosal nevi and in 2 melanomas. Only 1 blue nevus harbored the GNAQ209 mutation. None of the BRAF-positive samples harbored GNAQ mutations.

CONCLUSIONS

The finding of BRAF mutations in oral benign and malignant melanocytic lesions points to a potential initiating role of BRAF in malignant transformation, which may have important therapeutic implications as those with BRAF mutations may benefit from specific treatment using RAF inhibitors.

Rising incidence of mucosal melanoma of the head and neck in the United States

Background. While it is established that the incidence of cutaneous melanoma has risen over time in the United States, the incidence trend for mucosal melanoma of the head and neck (MMHN) is unknown. Methods. We used the Surveillance, Epidemiology, and End Results (SEER) database to determine incidence trends for MMHN from 1987 to 2009 in the United States. We determined annual percent change (APC) by weighted least squares and joinpoint regression analysis. Results. MMHN incidence increased from 1987 to 2009 (APC 2.4%; P < 0.01). Nasal cavity lesions increased in incidence (APC 2.7%; P < 0.01) over this duration, while the incidence of non-nasal cavity lesions remained stable. The highest rate of increase was in white females ages 55 to 84 (APC 5.1%; P = 0.01). Conclusions. The incidence of MMHN in the United States has been rising since 1987. This trend is driven primarily by increased incidence of nasal cavity melanomas.

Cytodiagnosis of mucosal malignant melanoma of nasal cavity: A case report with review of literature

Sinonasal malignant melanoma is of unusual occurrence. Common sites for melanomas are head, neck region, and the lower extremities as they are exposed to sunlight, which is one of the predisposing factors. We report a case of primary mucosal malignant melanoma of the nasal cavity in a 68-year-old male for its rare occurrence. The primary knowledge of its existence and evaluation of its cytological features are important for a correct preoperative cytological diagnosis and thereby clinical implications for appropriate therapeutic intervention. The cytological features when evaluated along with clinical, histopathological and immunohistochemical features are sufficiently diagnostic. The rarity of its occurrence warrants its mention.

Metastatic malignant melanoma of palate: A review of literature and report of an unusual case

Oral malignant melanoma is a rare tumor, accounting 0.8to 1.8 % of all oral malignancies. It occurs most commonly in Japanese and Negros. Radical surgery is mainstay of the treatment. Prognosis is very poor with 5 years survival rate. We present a case of malignant melanoma in a 55 years female, metastatizing to liver spleen and vertebrae.

[Melanoma of the nasal septum]

Sinonasal mucosal melanoma is a rare neoplasm, accounting for less than 1% of all melanomas. It is more aggressive than its cutaneous counterpart, with a very poor prognosis. We report a case of melanoma arising from mucosae of the nasal septum in a 73-year-old man. Clinical features, diagnosis, and treatment are described and a review of literature is made. Nasal location and relatively nonspecific symptoms frequently delay diagnosis. Optimal treatment guidelines are not established because of its rare occurrence.

Accuracy of the current TNM classification in predicting survival in patients with sinonasal mucosal melanoma

OBJECTIVES/HYPOTHESIS

The first International Union Against Cancer (UICC) TNM classification for aerodigestive malignant mucosal melanoma was not published until 2009, and since then, only a few studies have evaluated the accuracy of this staging system. Our aim was to evaluate the accuracy of this UICC staging system for sinonasal malignant mucosal melanoma (SMMM) in a nationwide survey.

STUDY DESIGN

Retrospective, population-based, multicenter study.

METHODS

The hospital surgical and discharge registries were used to identify the patients. A database including demographic and clinicopathologic variable was created.

RESULTS

Altogether, 50 SMMM patients diagnosed in Finland from 1990 to 2004 were evaluated. Three- and 5-year overall survival rates were 44% and 27%, respectively. Significant differences in overall survival according to T classification (P = .028, log rank) and stage (P = .02, log rank) were found. Tumor extension to the sphenoid sinus had a significant negative impact on survival (n = 11, P = .03, log rank).

CONCLUSIONS

The current UICC staging system for mucosal melanoma provides a useful format for staging SMMMs in clinical settings.

Second primary oral melanoma: A rare presentation

Melanomas are neoplasms of melanocytic origin. They are aggressive neoplasms with an unpredictable behavior, and can involve virtually any organ of the body. Oral melanomas are very rare and have an extremely poor prognosis. Early diagnosis and prompt treatment is the key to reduce the morbidity and mortality. A second primary tumor is a new primary tumor developing in a person with a history of tumor, in a new site or tissue and subsequent to the initial tumor. Patients with previous history of melanoma are associated with a higher risk of developing second primaries. A case of second primary oral melanoma in a 55-year-old female is reported here. The anachronistic presentation of the primary and the second primary lesions make this case clinically interesting. Noteworthy immunohistochemical findings were recorded, HMB-45 positive and S-100 negative.

Response to intra-arterial cisplatin and concurrent radiotherapy in a patient with primary mucosal malignant melanoma of the nasal cavity

BACKGROUND

The prognosis for patients with mucosal malignant melanoma (MMM) of the nasal cavity is very poor because of the radioresistance of melanoma cells.

METHODS

We present the first case report of the efficacy of superselective intra-arterial cisplatin (CDDP) infusion concurrent with hypofractionated radiotherapy (RT) for MMM of the nasal cavity.

RESULTS

A pink, polypoid mass, histopathologically diagnosed as an amelanostic melanoma, occupied the right nasal cavity. After the treatment, a nasal tumor disappeared, leaving only a small bulge in the medial wall of the middle turbinate. Histopathologic examination revealed scattered degenerated melanoma cells, remaining only in the small restricted area in the medial surface of the excised middle turbinate. Twelve months after the treatment, the patient has not experienced any local recurrence or regional and distant metastasis.

CONCLUSIONS

The superselective intra-arterial CDDP infusion concurrent with hypofractionated RT might be useful for the management of nasal MMM.

Sinonasal mucosal melanoma: retrospective survival study of 25 patients

OBJECTIVE

To determine potential prognostic factors for survival in patients with mucosal malignant melanoma of the sinonasal tract.

METHODS

Patients managed between 1991 and 2008 were assessed retrospectively. The seventh edition Union for International Cancer Control (7th UICC) tumour-node-metastasis classification was used for tumour staging. Kaplan-Meier and log rank tests were used for survival analysis.

RESULTS

Twenty-five patients were studied (six were tumour stage three, eight tumour stage four(a) and 11 tumour stage four(b)). Surgery was performed on 23 patients (92 per cent). Fifteen received post-operative radiotherapy. Mean follow up was 31.3 months (range, two to 99 months). Three-year disease-free survival was improved in patients with stage four tumour arising from the nasal fossa, versus other sites, and in those with stage four tumour treated with surgery plus adjuvant radiotherapy, versus other treatments.

CONCLUSION

Patients with melanoma of the nasal cavity have very poor survival rates. Treatment is still based on adequate surgical resection with safe margins. In this study, post-operative radiotherapy improved local control only for stage four tumours.

Head and Neck Mucosal Malignant Melanoma

Unlike their cutaneous counterparts, head and neck mucosal malignant melanomas (HNMM) behave much more aggressively and their prognostic markers have not been fully elucidated. Therefore, the aim of this study was to review the clinicopathologic features of a contemporary series of primary HNMM, retrieved from archival material of 2 large medical centers, and to explore the association, if any, between these variables, the clinical features, and outcomes. The clinicopathologic, radiographic, and follow-up information as well as the dominant histologic pattern, mitotic rate, presence/absence of pigmentation, necrosis, ulceration, vascular invasion, and host-associated lymphocytic response were retrieved and recorded. Twenty cases were identified including 1 melanoma in situ. Eight-five percent of tumors arose in the sinonasal tract and 3 (15%) in the oral cavity. After a median follow-up of 25 months, all patients with invasive melanoma developed recurrence and/or metastasis. Local recurrences occurred in 82% of the patients after a median of 12 months, and distant metastasis occurred in 71% of the patients after a median of 13 months. Of those with adequate follow-up, 82% died with disease, and the remaining 3 had recurrent or metastatic disease. Fourth-seven percent of tumors were pigmented, 89% showed at least focal necrosis, and 93% demonstrated ulceration. Sixth-eight percent showed vascular invasion and 63% had a brisk host lymphocytic response. Mitotic rates ranged from 2 to 60/10 high-power fields. The absence of an invasive component might be associated with a better prognosis but other clinical and pathological features that predict outcome, and/or could influence therapy, remain to be determined in HNMM.

Demographics and treatment trends in sinonasal mucosal melanoma

OBJECTIVES/HYPOTHESIS

To evaluate the population characteristics of mucosal melanoma of the nasal cavity and paranasal sinuses and determine the impact of the new staging classification.

STUDY DESIGN

Analysis of a national database.

METHODS

Patients were identified from the Surveillance, Epidemiology, and End Results tumor registry data with mucosal melanoma of the nasal cavity and paranasal sinuses between 2000 and 2007. Tumors were classified using the American Joint Committee on Cancer (AJCC) 6th edition site-specific staging as well as 7th edition staging for head and neck mucosal melanoma (HNMM). Incidence rates and descriptive statistics were calculated, and multivariate analysis was performed to examine the impact of demographic factors and staging on survival.

RESULTS

A total of 304 patients were identified. The incidence rate was 0.05 per 100,000. Fifty-six percent were female, 92% were >50 years old, and more than 90% were Caucasian; 81.6% of patients were treated with surgery, and 38.5% of patients received postoperative radiation. Overall, the 5-year survival rate was 24.2%. Significant differences in survival were observed for surgery with radiation (P = .005) and surgery alone (P = .04) compared with radiation alone. TNM staging using the AJCC 6th and 7th edition classification schemes yielded similar survival curves. However, the new classification for HNMM allows for better delineation of stage IV disease, revealing slightly improved survival for stage IVA disease.

CONCLUSIONS

HNMM is a rare disease with a poor prognosis. Surgery remains the treatment of choice, with some role for adjuvant therapy. The new staging classification for HNMM appears to more efficiently stage this disease. Demographics and therapeutic findings are discussed.

Lateral rhinotomy combined with anterior transantral approach for the treatment of large malignant melanoma of the nasal cavity involving the nasopharynx

The authors report a case of nasal malignant melanoma involving the septum, nasal turbinates and nasopharynx which was approached by lateral rhinotomy combined with an anterior transantral approach with excision of the septum and the lateral wall of the nasal cavity for wide exposure of the tumour. Using this technique complete surgical resection of a large nasal malignant melanoma was achieved with minimal morbidity and good aesthetics.

Clinical presentation, histology, and prognoses of malignant melanoma in ethnic Chinese: a study of 522 consecutive cases

Background

Malignant melanoma is a rare disease in Asia, and knowledge on its characteristics and clinical outcome in Asian patients is limited. The purpose of this observational study was to determine the clinical presentation and outcome of patients with melanoma in China.

Methods

A database was prospectively established for the purpose of this analysis. The elements of the database included basic demographic data of patients and prognosticators previously reported in literature, as well as follow-up data including clinical outcome after treatment. Medical record of all patients with pathologically diagnosed malignant melanoma consulted in our center since 2006 were retrieved and reviewed. No patient was excluded in this study. Statistical analyses including survival and multivariate analyses of factors associated with survival were respectively performed by Kaplan-Meier method and Cox proportional hazard model.

Results

A total of 522 consecutive and nonselected cases were evaluated. There were 218 cases (41.8%) of acral lentiginous melanoma (ALM), 118 (22.6%) of mucosal melanoma (MCM), 103 (19.7%) of nodular melanoma (NM), 33 (6.3%) of superficial spreading melanoma (SSM), and others were Lentigo maligna melanoma or unclassifiable disease. The proportion of patients with clinical stage I, II, III, and IV diseases were 6.1%, 55.9%, 25.1%, and 12.8%, respectively. Among the 357 cases of cutaneous melanoma, 234 patients (65.5%) had ulceration.

The 5-year overall survival rate of all 522 patients was 41.6%, and the median survival time was 3.92 years (95% CI, 3.282 to 4.558). Five-year survival rates of patients with stage I, II, III, and IV diseases were 94.1%, 44.0%, 38.4% and 4.6% respectively (P < 0.001). Multivariate analysis revealed that clinical stage and the ulceration were two significant prognosticators for OS. In addition, extent of surgery and use of adjuvant therapy were significant prognosticators for DFS in patients with non-metastatic disease after definitive treatment. Pathological subtype was not a significant prognostic factor to predict wither OS or DFS.

Conclusions

Prognoses of patients with malignant melanoma diagnosed in China were suboptimal, and most patients were diagnosed with locally advanced disease (i.e., stage II or above). ALM and MCM are the two most commonly diagnosed pathological subtypes. Clinical staging and presence of ulceration was significantly associated with clinical outcome in terms of OS, while treatment strategy including extent of surgery and use of adjuvant therapy were significant predictors of DFS.

Outcome of sinonasal melanoma: clinical experience and review of the literature

BACKGROUND

Primary sinonasal malignant melanoma (SNMM) is a rare clinical entity. There is neither a classification nor a staging system nor an evidence-based treatment concept established. Our objective was to find potential risk factors predicting the outcome.

METHODS

Twenty-five patients with histologically confirmed SNMM were consecutively included and retrospectively analyzed. Staging methods were nasal endoscopy, CT, MRI, and positron emission tomography (PET) scan. Patients were selected for a curative or palliative concept. All patients had postoperative follow-up with control-MRI at 3 and 6 months. Restaging was performed when local recurrence occurred.

RESULTS

Nineteen patients underwent primary surgery with curative intention; in 16 cases with tumor free margins. Thirteen patients (68%) had transnasal endoscopic surgery, 4 lateral rhinotomy, and 2 transfacial approach with orbital exenteration. Six patients (32%) had palliative therapy and 7 patients (37%) had adjuvant radiotherapy. Despite radical operations, 6 patients (37%) showed local recurrence and 8 patients (50%) developed distant metastasis. In 2 patients with incomplete surgery, regional metastasis was noted. The median disease-free interval was 18 months, and the median overall survival rate was 23 months.

CONCLUSION

SNMMs of the ethmoid and maxillary sinuses have a worse prognosis than other localizations in the nasal cavity; infiltration into the skull base, orbit, or facial soft tissue correlates with a very poor outcome corresponding to the palliative situations. Furthermore, local recurrence insinuates aggressive disease with short survival rate. A main difference from its cutaneous counterpart seems to be a primary tendency to hematogenic spread. Further research is needed to confirm these findings.

Primary mucosal sinonasal melanoma-Case report and review of the literature. The role of complex treatment-surgery and adjuvant radiotherapy

AIM

The place of adjuvant radiotherapy in the treatment of sinonasal melanoma.

BACKGROUND

Sinonasal mucosal melanoma is a rare disease with poor prognosis and requires a complex treatment. Elective neck dissection in patients with N0 and adjuvant radiotherapy has been a source of controversy. High late regional recurrence rates rise questions about elective irradiation of the neck nodes in patients with N0 stage disease.

METHODS

We present our two years' follow up in a case of locally advanced sinonasal melanoma and literature review of the treatment options for mucosal melanoma.

RESULTS

In locally advanced sinonasal melanoma treated with surgical resection, postoperative radiotherapy and chemotherapy we had local tumor control. Two years later, a regional contralateral recurrence without distant metastasis occurred.

CONCLUSIONS

Literature data for frequent neck lymph nodes recurrences justify elective neck dissection. Postoperative elective neck radiotherapy for patients with locally advanced sinonasal melanoma and clinically N0 appears to decrease the rate of late regional recurrences.

Neck dissection and post-operative chemotherapy with dimethyl triazeno imidazole carboxamide and cisplatin protocol are useful for oral mucosal melanoma

Background

Oral mucosal melanoma (OMM) is a clinically rare disease with poor prognosis. Various treatment methods have been investigated with the aim of improving the prognosis. This study aimed to analyze the data of a single institution in the management of OMM.

Methods

A total of 78 consecutive OMM patients were included in this retrospective study. The intraoral lesion was treated either by cryotherapy, surgery or both; the neck was treated by neck dissection or observation; post-operative chemotherapy with dimethyl triazeno imidazole carboxamide and cisplatin was performed in some patients. The Kaplan-Meier method was used for statistical analysis.

Results

Among the 78 patients, there were 50 males and 28 females with an average age of 53.8 years (ranging from 27 to 85 years). The most common sites of OMM were the hard palate and gingiva. The main cause of death in OMM was distant metastasis. No significant difference was found between the intraoral/cervical lesion recurrence/post-operative distant metastasis and the intraoral lesion site/biopsy method/treatment method. The metastasis rate of cervical lymph node was high in the OMM patients, even in the patients with clinically negative necks. Cervical lesion recurrence was correlated with N stage and intraoral lesion recurrence. The survival period was longer in the patients with T3 staging, clinical stage III disease, with post-operative chemotherapy and without post-operative distant metastasis when compared to those patients with T4a staging, clinical stage IV disease, without post-operative chemotherapy and with post-operative distant metastasis.

Conclusions

Radical surgery including wide intraoral resection and neck dissection is recommended for OMM patients. Post-operative chemotherapy may also be beneficial for both primary and recurrent OMM patients.

Melanin-associated pigmented lesions of the oral mucosa: presentation, differential diagnosis, and treatment

Intraoral pigmentation is quite common and has numerous etiologies, ranging from exogenous to physiological to neoplastic. Many pigmented lesions of the oral cavity are associated with melanin pigment. The differential diagnosis of mucosal pigmented lesions includes hematomas, varices, and petechiae which may appear to be pigmented. Unlike cutaneous melanomas, oral melanomas are diagnosed late and have a poor prognosis regardless of depth of invasion. As such, the clinical presentation and treatment of intraoral melanoma will be discussed. Developing a differential diagnosis is imperative for a clinician faced with these lesions in order to appropriately treat the patient. This article will focus on the most common oral melanocytic lesions, along with mimics.

Mucosal malignant melanomas in head and neck surgery: a retrospective study of six patients and review of the literature

INTRODUCTION

Of all malignant processes of the oral mucosa, 0.5% are malignant melanomas. Because of late diagnosis, pattern of growth, close proximity to the bone (particularly in palatinal localizations), and the correlated infiltration, malignant melanomas have a bad prognosis.

PATIENTS AND METHODS

In this retrospective study, six cases of patients with oral mucosal malignant melanoma are evaluated, and a critical review of the literature is presented. The female to male proportion was 1:1 with an average age of 60.2 years; all patients were treated between January 1999 and July 2007. A neck dissection was performed on two patients because of clinically positive lymph nodes; one patient received interleukin 2 therapy, and three patients received postoperative radiotherapy. Two male patients died.

CONCLUSIONS

We recommend biopsy on every growing lesion, pigmented or nonpigmented, for the required diagnosis and, in cases of malignant melanoma, wide excision as a second step. Neck dissections should be performed in patients with clinically positive lymph nodes. Concerning interleukin 2 therapy, further studies should be performed in order to evaluate a routine application.

Malignant mucosal melanoma in the nasal cavity: an uncommon cause of epistaxis

Malignant mucosal melanoma of the nasal cavity is extremely rare. It is usually diagnosed in the elderly. We report a 78-year-old man who had symptoms of occasional episodes of epistaxis and blood-tinged sputum for about 1 month. Physical examination showed a dark-colored mass lesion over the left nasal cavity, and biopsy of it revealed malignant melanoma. Wide excision of the tumor was performed via endoscopic surgery, and adjuvant radiotherapy was also arranged. Diagnosis of malignant melanoma mainly depends on histochemistry and immunostain. Up to now, surgery offers the best chance for local tumor control. However, postoperative radiotherapy or chemotherapy is often needed because mucosal melanomas tend to have distant metastasis and local failure. Immunotherapy may play a role in improving outcome, but evidence is lacking.

Radiotherapy after surgical resection for head and neck mucosal melanoma

OBJECTIVES

To present our single-institution experience with postoperative radiotherapy for mucosal melanoma of the head and neck.

METHODS

Between 1992 and 2007, 27 patients with mucosal melanoma of the head and neck underwent surgical resection followed by postoperative radiotherapy. Median age was 68 years (range: 45-89 years). Sites included were sinonasal in 24 patients, oral cavity in 2, and oropharynx in 1. All but 2 patients had stage I disease. Twenty-two patients received hypofractionated radiation. Radiation techniques were intensity-modulated radiation therapy in 13, 3-dimensional conformal in 4, and conventional in 10.

RESULTS

The median follow-up for living patients was 45 months (range: 24-122 months). The 3- and 5-year estimates of local progression-free, loco-regional progression-free, distant metastasis-free, and overall survival were: 47% and 35%; 34% and 22%; 30% and 24%; and 40% and 33%, respectively. Median time to local failure and distant metastasis was 32 and 14 months, respectively. Acute toxicities included 19% with grade 2 or higher mucositis. No late complications related to the optic structures were seen.

CONCLUSIONS

Modern radiotherapeutic techniques including intensity-modulated radiation therapy appear feasible and well-tolerated in the postoperative treatment of head and neck mucosal melanoma. Unusual or serious late complications have not been observed despite extensive use of hypofractionated regimens. However, rates of local and distant failure remain high.

Management of mucosal melanomas of the head and neck: did we make any progress?

PURPOSE OF REVIEW

Primary mucosal melanoma of the head and neck is a rare tumor associated with a poor outcome. This diagnosis carries a great deal of anxiety for the patients and puts the clinician in a predicament to find concise and reliable information for adequate risk stratification and treatment.

RECENT FINDINGS

Sinonasal mucosal melanomas should be staged according to the tumor node metastasis staging system and could be treated endoscopically with similar results to open surgery. Prophylactic neck dissection could be indicated in oral melanomas, given their tendency to regional failure. Adjuvant radiotherapy improves locoregional control in several series but does not improve survival. Definitive radiation with high linear energy transfer modalities achieves locoregional control rates comparable to surgery. Biochemotherapy improves survival in mucosal melanoma of the head and neck and should be considered for patients with metastatic or extensive locoregional disease.

SUMMARY

The standard therapy for melanoma continues to be surgical resection, possibly associated with adjuvant radiation. Biochemotherapy should be considered for bulky metastatic disease. In the future, definitive radiation regimes, molecular staging and targeted therapy may play a major role.

Mucosal melanomas: a case-based review of the literature

Mucosal melanoma is a rare cancer that is clearly distinct from its cutaneous counterpart in biology, clinical course, and prognosis. Recent studies have shown important differences in the frequencies of various genetic alterations in different subtypes of melanoma. Activating mutations in the c-KIT gene are detected in a significant number of patients with mucosal melanoma. This observation has resulted in the initiation of several clinical trials aimed at exploring the role of receptor tyrosine kinases that inhibit c-KIT in this patient population. We herein present a comprehensive literature review of mucosal melanoma along with case vignettes of a number of pertinent cases. We further discuss melanomas of the head and neck, the female genital tract, and the anorectum, which are the three most common sites of mucosal melanoma, with a particular focus on the diagnostic, prognostic, and therapeutic data available in the literature.