Sinonasal tract and nasopharyngeal melanomas: a clinicopathologic study of 115 cases with a proposed staging system

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.

Primary amelanotic mucosal melanoma of the oronasal region: report of two new cases and literature review

Primary amelanotic mucosal melanoma is a rare entity with challenging histopathological features. Because these tumors are thought to be biologically more aggressive, they have a poorer prognosis than that of pigmented melanomas. In this work, we present a literature review about the clinical, histopathological, and immunohistochemical features of primary amelanotic mucosal melanoma of the oronasal region and report two new cases. Amelanotic mucosal melanoma commonly affects men in the seventh decade of life and tend to have a poor prognosis, as seen by the high incidence of metastasis, recurrences, and, ultimately, death. There is a similar pattern in the clinic-pathological predilections (such as age, gender, primary site, and metastatic potential) of amelanotic mucosal melanoma when comparing with data reported for pigmented lesions. This work reinforces knowledge about amelanotic mucosal melanomas and epidemiologic predilections. The optimal management of this lesion remains controversial.

Unknown primary nasopharyngeal melanoma presenting as severe recurrent epistaxis and hearing loss following treatment and remission of metastatic disease: A case report and literature review

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Nasopharyngeal mucosal melanoma is a rare pathology with an unclear etiology and oftentimes obscure clinical presentation.

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We present a report of a lady who had a complete response to systemic treatment of metastatic melanoma of unknown origin.

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Six years later, a diagnosis of primary nasopharyngeal melanoma was made after an extensive work-up for recurrent symptoms of severe right-sided epistaxis and hearing loss.

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Surgical resection was performed followed by radiation therapy. The patient has since been without evidence of recurrent or metastatic disease and resolution of bleeding.

Introduction

Primary nasopharyngeal melanoma is an exceedingly rare pathology with unclear etiology and oftentimes obscure clinical presentation. Despite improved diagnostic capabilities, these lesions are often diagnosed at an advanced stage and associated prognosis is poor, partly due to high rates of recurrences and metastasis.

Presentation of case

A 74-year-old woman was diagnosed with metastatic melanoma to the liver, of unknown primary. Just prior to the time of diagnosis, she experienced several episodes of severe epistaxis which she managed conservatively. Her symptoms eventually subsided without further medical evaluation. The patient was initially treated with interleukin-2 (IL-2) for her advanced disease, but her cancer progressed. She was then enrolled in a protocol for percutaneous hepatic perfusion (PHP) with melphalan and had complete radiographic resolution of disease, yet her nosebleeds recurred and persisted despite conservative measures. Six years after her initial diagnosis, a nasopharyngoscopy demonstrated a pigmented lesion in the posterior nasopharynx. Surgical resection was performed (pathology consistent with mucosal melanoma) followed by radiation therapy. She has since had complete resolution of bleeding and shows no evidence of cancer.

Discussion

To our knowledge, this is the first report of a diagnosis of primary nasopharyngeal melanoma 6-years following complete remission of metastatic disease. Surgery remains the primary treatment for disease and symptom control in this setting.

Conclusion

Timely diagnosis of nasopharyngeal melanomas remains challenging. Thorough clinical evaluations should be performed in such patients, and attention should be paid to recurrent and persistent symptoms, such as epistaxis and hearing loss. This may allow for earlier detection of primary disease.

Clinicopathological characterization of primary oral and sinonasal melanoma in a referral centre in Mexico City: 2000-2012

In Mexico, there have been few studies on primary oral and sinonasal melanoma, an aggressive neoplasm with a low survival rate and few therapeutic alternatives. Further, there is limited information about its clinical and histopathological characteristics. The aim of this retrospective study was to describe the clinicopathological profile of these tumours in patients attending a major oncology reference centre in Mexico City over a 12-year period. Demographic and clinical data were obtained from the clinical charts, and histopathological features were evaluated. χ(2), Fisher's exact, and Mann-Whitney U-tests were used for analysis; significance was set at P<0.05. Thirty-three cases were studied (73% sinonasal melanoma (SNM) and 27% oral melanoma (OM)); 58% were female and the median age was 66 (Q1-Q3 55.5-75) years. Compared with OM patients, SNM patients had a shorter time to diagnosis (16.7 vs. 11.7 months, P=0.022), were identified at earlier stages (33.3% vs. 58.3%, P=0.010), and all presented symptoms (66.7% vs. 100%, P=0.015). All samples showed vertical growth and 96.9% exhibited pleomorphism. A higher proportion of cases with pleomorphism developed metastases at follow-up than those without (60% vs. 12.5%, P=0.026). The present study provides valuable information that could form the basis of future studies in the search for advanced therapy modalities.

Primary mucosal melanoma of the sinonasal tract: a clinicopathologic and immunohistochemical study of thirty-two cases

Sinonasal mucosal melanoma is a rare disease with poor survival. These tumors may have associated intraepithelial melanocytic proliferations, which are not extensively characterized. This retrospective analysis of 32 patients with sinonasal mucosal melanoma examined associated intraepithelial melanocytic proliferations in the context of diagnostic and prognostic features. Patient age ranged from 30 to 90 years (median 71) with a male to female ratio of approximately 3:2. Follow up for 31 patients ranged from 5 to 211 months (mean 42 months). Most patients died from melanoma-associated causes (18/31, 58 %), six (19 %) died from unknown causes, two (6 %) were alive with metastatic disease, and only five patients (16 %) remained alive without melanoma. The tumors were histopathologically heterogeneous, displaying epithelioid, spindled, and small cell cytomorphology. The presence of >2 mitoses/mm(2) and necrosis correlated with tumor progression and overall survival, respectively (p = 0.04 for both). Melanoma in situ, defined as a confluent intraepithelial proliferation of cytologically atypical melanocytes, was identified in 20 of 30 evaluable cases (67 %) and confirmed with immunohistochemical staining for microphthalmia-associated transcription factor. Melanocytic hyperplasia, defined as intraepithelial melanocytic proliferation without confluent growth or marked atypia, was seen in five cases (16 %). This incidence of associated intraepithelial melanocytic proliferations (83 %) is higher than previously reported. Because of the locally aggressive nature of these tumors, an awareness of the high rate of associated intraepithelial melanocytic proliferations may inform future studies of therapeutic options.

Extracutaneous melanoma epidemiology in British Columbia

The epidemiology of extracutaneous melanoma (ECM) is sparsely reported upon in the literature, and studies to date have been limited both by time and by geographic gaps in available data. Utilizing a comprehensive provincial cancer registry, we sought to analyze the incidence and survival rates of ECM on the basis of sex and anatomic distribution for the British Columbia, Canada population. Data on ECMs diagnosed between 1 January 1992 and 31 December 2006 were obtained from the BC Cancer Registry. Anatomical sites of ECM were classified on the basis of ICD-9 codes, and incidence rates for each site were age standardized and grouped by sex. The 5-year survival rate for each anatomical grouping was tracked until 31 December 2011. A total of 922 primary ECMs were recorded in the BC Cancer Registry between 1992 and 2006, representing 5.1% of melanoma incidence. Ocular melanomas were most frequently reported, with an age-standardized incidence rate (per million) of 10.6 for men and 8.5 for women. ECM patients were generally older at diagnosis and had poorer survival rates compared with cutaneous melanoma cases. Five-year survival rates for ECM varied markedly from 23.5% for genital lesions to 87.0% for ocular cases. Our ECM epidemiology results are largely consistent with previous studies from the USA and Europe. Where considerable differences in reported values do exist, the opportunity arises to assess the efficacy of melanoma detection, monitoring, and treatment strategies in different geographic regions. Our study represents the largest epidemiological investigation of ECM in Canada and provides a framework for future epidemiological comparisons.

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.

Primary sinonasal mucosal melanoma with aberrant diffuse and strong desmin reactivity: a potential diagnostic pitfall!

The broad morphologic spectrum, inherent immunophenotypic heterogeneity of malignant melanoma and its rarity in the sinonasal tract are major challenges in eliciting the correct diagnosis, which may lead to misclassification and inadequate medical management. Herein, we describe a single case of a 70 year-old male with sinonasal mucosal melanoma, exhibiting varying histologic phenotypes including small round blue cell morphology, epithelioid and focal rhabdoid morphology and strong, diffuse desmin immunoreactivity. These constellation of features initially prompted the diagnosis of rhabdomyosarcoma. The differential diagnosis in this anatomic area includes other malignant small round blue cell tumors of the sinonasal mucosa such as rhabdomyosarcoma, olfactory neuroblastoma, sinonasal undifferentiated carcinoma, and lymphoma. We reviewed precedent literature and further discuss the potential pitfalls to which pathologists may be prone.

Mucosal melanomas in the elderly: challenging cases and review of the literature

Melanomas are malignant tumors that originate from melanocytes. They are most frequently localized in the skin, but 5% of all melanomas interest also extracutaneous sites as mucosal surfaces, parenchymatous organs, the retroperitoneum area, and the ocular ball. The purpose of this study was to investigate the epidemiologic and morphologic data of mucosal melanomas diagnosed at Emergency City Hospital (Timisoara, Romania) during a period of 12 years. The study included 17 cases of extracutaneous, extraocular melanomas, with 16 primary melanomas and one secondary melanoma. All our patients were older than 53 years and were mostly men. Most of the patients presented with localized disease; only one case had regional lymph node metastases, and another one had systemic metastases at the time of diagnosis. Regarding localization, nine of 16 melanomas were in the head and neck region, six were diagnosed in the gastrointestinal and urogenital tracts (three cases each), and one case had a rare localization (retroperitoneum). The most common histologic type was represented by epithelioid cells, and the majority of the tumors were achromic. Mucosal melanoma is a tumor associated with aging, all our patients being older than 53 years. Because of unspecific symptoms and low incidence, the diagnosis is often delayed and requires teamwork among the clinician, pathologist, radiologist, and oncologist. Different genetic fingerprints impose a correct diagnosis to offer the patient the best novel, personalized therapy.

Mucosal melanoma of the nasal cavity and paranasal sinuses

Mucosal melanoma of the nasal cavity and paranasal sinuses is a rare disease, but its incidence appears to be increasing. The mean age at diagnosis is between 65 and 70 years. Unilateral nasal obstruction and epistaxis are the most common presenting complaints. Melanoma arises in the septum or lateral wall of the nasal cavity in the great majority of cases. The histological diagnosis is based on specific immunohistochemical labelling and is usually established at an advanced stage of disease: stage T3 or T4 tumours according to the 7th edition of the American Joint Committee on Cancer (AJCC) classification of tumours. First-line treatment consists of surgery. The place of intranasal endoscopic surgery remains controversial due to the difficulty of controlling surgical margins and should be reserved for experienced teams. Adjuvant radiotherapy is usually performed due to its efficacy on local and regional disease control. Five-year overall survival of mucosal melanoma of the nasal cavity and paranasal sinuses in the most recent series does not exceed 40%. Local recurrence is observed in about 50% of cases and metastatic disease is common. The quality of initial tumour resection with negative surgical margins is the most important prognostic factor for tumours confined to the nasal cavity. Hopes for improvement of survival are based on early diagnosis, progress in radiotherapy techniques and cell and gene therapy that are currently under evaluation.

Surgical management of recurrent sinonasal mucosal melanoma: endoscopic or transfacial resection

Sinonasal mucosal melanoma (SNMM) is associated with poor prognosis. Local recurrence is common and represents a major problem in the therapy. Wide resection surgery is usually applied. However, given the almost futile prognosis, optimal symptom control may be preferable to wide resection at all costs. The aim of our study was to analyze the outcome in patients with recurrent SNMM treated by transfacial radical surgery or by a less invasive endoscopically controlled approach. Patients with recurrent grade III or IV staged SNMM who presented to our ENT department between 2000 and 2010 were either treated by transfacial (n = 10) or endoscopically controlled surgery (n = 12). The patients' charts were reviewed for clinical symptoms, relapse-free time and survival time. Clinical symptoms improved after surgery. The morbidity after endoscopic surgery was significantly lower than after transfacial surgery. The chosen surgical technique did neither affect relapse-free nor survival time. When treating recurrent SNMM, the comparatively gentle and less mutilating endoscopic approach proved to be a sufficient surgical procedure, being not inferior to aggressive surgery with respect to recurrence and survival rate.

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.

[Malignant melanoma: a rare tumor of the nasal cavity--about a series of 10 cases]

Le mélanome malin des fosses nasales est une tumeur rare mais très agressive, de traitement complexe et de pronostic défavorable. Son traitement relève en principe d'une prise en charge essentiellement chirurgicale complétée par une radiothérapie. L'objectif de ce travail est de rapporter les caractéristiques cliniques, thérapeutiques et évolutives des mélanomes des fosses nasales. Nous avons analysé rétrospectivement 10 cas de mélanomes des fosses nasales suivis à l'institut national d'oncologie de Rabat. La rhinoscopie avec biopsie a permis la confirmation histologique du diagnostic de mélanome. Le bilan d'extension comprenait une tomodensitométrie ou imagerie par résonnance magnétique du massif facial, une radiographie thoracique et une échographie abdominale. Dans notre série, l’âge médian était de 67.5 ans, avec une prédominance féminine (7femmes et 3hommes). Le délai médian de découverte était de 6 mois. Deux patients étaient métastatiques d'emblée, et toutes les tumeurs étaient localement avancées au moment du diagnostic. Sept patients ont été opérés avec des limites chirurgicales envahies dans 2 cas et 3 patients étaient inopérables. 2 patients ont été irradiés après la chirurgie et 2 patients ont reçu une chimiothérapie arrêtée au moment de la progression. Deux patients ont récidivé après traitement, et un patient était en mauvais état général et a bénéficié uniquement de soins palliatifs. Tous les patients sont décédés avec un délai médian de survie de 12 mois. Le mélanome malin muqueux des fosses nasales, bien que rare, demeure une pathologie de pronostic défavorable et pose des problèmes de prise en charge.

Update on primary mucosal melanoma

Mucosal melanomas are aggressive cancers of mucosal surfaces with clinical and pathologic characteristics distinct from cutaneous melanomas, warranting different staging systems and treatment approaches. Surgical resection is performed frequently for the primary tumor, although the utility of lymph node surgery and radiation therapy is not established. Therapies targeted against C-KIT activating mutations, identified in many mucosal melanomas, are emerging as promising treatments.

Brachytherapy as a treatment for malignant melanoma of the nasal cavity and nasopharynx - case report

Purpose

Primary malignant melanoma of the nasal cavity and nasopharynx is rarely seen. Clinically, most patients display initial nonspecific symptoms of unilateral nasal obstruction or epistaxis. The prognosis is generally poor, with a mean survival time of 3.5 years.

Material and methods

In this paper, we have reported the case of malignant melanoma of the nasal cavity and nasopharynx. 79 years old man had presented with the swelling of the nose, nasal blockage and epistaxis during the six months before diagnosis. Functional endoscopic sinus surgery was performed to excised the nasal cavity tumor. Using positron emission tomography/computed tomography examination with 18-fluorodeoxyglucose, the patient was diagnosed with residual nasopharyngeal tumor after surgery.

Results

Following the diagnosis, intracavitary brachytherapy for nasopharynx was administered. Solitary cervical nodal involvement occurred 6 months after the diagnosis when had been completely removed. After that, external beam radiotherapy was performed on the submandibular area on the right side. Thereafter, the patient was given follow-up care in the Department of Radiation Oncology until the time of distant progression of the disease.

Conclusions

We have chosen to discuss this condition, because of its rarity and the possibility of using radiotherapy, even though the malignant melanoma had been regarded as a radioresistant disease, and also to emphasize the importance of a multidisciplinary approach to treatment of such patients.

Phase II randomized trial comparing high-dose IFN-α2b with temozolomide plus cisplatin as systemic adjuvant therapy for resected mucosal melanoma

PURPOSE

Mucosal melanoma is rare and associated with extremely poor prognosis. However, standard adjuvant therapy for mucosal melanoma has not been established. We conducted a randomized phase II clinical trial in patients with resected mucosal melanoma to compare the efficacy and safety of high-dose IFN-α2b (HDI) and temozolomide-based chemotherapy as adjuvant therapy.

EXPERIMENTAL DESIGN

Patients with mucosal melanoma in stage II/III after surgery were randomized into three groups: observation group (group A, surgery alone), HDI group (group B, treated with 15 × 10(6) U/m(2)/d IFN-α2b, followed by 9 × 10(6) U IFN-α2b), and temozolomide (200 mg/m(2)/d) plus cisplatin (75 mg/m(2)) group (group C). The endpoints were relapse-free survival (RFS), overall survival (OS), and toxicities.

RESULTS

One hundred and eighty-nine patients were enrolled and finally analyzed. With a median follow-up of 26.8 months, the median RFS was 5.4, 9.4, and 20.8 months for group A, B, and C, respectively. Estimated median OS for group A, B, and C was 21.2, 40.4, and 48.7 months, respectively. Patients treated with temozolomide plus cisplatin showed significant improvements in RFS (P < 0.001) and OS (P < 0.01) than those treated with either HDI or surgery alone. Toxicities were generally mild to moderate.

CONCLUSION

Both temozolomide-based chemotherapy and HDI are effective and safe as adjuvant therapies for resected mucosal melanoma as compared with observation alone. However, HDI tends to be less effective than temozolomide-based chemotherapy for patients with resected mucosal melanoma in respect to RFS. The temozolomide plus cisplatin regimen might be a better choice for patients with resected mucosal melanoma.

The small round blue cell tumors of the sinonasal area: histological and immunohistochemical findings

Background

Primary Small round blue cell tumors (SRBCT) in sinonasal comprise histogenetically diverse entities with overlapping morphologic features. Because of the limited initial biopsy tissue materials, differential diagnostic difficulties may arise, and as they have different management, exact diagnosis and classification are very important.

Objectives

In this study, we analyzed the immunohistochemical expression of a panel of markers in the classification and diagnosis of sinonasal SRBCTs.

Material and Methods

This cross sectional study was performed on 36 paraffin embedded tissue samples. Histologic and immunohistochemical slides from 36 patients with SRBCT were analyzed retrospectively. The patients were admitted in Khalili hospital, Shiraz from 1383 to 1388.

Results

There were 13 women and 23 men with the mean age of 53 ±12.1. There were 9 malignant melanoma, seven poorly differentiated SCC; six lymphoma (DLBL); 4 SCNEC; three SNUC; two ON; two Ewing/PNET; two embryonal rhabdomyosarcoma, and one plasmacytoma. Pan-cytokeratin was strongly expressed poorly differentiated SCC and all cases of SNUC. Coexpression of desmin and nuclear myoD1 was only detected in rhabdomyosarcoma. HMB45 was only expressed in sinonasal melanoma. CD99 expression was identified only in Ewing/PNET. FLI-1 was detected in 50% of PNET. P63 was expressed in poorly differentiated SCC (2/7) and SNUC (1/3).

Conclusions

The results of our study indicate that the integration of histopathologic findings with application of limited but highly specific markers led to the separation of carcinomas, lymphoma and melanomas from other small cell tumors. Using a panel of keratin, LCA, desmin, and HMB45 is the most practical and economic approach to accurately classify these tumors.

Survival in Sinonasal Melanoma: A Meta-analysis

Sinonasal melanoma is an uncommon tumor which carries a poor prognosis and high rates of local and regional recurrence and distant metastasis. While surgical resection is the mainstay of treatment, the utility of multimodality therapy has not been well studied or established. We sought to better evaluate the optimal treatment modality for sinonasal melanoma. We reviewed 39 case reports involving 423 patients with sinonasal melanoma and present a meta-analysis comparing survival by treatment modality. The two-tailed p-value for survival by treatment modality was determined. The number of primary site/local, regional, and distant recurrences was determined where data was available. There was a nonsignificant increase in survival for patients treated with surgery + radiotherapy versus surgery alone. There was a statistically significant increase in survival for surgery + chemotherapy versus chemotherapy alone and versus surgery alone. Patients treated with combined surgery, radiation, and chemotherapy had a statistically shorter survival interval than patients treated with surgery + chemotherapy, which may reflect more advanced disease in patients treated with triple therapy. There was no statistically significant increase in survival found for the addition of radiation to surgery. This meta-analysis demonstrates that multimodality therapy, particularly the addition of chemo-or immunotherapy to surgery, may increase survival in a subset of patients. Radiation therapy did not appear to increase survival. There may be a significant increase in overall survival with combined modality therapy with surgery and chemo/immunotherapy versus single modality therapy.

LEVEL OF EVIDENCE

III. Grade of recommendation: C.

Sinonasal mucosal melanomas: the prognostic value of tumor classifications

BACKGROUND

The purpose of this study was to assess the prognostic value of the 3 staging systems found in the literature for sinonasal mucosal melanomas tumors: the Ballantyne staging system modified by Prasad (Ballantyne/Prasad staging system), the American Joint Committee on Cancer (AJCC) TNM classification for mucosal melanomas (mmTNM), and the 2009 AJCC TNM classification for carcinomas of the nasal cavity and sinuses (carTNM).

METHODS

A retrospective study of 35 patients treated between 1995 and 2010 was conducted for this study. Each patient was retrospectively staged using the Ballantyne/Prasad staging system, mmTNM, and carTNM.

RESULTS

There were 20 women (57.1%) and 15 men (42.9%). Only carTNM was significantly correlated with overall survival (p = .012) and disease-free survival (p = .041). The other 2 classifications were not correlated with survival except for metastatic patients whose overall survival was lower (p = .032).

CONCLUSION

On the basis of these findings, we believe that carTNM should be the primary staging system for patients with mucosal melanomas of the sinonasal tract

Oncogene abnormalities in a series of primary melanomas of the sinonasal tract: NRAS mutations and cyclin D1 amplification are more frequent than KIT or BRAF mutations

Primary malignant melanoma of sinonasal tract is a rare but severe form of melanoma. We retrospectively analyzed 17 cases and focused on the histologic presentation and the expression of c-Kit, epidermal growth factor receptor (EGFR), cyclin D1/Bcl-1, PS100, and HMB45 and searched for BRAF, NRAS, and KIT mutations that are known to be associated with melanoma subtypes, together with amplifications of KIT, cyclin D1, cyclin-dependent kinase 4, MDM2, and microphthalmia-associated transcription factor using quantitative polymerase chain reaction. In most cases (78%), an in situ component was evidenced. Invasive components were composed of diffuse areas of rhabdoid, epithelioid, or spindle cells and, in most cases, lacked inflammatory reaction, suggesting that an immune escape phenomenon probably develops when the disease progresses. EGFR was rarely and weakly expressed in the in situ component of 2 cases. None of the investigated case showed BRAF V600E, but 1 had a D594G mutation. NRAS mutations in exon 2 (G12D or G12A) were found in 3 cases (18%), and a KIT mutation in exon 11 (L576P), in 1, whereas c-Kit was expressed at the protein level in half of the cases. Amplifications of cyclin D1 were evidenced in 5 cases, confirmed in 3 by fluorescence in situ hybridization, but this was not always correlated with protein expression, found in 8 patients (62.5%), 3 having no significant amplification. In conclusion, primary malignant melanoma of sinonasal tract is not associated with BRAF V600E mutations. Instead, NRAS or KIT mutations and cyclin D1 amplification can be found in a proportion of cases, suggesting that primary malignant melanoma of sinonasal tract is heterogeneous at the molecular level and should not be sensitive to therapeutic approaches aiming at BRAF.

Gastroduodenal metastasis of malignant melanoma: A case report

Malignant melanoma metastasis to the gastroduodenal tract is a rare, likely misdiagnosed entity. Here we report a case of choroidal melanoma lesion metastatic to the alimentary canal which was confirmed by digestive endoscopy and histopathology. Besides, we also reviewed the related literatures and summarized the endoscopic manifestations, clinicopathological characteristics and prognosis of this disease. Physicians should raise awareness of the endoscopic manifestations and histological characteristics of this rare clinical condition.

Evidence-based practice: endoscopic skull base resection for malignancy

Successful outcomes of endoscopic approaches to benign sinonasal tumors have launched interest in expanding its use for sinonasal malignancy. Because of the heterogeneity and rarity of sinonasal malignancy, evidence for clinical outcomes of endoscopic approaches versus traditional craniofacial resection is low. Using the Oxford Center for Evidence-based Medicine guidelines, we present the existing evidence comparing both techniques for a variety of sinonasal malignancies.

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.

Mucosal melanoma of the head and neck: 32-year experience in a tertiary referral hospital

INTRODUCTION

Primary mucosal melanomas of the head and neck (HNMM), albeit being rare, are rapidly lethal. Here we report the experience of patients with HNMM treated in our institution over a 32-year period.

OBJECTIVES/HYPOTHESIS

We aim to review our experience in managing HNMM patients over a 32-year period.

STUDY DESIGN

Retrospective study.

METHODS

Thirty-five patients diagnosed with HNMM from 1978 to 2009 were retrospectively reviewed, with an emphasis on predictors on survival outcome.

RESULTS

Twenty-four patients received curative resection, 6 of them followed by adjuvant radiotherapy. Neck dissections were performed in 8 patients. Four patients received radiotherapy as primary treatment. Seven patients were treated conservatively. The overall mean and median survivals were 50 and 26 months, respectively. The median survival of stage I, II, and III diseases in our group of patients were 39, 10, and 16 months, respectively. The 1-year and 5-year overall survival rates were 65.7% and 22.9%, respectively. Age above 60 (p = 0.007), nodal involvement (p = 0.047;) and stage at presentation (p = 0.046) were shown to be associated with worse overall survival. Sites of tumour did not seem to impact on survival. On multivariate analysis, only age (below or above 60) was found to be statistically significant [RR 4.79 (1.65-13.9), p = 0.004].

CONCLUSIONS

Oral cavity melanomas are more likely to have nodal involvement at presentation. Prognosis of HNMM remains grave. Current evidence still supports surgery as the best chance of cure. Role of adjuvant radiotherapy is controversial and does not appear to improve overall survival. Similarly, role of neck dissection is ill-defined.

Accuracy of intraoperative frozen margins for sinonasal malignancies and its implications for endoscopic resection of sinonasal melanomas

BACKGROUND

The main objective of endoscopic tumor surgery remains similar to open approaches, with the goal being total tumor resection with clear margins. Beyond cosmesis, endoscopes offer the advantage of limiting the size of the resection as well as aiding in the procurement of tissue margins in areas adjacent to critical structures or deep in the sinonasal cavity. Because of the close proximity of these tumors to critical structures and classic otolaryngology teaching with the goal sparing normal sinonasal mucosa, sinonasal tumor resection margins tend to be more conservative than those practiced for the same type of tumor in a different anatomic location. What is not uniformly agreed upon is the optimal margin of resection as well as the reliability of intraoperative frozen margins for the varied histologic subtypes seen in sinonasal malignancies.

METHODS

Retrospective review of malignant sinonasal tumors resected endoscopically by 1 surgeon at 2 institutions between 2006 and 2011.

RESULTS

Thirty-one patients with mixed histologies were identified, with the most common being mucosal melanoma (25.8%) and squamous cell carcinoma (23.3%). The overall false-negative rate for intraoperative frozen margins was 6.5%, with both false negatives associated with mucosal melanoma. The false-negative margin rate for mucosal melanoma was 25%.

CONCLUSION

Intraoperative frozen margins for sinonasal tumors are reliable for most histologic subtypes, with the exception of those for sinonasal mucosal melanomas. This has implications for the size of margins needed for the resection of sinonasal melanomas as they may need to be larger than those for other tumors.

Sinonasal carcinomas: epidemiology, pathology, and management

Sinonasal carcinomas are uncommon neoplasms accounting for approximately 3% to 5% of all upper respiratory tract malignancies. Sinonasal malignancies in most cases do not cause early symptoms and present in an advanced stage of disease. Exact staging necessitates a clinical and endoscopic examination with biopsy and imaging. Tumor resection using an open or endoscopic approach is usually considered the first treatment option. In general, sinonasal carcinomas are radiosensitive, so adjuvant or neoadjuvant radiation treatment may be indicated in advanced disease. Multidisciplinary surgical and medical oncologic approaches, including ablation and reconstruction, have enhanced the survival outcome over the past few decades.

Expression of Sox10 and c-kit in sinonasal mucosal melanomas arising in the Chinese population

Sinonasal mucosal melanomas (SNMM) of the head and neck regions are rare and aggressive malignancies. Although they can affect patients of any ethnicity, they are more numerous in Chinese patients. The diagnosis and treatment of these tumors can be challenging. Recent studies have reported that Sox10 is a sensitive melanocytic marker for cutaneous melanoma (Nonaka et al. in Am J Surg Pathol 32:1291-1298, 2008). In addition, a CD117 (c-kit) gene mutation has been identified in cutaneous melanomas, indicating that there may be potential therapeutic benefits of tyrosine kinase inhibitors, such as Imatinib. The purpose of this study was to detect and test the immunohistochemical expression of Sox10 and c-kit in mucosal melanomas (MM) arising in the nasal cavities of Chinese patients. Twenty eight patients with mucosal melanomas of the nasal cavity were treated in two major hospitals in China. All cases had been locally diagnosed as primary SNMM. We confirmed all diagnoses with positive immunohistochemical stains for S100 and HMB-45. Additionally, automated immunohistochemistry was performed using a goat polyclonal Sox10 antibody and a monoclonal c-kit antibody counterstained using a standard avidin-biotin complex method. Immunohistochemical positive expression of Sox10 was defined by nuclear stain; and positivity for c-kit resulted in a distinct membranous staining. The extent of nuclear positivity for Sox10 and membranous stain for c-kit was graded by 4 board certified pathologists as follows: 1+, 1-25 % of positive tumor cells; 2+, 25-50 %; 3+, 50-75 %; and 4+, ≥75 %. Sox10 nuclear expression was found in all cases (100 %), with 4+ staining in 26 out of 28 cases (92.8 %) and 3+ staining in two cases with (7.1 %). The overall positivity for S100 staining was 23 out of 28 (82.1 %), with 1+ staining in 10 cases, 2+ staining in 6 cases, 3+ staining in 7 cases, and no staining in 5 cases. The sensitivity and intensity of Sox10 immunohistochemistry were both higher than with S100 immunohistochemistry. Immunopositivity of membranous stain for c-kit (CD117) was seen in 24 out of 28 cases (85.7 %), including 6 tumors that were 4+, eight that were 3+, six that were 2+, and four that showed 1+ staining. Our results demonstrate that Sox10 is a sensitive marker for SNMM and it may possess diagnostic value in addition to that of S100 protein. The expression of c-kit in the majority of MMs suggests that it may be useful in the assessment of these tumors for potential treatment with tyrosine kinase inhibitors.

Sinonasal tumors: a clinicopathologic update of selected tumors

The sinonasal cavities show a wide variety of neoplasms of epithelial, mesenchymal, neural/neuroectodermal or hematopoietic origin. The differential diagnosis for these tumors may be difficult due to overlapping morphologies, variable patterns in ancillary studies, and potentially confusing terminology. In this report, an updated review of the spectrum of neoplasia is provided, using the World Health Organization 2005 classification as a guide. Classic tumors that are generally limited to the sinonasal tract are described and new information regarding molecular pathogenesis is reviewed. Also new entities that have the sinonasal tract as a site of predilection, such as sinonasal renal cell-like adenocarcinoma and NUT midline carcinoma are highlighted.

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.

Ectopic sphenoid sinus pituitary adenoma (ESSPA) with normal anterior pituitary gland: a clinicopathologic and immunophenotypic study of 32 cases with a comprehensive review of the english literature

Ectopic sphenoid sinus pituitary adenoma (ESSPA) may arise from a remnant of Rathke's pouch. These tumors are frequently misdiagnosed as other neuroendocrine or epithelial neoplasms which may develop in this site (olfactory neuroblastoma, neuroendocrine carcinoma, sinonasal undifferentiated carcinoma, paraganglioma, melanoma). Thirty-two patients with ESSPA identified in patients with normal pituitary glands (intact sella turcica) were retrospectively retrieved from the consultation files of the authors' institutions. Clinical records were reviewed with follow-up obtained. An immunohistochemical panel was performed on available material. Sixteen males and 16 females, aged 2-84 years (mean, 57.1 years), presented with chronic sinusitis, headache, obstructive symptoms, and visual field defects, although several were asymptomatic (n = 6). By definition, the tumors were centered within the sphenoid sinus and demonstrated, by imaging studies or intraoperative examination, a normal sella turcica without a concurrent pituitary adenoma. A subset of tumors showed extension into the nasal cavity (n = 5) or nasopharynx (n = 9). Mean tumor size was 3.4 cm. The majority of tumors were beneath an intact respiratory epithelium (n = 22), arranged in many different patterns (solid, packets, organoid, pseudorosette-rosette, pseudopapillary, single file, glandular, trabecular, insular). Bone involvement was frequently seen (n = 21). Secretions were present (n = 16). Necrosis was noted in 8 tumors. The tumors showed a variable cellularity, with polygonal, plasmacytoid, granular, and oncocytic tumor cells. Severe pleomorphism was uncommon (n = 5). A delicate, salt-and-pepper chromatin distribution was seen. In addition, there were intranuclear cytoplasmic inclusions (n = 25) and multinucleated tumor cells (n = 18). Mitotic figures were infrequent, with a mean of 1 per 10 HPFs and a <1% proliferation index (Ki-67). There was a vascularized to sclerotic or calcified stroma. Immunohistochemistry highlighted the endocrine nature of the tumors, with synaptophysin (97%), CD56 (91%), NSE (76%) and chromogranin (71%); while pan-cytokeratin was positive in 79%, frequently with a dot-like Golgi accentuation (50%). Reactivity with pituitary hormones included 48% reactive for 2 or more hormones (plurihormonal), and 33% reactive for a single hormone, with prolactin seen most frequently (59%); 19% of cases were non-reactive. The principle differential diagnosis includes olfactory neuroblastoma, neuroendocrine carcinoma, melanoma, and meningioma. All patients were treated with surgery. No patients died from disease, although one patient died with persistent disease (0.8 months). Surgery is curative in the majority of cases, although recurrence/persistence was seen in 4 patients (13.8%). In conclusion, ESSPAs are rare, affecting middle aged patients with non-specific symptoms, showing characteristic light microscopy and immunohistochemical features of their intrasellar counterparts. When encountering a tumor within the sphenoid sinus, ectopic pituitary adenoma must be considered, and pertinent imaging, clinical, and immunohistochemical evaluation undertaken to exclude tumors within the differential diagnosis. This will result in accurate classification, helping to prevent the potentially untoward side effects or complications of incorrect therapy.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Noncutaneous melanoma have distinct features from each other and cutaneous melanoma

OBJECTIVE

Compared to the cutaneous melanoma, noncutaneous melanomas are relatively rare and have a distinct pattern of behavior. We performed this study to define the clinical characteristics and outcomes of patients with noncutaneous melanomas and emphasize how they differ from cutaneous melanomas.

METHODS

216 patients who were diagnosed with noncutaneous melanoma were assessed and their medical records between 2000 and 2010 were retrieved from the cancer registry. 475 patients with cutaneous melanoma were used for comparison.

RESULTS

Of the 216 noncutaneous melanoma patients, 83 had mucosal melanoma, 101 had ocular melanoma and 32 had unknown primaries. For mucosal melanoma, the head and neck was the most common anatomic site (53%), followed by the gastrointestinal tract (37%), female genital (6%) and urinary tract (4%). The majority of the ocular melanomas (94%) originated in the uvea. 32 patients demonstrated a primary unknown disease with regional metastasis as the dominant behavior (72%). Age was found to be statistically significantly different among melanoma patients (p < 0.001). Younger patients had more cutaneous and unknown primary melanomas, whereas older patients had more ocular and mucosal melanoma. In subset analyses, we found significant differences between cutaneous and ocular (p = 0.038) or mucosal (p < 0.001) melanomas. The ratios of metastasis on admission were higher in patients with mucosal (27.7%) and unknown primary (28.1%) melanomas, and lower for ocular (3%) melanomas (p < 0.001). Patients with cutaneous melanoma had an intermediate (12%) ratio. Patients with ocular melanoma had better outcome than patients with other melanoma sites (p < 0.05). While overall survival for cutaneous melanoma was significantly negatively correlated with male gender (p < 0.001), advanced stages (p < 0.001) and old age (p = 0.005), stage IV disease was the only independent prognostic factor in patients with ocular melanoma (p = 0.006). No prognostic factor for outcome was found for either mucosal or unknown primary melanomas.

CONCLUSION

The clinical presentations and prognoses of different primary sites of melanoma are distinctive. Therefore, approaches to these melanomas should be different.

Review: mucosal melanoma of the head and neck

Head and neck mucosal melanoma (MM) is a rare and aggressive neoplasm, with high rates of local, regional, and distant failure. Owing to the small size of most reported series and their retrospective nature, and the lack of uniform comprehensive staging system, the effect of various treatment strategies on disease control and survival has been difficult to assess. The optimal management of head and neck MM is not well defined. Surgical treatment has being advocated as the primary treatment modality, with growing consideration for postoperative radiotherapy, as wide surgical resection in the head and neck region is often difficult. Radiotherapy is recently reported as a beneficial management modality, regardless of the fact that MM has been considered to be radioresistant. As significant morbidity is expected in high doses of radiotherapy to the head and neck region, new radiographic modalities with better precision are required. Furthermore, high-energy radiotherapy was suggested as a better therapy to mucosal MM due to the suggested biology of the tumor. The high rates of locoregional recurrence and distant metastasis also suggest that a systemic treatment is needed. Currently, there is no role for adjuvant systemic therapy for patients who have been successfully resected, but recent developments in the understanding of the biology of melanoma and, in particular, specific growth pathways holds promise for the future. We strongly recommend further evaluation of the role of chemotherapy and immunotherapy to decrease the rates of distant metastasis and improve survival.

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.

Sinonasal mucosal melanoma: a 13-year experience at a single institution

OBJECTIVE

Report the experience of the Karmanos Cancer Institute with sinonasal mucosal melanoma (SNMM) in patients diagnosed between 1995 and 2007.

RESULTS

Eighteen patients, ages 31 to 85 (mean, 67), whose most common presenting symptoms included epistaxis and facial pressure. Most common anatomic locations were the maxillary sinus and nasal cavity. Seventy-two percent presented with tumors extending to the skull base, frontal sinus, orbit, or cranium. Tumor size ranged from 0.3 cm to 5.3 cm. Most common surgical procedure was medial maxillectomy (12 patients). Eight patients received chemotherapy, ten received radiotherapy and six received both. One third of patients received interferon-alpha. Median recurrence-free survival (RFS) was 14.4 months, with a 1-year RFS rate of 55%. Median overall survival (OS) was 19.3 months with a 1-year OS rate of 60% and a 2-year OS rate of 42%. The 5-year OS rate was 34%.

CONCLUSION

SNMM remains a disease that has eluded breakthroughs in treatment. Patients are typically treated with wide local resection; however unique to our institution was the frequent use of interferon and chemoradiation. Further research in adjuvant therapies will be necessary to improve outcomes.

The value of 18F-FDG-PET/CT imaging for sinonasal malignant melanoma

The aim this study was to evaluate imaging findings using position emission tomography (PET) in combination with computed tomography (CT) and 18F-fluorodeoxyglucose ((18)F-FDG) in sinonasal malignant melanoma (SNMM) of the head and neck in a retrospective analysis of a consecutive cohort of patients. (18)F-FDG-PET/CT examinations were performed for initial staging and compared with CT or magnetic resonance tomography (MRI), and (18)F-FDG-PET alone. Medical records were reviewed retrospectively with regard to the location and the size of the tumor. Furthermore, locoregional and distant metastases with a consecutive change in therapy detected by (18)F-FDG-PET/CT were assessed. Ten patients suffering from sinonasal malignant melanoma were staged and followed by (18)F-FDG-PET/CT imaging. A total of 34 examinations were obtained. (18)F-FDG-PET/CT depicted all primary tumors adequately. Aside from one cerebral metastasis all regional and distant metastases were truly identified by using this method. In summary, if available, (18)F-FDG-PET/CT is a valuable imaging modality for staging and re-staging sinonasal malignant melanoma to evaluate expansion of the primary tumor, locoregional disease, and distant metastases.

Malignant melanoma of the nasal septum

Primary malignant melanoma involving the nasal and paranasal sinus mucosa is a rare neoplasm, accounting for less than 1% of all melanomas. Being more aggressive than its cutaneous counterpart, it carries a poor prognosis. We report a case arising from the nasal septum mucosae in a 78-year-old man. We describe clinical features, diagnosis, and treatment of this rare disease along with a review of the pertinent literature. Endoscopic resection of the neoplasm was performed, enabling diagnosis of sinonasal mucosal melanoma involving the frontal sinus floor. Because the patient was too compromised to achieve radical surgical approach (craniofacial resection), he underwent radiation therapy. Through this article, we wish to emphasize that early diagnosis with a high index of suspicion is critical because this type of tumor is extremely aggressive. Its location and relatively nonspecific features frequently delay diagnosis, and its rarity avoids an optimal treatment guideline setting.

Current diagnostic strategies for undifferentiated tumours of the nasal cavities and paranasal sinuses

Several malignant tumours occurring in the sinonasal tract may present with an undifferentiated morphology. Overall, these lesions pose significant diagnostic difficulties for the surgical pathologist, especially in limited biopsy material, but their correct classification is becoming increasingly important for an appropriate treatment strategy. This review deals with the criteria for differential diagnosis of these neoplasms, with emphasis on recent advances in immunohistochemistry and molecular biology, as well as with previous progress in electron microscopy. Through careful microscopic examination of haematoxylin and eosin-stained sections, in the light of clinical information and imaging data, a list of differential diagnoses can be made and an appropriate panel of antibodies can be chosen to further categorize the tumour. An initial panel including cytokeratins, synaptophysin, S100 protein, desmin and CD45 may allow the classification of most lesions or may help to narrow the list of differential diagnoses. Further refinement can be obtained through second-line markers, including in-situ hybridization for Epstein-Barr virus, other neuroendocrine markers, melanocytic markers, myogenin, CD99, other lymphocyte markers, and CD138 and light chains. Finally, molecular analysis can further assist in the recognition of specific entities such as nuclear protein in testis midline carcinoma, Ewing's sarcoma/peripheral neuroectodermal tumour, alveolar rhadbomyosarcoma, and poorly differentiated synovial sarcoma.

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.

Malignant melanoma of nasal cavity and paranasal sinuses: report of 24 patients and literature review

OBJECTIVE

To report our experience of the management of patients with primary sinonasal malignant melanoma, and to review the relevant medical literature.

METHOD

Retrospective review examining treatment and outcomes.

RESULTS

Twenty-four patients were treated between 1982 and 2007. The mean age at presentation was 67.5 years. The overall five-year survival was 30 per cent; mean survival was three years and eight months.

CONCLUSION

Sinonasal malignant melanoma is associated with a poor outcome, and survival statistics have not improved over the last 40 years. Treatment should include radical surgery wherever possible. Local recurrence is common; radiotherapy may help control this but does not appear to affect overall survival. The limited evidence available suggests that endoscopic removal of sinonasal malignant melanoma is as effective as other local surgical means, but that craniofacial resection remains the 'gold standard' for tumours that contact or traverse the skull base. Novel biological treatments are emerging and hold promise for the future.