METASTATIC MELANOMA. A CLINICOPATHOLOGICAL STUDY

Primary biliary tract malignant melanoma

Primary melanoma is rarely diagnosed in the biliary tract; only three cases of primary melanoma of the bile ducts have been reported previously. The skin and squamous mucous membranes are the most common primary sites. We report two patients who represent the fourth and fifth reported cases of primary bile duct melanoma.

[Cerebrospinal fluid in the diagnosis of cerebro-meningeal metastasis from malignant melanoma arising from giant congenital melanocytic nevus: case report]

We describe the case of a 28-year-old man with a giant congenital melanocytic nevus (GCMN) with malignant transformation to melanoma and metastasis on the central nervous system (CNS). We also make a summary of the pathological features from both lesions (GCMN and Melanoma), the occurrence of malignancy of GCMN, the organs more frequently involved with metastatic melanoma--with emphasis to involvement of CNS--just as the factors that cause malignant transformation of GCMN; the methods to diagnose metastases in CNS--emphasizing the importance of cerebrospinal fluid--and some therapeutical modalities for the metastatic melanoma in CNS.

Clinical and histological features of poor prognosis in cutaneous metastatic melanomas

Patients with melanoma metastatic to the skin show variable prognosis. Though some may survive for quite a long time, some die of disseminated disease within 1 year of removal of cutaneous metastases. The aim of this study was to find out whether there are any histological criteria indicating particular poor outcome. Clinical and histological features of 344 melanoma lesions metastatic to the skin were assessed and their prognostic relevance was investigated. H&E stained histological slides were scanned for the presence of morphological criteria expressing certain tumor cell-stroma interactions: capsule formation (CAPSULE), formation of intratumoral septa (NEWSEPTA), simple invasion between collagen of reticular dermis (DERM-SIMPLE), or subcutis (SCSIMPLE), preservation of preexistent collagen (PRECOLL) or fatty tissue (PREFAT) and, finally, histological site of metastasis. Additionally, anatomical location of the metastases, time between removal of primary tumor and metastases age and sex of patients were recorded. The metastases were divided into two groups: lesions of patients who died within 1 year after resection (n = 59) and lesions from patients with a longer survival (n = 285). Metastases which were associated with death within one year were significantly more often found in male patients (54.2% versus 34.7%), in younger patients (mean age 51.1 +/- 14.1 years versus 58.8 +/- 15.3 years), had developed earlier after the primary tumor (mean time of 21.7 +/- 19.9 months versus 43.3 +/- 27.4 months) and were more often found at distant sites than in localregional sites (45.7% versus 30.5%), and were more often involved in the subcutis (74.5% versus 56.1%). From a histological point of view, DERMSIMPLE (80% versus 46%; p < 0.001) and PRECOLL (82.8% versus 57.6; p < 0.01) were more frequent in metastases of poor outcome. The same was true for SCSIMPLE (50% versus 25.6%; p < 0.01) and PREFAT (68.1% versus 46.8%; p < 0.05) in lesion with subcutaneous growth, whereas CAPSULE (54.5% versus 75%) was less frequently seen. In conclusion, melanoma deposits metastatic to the skin with particular poor outcome differ clinically and histologically from other cutaneous melanoma metastases. This should be taken into account in the design of therapeutic clinical trials.

Malignant melanoma metastatic to the tonsil

Metastasis to the oral cavity from melanoma arising in distant sites is very rare. The authors present three cases of melanoma metastatic to the palatine tonsil: two were cutaneous melanomas and one arose from the mucous membrane of the hard palate. Fewer than 30 cases of metastatic melanoma to the palatine tonsil have been reported, and none have been from mucosal melanoma originating from another mucosal primary site in the head and neck. From this perspective, one of the cases in this article is unique. The authors present clinical histories of the three cases of melanoma metastatic to the palatine tonsil. Two patients were still alive a substantial time after treatment. The case presentations indicate that careful examination of the head and neck should be part of the routine follow-up examination in all melanoma patients.

Cranial irradiation after surgical excision of brain metastases in melanoma patients

BACKGROUND

Brain metastases account for 20-54% of reported deaths from melanoma. Duration and quality of survival depend on the extent of metastatic disease and response to treatment. Treatment goals are palliation of symptoms and prolongation of life. No studies have directly compared surgery alone and surgery with adjunctive cranial irradiation in patients with solitary brain metastases.

METHODS

We evaluated postoperative adjunctive cranial irradiation in 34 patients with solitary brain metastases.

RESULTS

Overall survival was significantly improved in the 22 patients who received adjunctive cranial irradiation versus that in the 12 patients who had surgery alone. Twenty-eight patients subsequently relapsed. Nine of 10 patients with surgery alone had brain recurrence as a component of failure. Six of 10 patients not receiving irradiation had brain recurrences as a component of relapse at multiple sites whereas only 1 of 18 patients receiving irradiation relapsed with the brain.

CONCLUSIONS

Adjunctive cranial irradiation is justified for melanoma patients who undergo surgical therapy for solitary brain metastases. Survival in patients presenting with solitary brain metastases was improved by a reduction of relapse in the brain as a component of failure by combined surgery and irradiation.

Clinical and Pathologic Distinction between Primary and Metastatic Mucosal Melanoma of the Head and Neck

Metastatic mucosal melanoma is extremely rare. Only 0.6% to 9.3% of patients with cutaneous malignant melanoma will have metastases to the mucosa of the upper aerodigestive tract. The records of all patients with mucosal melanoma of the head and neck at the University of California, Los Angeles Medical Center during the past 30 years were reviewed. Patients with primary tumors were separated from those with metastatic involvement from a cutaneous primary site. These two groups were compared for differences in clinical symptoms, histopathologic findings, treatment, and survival characteristics. Frequent sites of metastatic involvement included the base of tongue and nasal cavity. These arose from a variety of cutaneous sites including the trunk and extremities and, in most instances, did not arise until 2 to 7 years after the initial cutaneous lesion. Most of those with metastases to the head and neck mucosa had disseminated disease. The histopathologic distinction between the two groups is described with photomicrographs. Junctional activity in the overlying or adjacent mucosa distinguishes primary mucosal melanoma from metastatic disease, in which the overlying mucosa is usually intact. This difference is useful in determining workup and treatment options. Aggressive surgical resection is suggested in treatment of primary melanomas, whereas surgery is at best palliative in those with metastatic disease.

CT of small-bowel neoplasms

The diagnosis of neoplasms of the small intestine remains a difficult challenge owing to their nonspecific clinical presentation. CT is an efficient and contributive tool in their diagnosis and preoperative staging. Enabled by CT, the evaluation of the intramural and extramural portions of such tumors complements the mucosal analysis allowed by barium examination. Strict technical rules should be applied to minimize pitfalls mainly resulting from insufficient bowel opacification. Although characteristic appearances are rare, typical CT findings may suggest a specific diagnosis where lipomas and carcinoid tumors are concerned.

Primary malignant melanoma of the biliary tract

Primary malignant melanoma of the biliary tract is an obscure entity, with only four previously reported cases. We report two cases involving the common bile duct. A 43-year-old male who underwent a right hepatectomy and excision of the extrahepatic biliary tree for a lesion at the bifurcation of the common bile duct. He remains alive and well 11 months after resection. The second patient is a 45 year old male with obstructive jaundice due to an ampullary lesion. Pancreaticoduodenectomy was performed with no signs of metastatic disease. He is 6 years following resection without evidence of disease. This is an unusual cause of obstructive jaundice and a definitive search for a possible extra-biliary primary should be pursued. In appropriately selected patients without evidence of metastatic disease, resection can potentially afford long-term survival if these lesions are true primary lesions and not metastatic from an undefined primary. However, given the high metastatic potential of melanoma it is unclear whether resection of these lesions results in cure or just effective long-term palliation.

Malignant melanoma with mesenteric metastasis causing an intrapelvic abscess: report of a case

We present herein the case of a 66-year-old woman with disseminated malignant melanoma in whom a metastasis in the ileal mesentery ruptured into the peritoneal cavity causing an acute abdomen. The patient suddenly developed lower abdominal pain and a computed tomography (CT) scan of the pelvis confirmed the presence of an intrapelvic abscess. At emergency laparotomy, a 10 x 10 cm ruptured metastatic melanoma was found in the ileal mesentery, which demonstrated no communication with the ileum itself. To our knowledge, no other case of an acute abdomen being caused by the rupture of mesenteric metastatic melanoma lacking any communication with the bowel lumen has ever been reported.

Metastatic malignant melanoma of the oral cavity. A retrospective study

Metastatic malignant melanoma of the oral cavity is rarely reported in the dental literature. This retrospective study identified metastatic oral lesions in 3.0% of 809 patients with melanoma treated at the National Institutes of Health between 1953 and 1989. Fifteen cases met established rigorous criteria for metastatic tumors and were reviewed for disease course and outcome. Nine white men and six white women, with an average age of 40.6 years, had cutaneous primary tumors predominantly of the trunk and head and neck region that commonly presented as moles that were enlarging, bleeding, or showing both of these signs. A mean of 4.2 years elapsed between primary tumor and oral metastasis diagnosis. Tongue, buccal mucosa, and parotid gland were the predominant oral sites. Enlarging oral masses, pigmented lesions, and nonhealing extraction sites with masses were common oral presentations. Surgery, chemotherapy, radiation therapy, and immunotherapy were used in various combinations for treatment of the primary lesion and oral metastasis. Prognosis, although poor, was highly variable.

Management of recurrent cutaneous melanoma

Recurrent melanoma occurs in approximately one third of patients treated for cutaneous melanoma. Although the majority of recurrence occurs within the first few years of primary therapy, a significant number remains at risk beyond 10 years. With rising incidence of recurrent melanoma in Western countries, physicians will undoubtedly face the challenge of managing these patients with the limited therapeutic options currently available. Once melanoma has recurred, the overall prognosis is poor. Localized disease is best treated with complete resection, if indicated. Our existing armamentarium for systemic treatment falls short of altering the course of natural history of melanoma, but regional chemotherapy is an effective modality for in-transit disease and satellitosis. Translational research in molecular genetics and immunology will fuel new ideas for the design of rational strategies toward tumor eradication. Ongoing trials that use gene-modified melanoma cells have begun a new chapter in cancer therapeutics and lend us a closer examination of bench-top science at the bedside.

Radical resection of primary malignant melanoma of the gallbladder with multiple metastases: report of a case

We present herein an usual case of primary malignant melanoma of the gallbladder in a 51-year-old man in whom an exploratory laparotomy for melena revealed six malignant melanoma lesions located in the gallbladder, main pancreatic duct, stomach, duodenum, jejunum, and a mesenteric lymph node. Total pancreatectomy was performed and histologically, junctional activity was seen only in the gallbladder, suggesting that this was the primary site. No melanotic lesions were found on the skin or eyes. The metastases to the main pancreatic duct and gastrointestinal tract appeared likely to have occurred as a consequence of the mucosal dissemination of the tumor cells shed into the bile. The post-operative course was uneventful and combined chemotherapy was administered for 16 months. No new metastatic lesions were found until 21 months postoperatively, when metastases were detected in the brain and thoracic spinal cord. These metastatic tumors were removed surgically, but the patient died from cerebral disturbance 26 months after the initial operation. Thus, we consider that aggressive surgical therapy was effective for extending the survival time and improving the quality of life of this patient.

Prognosis and treatment of disseminated uveal melanoma

BACKGROUND

The clinical course of uveal melanoma differs greatly from that of cutaneous melanoma.

METHODS

Twenty-four patients with metastatic uveal melanoma (13 men and 11 women; median age at diagnosis, 56 years [range, 17-67 years]) were evaluated retrospectively.

RESULTS

Main sites of metastases were liver (87%), lung (46%), bone (29%), and skin (17%). Median relapse-free survival time was 36 months (range, 5-240 months). Median survival time after clinical detection of metastases was 9 months (range, 1-54 months). Relapse-free survival time was significantly greater in patients 50 years of age or younger. After manifestation of metastases, the clinical course was more favorable in patients in whom the liver was either not involved at all or not among the first sites of dissemination. These patients had a median survival time of 19 months, compared with 7 months for patients in whom the liver was involved initially. First-line systemic treatment of metastatic disease yielded three cases of stable disease lasting 6-14 months, but no complete or partial response. Three patients received intraarterial liver perfusion as first- or second-line treatment, resulting in one partial response, which lasted 6 months.

CONCLUSION

Treatment and prognosis results of patients with metastatic uveal melanoma were poor, especially when the disseminated to the liver; survival time of approximately 9 months can be expected.

Common bile duct obstruction due to intraluminal metastatic melanoma

Although metastatic melanoma is renowned for its propensity to spread to a wide range of sites, symptomatic metastases within the biliary tree are very rare. A patient with a past history of melanoma who presented with obstructive jaundice and in whom computerized tomography (CT) scanning revealed a spherical filling defect 1 cm in diameter at the lower end of the common bile duct is reported. The obstructing lesion was thought likely to be a gallstone. However, on surgical exploration it was found to be a polypoid melanoma metastasis, freely mobile within the lumen of the lower duct but attached to its wall by a thin stalk. There was no evidence of metastatic melanoma elsewhere in the abdomen. The tumour was removed without difficulty, completely relieving the obstructive jaundice. The patient remains well 14 months later, with no evidence of recurrent visceral melanoma.

Pigmented pheochromocytomas of the adrenal medulla

Three primary pigmented pheochromocytomas of the adrenal gland are presented. The pigment in all cases proved to be melanin. Two of the pheochromocytomas were sporadic and histologically typical, except for a focal spindle cell configuration in one. It is believed that the morphologic appearance of these tumors represents divergent differentiation from neural crest, expressing typical pheochromocytoma (polygonal cells) and melanocytic features (melanin pigment).

The efficacy of a single posteroanterior radiograph in the assessment of metastatic pulmonary melanoma

Posteroanterior (PA) and lateral chest radiographs are performed as part of the routine staging and follow-up investigation of patients with malignant melanoma. We have assessed the contribution of the lateral chest radiograph in the follow-up of 227 consecutive patients with proven malignant melanoma. In only once case was an abnormality evident on the lateral radiograph which was not previously detected on the PA films. Our department, as a result of this study, has discontinued the routine use of lateral chest radiography in the follow-up of patients with malignant melanoma.

Surgical management of distant melanoma metastases

Disseminated melanoma remains a tumour that is poorly responsive to chemotherapy and radiotherapy. However, this review demonstrates that surgical removal of visceral metastases such as at the, lung or digestive sites, as well as the brain, yields consistent median survivals, often longer than 12 months, and long-term survivors. Such surgery is followed by little complication cost and low perioperative mortality. Our experience tends to confirm that complete debulking offers longer survivors as compared to partial. Also, one site of metastases, whatever its anatomical location, when operated on, gives a better chance for survival than when there are multiple sites.

Spontaneous rupture of spleen in a patient with splenic metastasis of melanoma. A case report

We report a case of spontaneous splenic rupture in a patient with metastatic melanoma. Spontaneous splenic rupture without previous trauma has been observed in various pathological conditions such as infectious mononucleosis, malaria, typhoid fever and, rarely, neoplasms affecting the spleen. There have been several reported cases of splenic rupture in leukemias. Despite the high incidence of splenic metastases in metastatic melanoma, there have been only 3 cases of spontaneous splenic rupture reported in the past.

Treatment of metastatic uveal melanoma: review and recommendations

This article reviews the published clinical responses of metastatic uveal melanoma and metastatic cutaneous melanoma with visceral involvement to current therapeutic protocols. Despite isolated patient responses to systemic treatment, no effective treatment currently exists for metastatic uveal melanoma. However, several new approaches involving interferons and interleukin and combination chemotherapy have shown some activity against metastatic cutaneous melanoma. The effectiveness against metastatic uveal melanomas has not been determined. A new approach to intrahepatic administration of chemotherapy also warrants further evaluation because of the high incidence of hepatic involvement with metastatic uveal melanoma. When an effective systemic treatment is found, early administration as an adjuvant to primary treatment may provide the best strategy for control of systemic spread.

Role of surgical intervention in the management of intestinal metastases from malignant melanoma

Malignant melanoma is the most common metastatic lesion of the intestine. Surgical consultation is often sought when bowel metastases become symptomatic. To determine the role of surgical intervention in such cases, a database of 6,000 melanoma patients was examined, and a subset of 102 patients with small intestinal or colonic metastases were identified premortem. Common presenting features included abdominal pain with or without acute symptoms (29% of patients), obstruction or intussusception (27%), and bleeding (26%). The presence of metastatic lesions was confirmed by surgical exploration in 80% of patients, endoscopic procedures in 11%, and percutaneous biopsy in 5%. Cure was achieved in 36 patients by resection, which resulted in the removal of all demonstrable disease. The subsequent mean length of survival in this group was 31 +/- 5.2 months. Forty-two patients underwent palliative enteric bypass or debulking procedures, and 24 patients received either chemotherapy alone or symptomatic treatment. The average length of survival in these latter groups was 9.6 +/- 15.9 and 9.6 +/- 3.6 months, respectively, both of which were significantly less than the duration of survival in the complete resection group (p less than 0.05). Small or large bowel resection for bleeding or obstruction and enteric bypass for obstruction provided symptomatic relief in 92% of patients thus treated. There was no operative mortality in the series. An aggressive search for resectable disease in patients with symptoms secondary to intestinal metastases from malignant melanoma should be performed. Surgical intervention may then allow the palliation of pain, obstruction, and bleeding. Survival can be significantly prolonged if it is possible to remove all demonstrable disease.

Improved survival after resection of pulmonary metastases from malignant melanoma

The value of resecting pulmonary metastases from malignant melanoma was retrospectively examined. Between 1981 and 1989, 56 patients (35 men and 21 women with a mean age of 49 years) had 65 pulmonary resections for histologically proven metastatic melanoma after treatment of the primary tumor. In patients undergoing thoracotomy, 50% (28/56) had pulmonary metastases as the initial site of recurrence. Twenty-eight patients (50%) had local-regional recurrence before the development of lung metastases. Eight lobectomies, two segmentectomies, and 55 wedge excisions were done. Fifty-four patients (54/56, 96%) underwent complete resection, and there were no operative deaths. The postthoracotomy actuarial survival was 25% at 5 years (median interval, 18 months). Location of the primary tumor, histology, thickness, Clark level, local-regional lymph node metastases, or type of resection was not associated with improved survival. Patients without regional nodal metastases before thoracotomy had a median survival of 30 months compared with 16 months for all others (p = 0.04). Patients with lung as the site of first recurrence had a median survival of 30 months compared with 17 months for patients with initial local-regional recurrence (p = 0.038, log-rank test). Despite systemic spread, patients with isolated pulmonary metastases from melanoma may benefit from metastasectomy.

Rupture of liver metastasis of malignant melanoma--a case of hepatic resection

A case is reported in which resection of the left lateral segment of the liver was performed for rupture of a metastatic malignant melanoma in an attempt to control hemorrhaging. The primary lesion was located in the skin of the head, and there were multiple metastases to the lung, liver and distant nodes. The patient, a 47-year-old woman, had been undergoing systemic chemotherapy for the disseminated disease, but she presented with intraabdominal bleeding from a metastatic nodule in the left lateral segment of the liver. An emergency operation was performed, and the immediate postoperative course was uneventful. She was discharged 10 days after the operation. The patient died, however, of hemorrhagic shock due to renewed intraabdominal bleeding on the 39th postoperative day. It is concluded from the above case that hepatic resection for a bleeding metastasis of malignant melanoma is a viable option even in patients with disseminated disease.

Metastatic melanoma of the orbit. A case report

We report a metastatic cutaneous melanoma of the medial rectus muscle of the right orbit which presented with diplopia, exophthalmos and retrobulbar pain. Radioimmunoscintigraphy using melanoma-specific monoclonal antibody was used to confirm the diagnosis and to show the presence of disseminated disease in other areas. Effective palliation was achieved with external beam irradiation.

Fine-needle aspiration biopsy of malignant melanoma: a cytologic and immunocytochemical analysis

The immunoreactivity of alcohol-fixed cell blocks from 15 fine-needle aspiration (FNA) specimens of malignant melanoma was investigated using monoclonal antibodies to keratin and vimentin intermediate filaments, melanoma cytoplasmic antigen (HMB-45), and S-100, as well as polyclonal antibodies to S-100. The results were compared with the immunoprofiles obtained using formalin-fixed surgical specimens from 10 of the same patients. In all cases, immunostaining for keratin was negative and immunostaining for vimentin was positive. Immunostaining for HMB-45 was positive in 13/15 aspirates and in 9/10 surgical specimens. Immunostaining for S-100 protein showed the greatest variability in staining, with 5/15 fine needle aspiration biopsies and 9/10 surgical specimens being positive using the polyclonal antibody and only 1/15 FNA specimens and 7/10 surgical specimens being positive using the monoclonal S-100 reagent. Our findings indicate that immunocytochemical studies can be very useful as an adjunct in the FNA diagnosis of melanoma. Also included in our series is an unusual variant of malignant melanoma, the so-called signet ring melanoma. Given the location of the anal verge, the use of immunocytochemical markers was essential in establishing the correct diagnosis in this case. While S-100 protein is of limited value as a marker of melanoma in alcohol-fixed FNA specimens, a definitive diagnosis of malignant melanoma can be made using a panel of antibodies including keratin, vimentin, and HMB-45.

Neurocutaneous melanosis: definition and review of the literature

Neurocutaneous melanosis is a rare congenital syndrome characterized by the presence of large or multiple congenital melanocytic nevi and benign or malignant pigment cell tumors of the leptomeninges. The syndrome is thought to represent an error in the morphogenesis of the embryonal neuroectoderm. We review 39 reported cases of neurocutaneous melanosis and propose revised criteria for diagnosis. Most patients with neurocutaneous melanosis presented in the first 2 years of life with neurologic manifestations of increased intracranial pressure, mass lesions, or spinal cord compression. Leptomeningeal melanoma was present in 62% of the cases, but even in the absence of melanoma, symptomatic neurocutaneous melanosis had an extremely poor prognosis. Useful diagnostic procedures include cerebrospinal fluid cytology and magnetic resonance imaging with gadolinium contrast. Patients may be aided by palliative measures such as shunt placement to reduce intracranial pressure. Dermatologists in their follow-up of patients with large or multiple congenital melanocytic nevi should be aware of this condition, to aid in prompt diagnosis and because the treatment of cutaneous lesions may be altered in the presence of symptomatic neurocutaneous melanosis.

Unusual presentation of cutaneous metastatic malignant melanoma

This report describes an unusual presentation of cutaneous metastases suspected to have occurred through lymphatic spread in a patient with malignant melanoma. Punctate papular skin lesions correlated histologically with small tumor foci in the papillary dermis.

Metastatic cutaneous malignant melanoma of the vitreous and retina

A case of cutaneous malignant melanoma metastasising to the retina in a 71-year-old patient who presented with vitreous opacities is discussed. In view of the increasing incidence of cutaneous malignant melanoma in our community the possibility of ocular metastases merits consideration.

The computed tomographic appearances and clinical significance of intussusception in adults with malignant neoplasms

The computed tomography (CT) appearances of intussusception in 14 patients and the clinical follow-up of this condition in 17 adults with known primary malignant neoplasms were retrospectively reviewed. The ages of the 11 men and six women ranged from 25 to 83 years. Nine patients had been treated for malignant melanoma and the others for various primary neoplasms. Intussusception on CT was characterized by thickening of the affected bowel segment in all 14 patients and by the presence of intraluminal fat density material in 13, a concentric ring or "target" lesion in four, and an intra-luminal soft-tissue mass in nine. Five patients had intussusception, without other evidence of disease, caused by metastases in three patients, lipoma in one and idiopathic in one. Eleven of the other 12 patients had extensive disease, and one had small bowel cytomegalovirus infection. Five of these patients had more than one site of bowel involvement. Ten of the 12 patients had progression of disease on follow-up CT examinations and six died between 26 days and 7 months after diagnosis of intussusception. Intussusception may occur as the first indication of tumour recurrence or metastasis, but is more commonly a manifestation of widespread disease. However, even in patients with malignant neoplasms, it may be idiopathic or a result of benign neoplasm.

Surgery for melanoma metastatic to the gastrointestinal tract

Melanoma frequently disseminates to the gastrointestinal tract, being found post-mortem in 60 per cent of patients with disseminated disease, while during life it is diagnosed in only 4 per cent. During the period 1981-87, 835 melanoma patients were referred and 30 developed complaints caused by gastrointestinal metastatic melanoma. Twenty-three patients were treated surgically. The interval between treatment of the primary melanoma and detection of intestinal involvement was a median of 34 months (range 2-87 months). In four patients recurrence in the gut was the first evidence of dissemination. Major complaints were nausea and vomiting, abdominal pain, signs of anaemia, and blood in the stools. Complications were bleeding (ten cases), ileus due to intussusception (five cases), bowel perforation (four cases) and cholecystitis (one case). The metastases, mainly localized in the small bowel, were removed by relatively simple procedures. Symptoms were reduced in 19 patients. Two patients died after operation: one from sepsis due to suture leakage, the other from pneumonia and a cerebrovascular accident. Of the remaining patients, 16 survived a median of 7.5 (range 0.7-32.0) months. Five patients are still alive 72, 72, 70, 7 and 2 months after the metastasectomy, three of whom are tumour-free. The actuarial 5-year survival of all patients is 19 per cent. These results support surgical intervention for patients with complaints and/or complications attributable to gastrointestinal metastatic melanoma.

Addisonian crisis as presenting feature in malignancies

Metastases to the adrenal glands are common in patients with malignancy but malignant disease presenting as Addisonian crisis is rare. The authors presented two patients with acute Addisonian crises due to metastatic infiltration of the adrenal glands. They were otherwise asymptomatic from the primary tumor. Computed tomographic scan showed bilateral adrenal enlargement and transcutaneous biopsy confirmed metastatic adenocarcinoma in the adrenals. Adequate glucocorticoid replacement improves quality of life and prolongs survival.

Comparative histopathology of porcine and human cutaneous melanoma

Pigmented tumors resembling cutaneous melanoma were first reported in Sinclair miniature swine in 1967. Since that time, carefully planned breeding has established that this is an inherited malignancy the natural history of which mimics human cutaneous melanoma in a number of ways. Because of these characteristics, miniature swine melanoma appears to be an effective model with which to investigate the mechanisms influencing initiation, growth, and progression of human melanoma. This investigation characterized histologically the cutaneous melanoma in miniature swine and compared the findings with human neoplasm. Primary cutaneous melanoma in swine has been reclassified and standardized according to the classifications currently in vogue in human melanoma. Our results suggest that the condition in miniature swine is histologically similar to that in humans. These observations will provide a basis for interpretation of the results derived in the biologic studies performed in this model.

Malignant melanoma of the cerebello-pontine angle region

A case of malignant melanoma in the cerebello-pontine angle region is presented in a 72 year old female patient, who had neurological examination and CT scan suggestive of acoustic neuroma. The surgical finding and the histological examination provided the diagnosis. As a primary focus was not found on clinical examination and although autopsy was not carried out, there is a possibility of the diagnosis being a primary malignant melanoma in CNS. This specific location for this kind of tumor was found to be rare when literature is looked up.

Malignant melanoma metastatic to the esophagus

A rare case of metastatic malignant melanoma of the esophagus 11 years after wide excision of a cutaneous malignant melanoma is presented and the relevant literature reviewed. Symptomatic esophageal metastasis is unusual in malignant melanoma. Although the eventual outlook is poor in such cases, worthwhile palliation can be achieved by prompt diagnosis and treatment.

Generalized melanosis in occult primary melanoma

Once encountered, generalized melanosis as a consequence of disseminated melanoma is not easily forgotten. Cases in the literature usually have resulted from primary cutaneous melanoma. A case of generalized melanosis caused by an occult primary melanoma is reported in a patient who originally complained of increased pigmentation. Findings of light microscopic studies of involved skin, pathogenesis of generalized melanosis, and possible sites of origin of the primary neoplasm are discussed.

Computed tomography of posterior pararenal and properitoneal metastases

Identification of the retroperitoneal fascial planes with modern computed tomographic scanners allows for precise localization of pathologic processes in the individual compartments of the retroperitoneum. Metastatic disease to the posterior pararenal space or properitoneal space in 6 patients is reported. Two patients had diffuse histiocytic lymphoma and 4 had metastatic melanoma.

Primary malignant melanoma of the gall bladder

A case of primary malignant melanoma of the gall bladder is reported, in which a 29 year old man presented with acute cholecystitis which led to perforation of the gall bladder and biliary peritonitis. To help in the differentiation between primary and secondary malignant melanoma in the gall bladder and to overcome some of the difficulties posed by the clinical identification of what is often a small or relatively inaccessible primary tumour, it is suggested that certain criteria should be fulfilled before primary melanoma is diagnosed. (i) Tumours must be solitary and arise from the mucosal surface of the gall bladder; (ii) they must either be papillary or polypoid; (iii) they must either display junctional activity or have any other primary sites excluded by history taking, examination, and investigation. If these criteria are applied to the published case reports of primary malignant melanoma, only six cases, including the present one, can be regarded as true primary tumours.

Two cases of primary malignant melanoma of the oesophagus

Primary malignant melanoma of the oesophagus is an extremely rare tumour. The presentation of two such tumours in one hospital over a short period is thus unusual. The tumour is usually polypoid in nature, occurring anywhere in the oesophagus. Differentiation from other polypoid tumours by barium studies is very difficult, but at endoscopy primary melanoma has a characteristic appearance. At microscopy, junctional activity or atypical melanocytic hyperplasia are required to make the diagnosis. Treatment is surgical but the prognosis is very poor.

Ocular and orbital metastasis of cutaneous melanomas

Two patients with orbital metastasis from cutaneous melanoma are described. In one patient the metastatic tumour was located in the iris, in the other one it was located in the lateral rectus muscle. Only symptomatic treatment is indicated as the term of survival is short.

Primary malignant melanoma of the lung

A case of primary malignant melanoma of the lung in a 42-year-old white female is presented. A 6 cm localized mass in the left lower pulmonary lobe was discovered on a thoracic spine X-ray done for unrelated chronic back pain. The patient underwent left lower lobectomy for cure. Multiple detailed physical examinations did not disclose any primary lesions. Other cases from the English literature are reviewed briefly.

Metastatic melanoma of the gallbladder: a case report and review of the literature

A single case of symptomatic metastatic melanoma to the gallbladder, with roentgenographic findings of gallbladder disease, is presented. Review of the 12 previously reported cases of symptomatic metastatic biliary melanoma and of those reports of "primary" melanoma of the gallbladder reveals marked similarity between the two groups, with regard to relative size, pathologic description, number, and location of lesions. This, together with the finding of "junctional activity" in our case, leads us to believe that most if not all melanomas present in the gallbladder are metastatic deposits from a known, undetected, or regressed primary locus elsewhere. Surgical removal, even in the presence of disseminated disease, is a worthwhile palliative procedure.

Ultrastructural diagnosis of melanoma from an endoscopic biopsy

A 56-year-old male with abdominal symptoms and hypoalbuminemia was found to have multiple polypoid lesions on an upper gastrointestinal series, suggesting intestinal involvement by lymphoma. An endoscopic biopsy was interpreted by light microscopy as poorly differentiated adenocarcinoma. Study of the endoscopic biopsy by electron microscopy revealed epithelial features including intracytoplasmic acini, but the presence of premelanosomes in the tumor cells established the diagnosis of malignant melanoma.

Detection of adrenal melanoma with computed tomography

Primary adrenal melanoma is a rare tumor. We present a case in which the diagnosis was established by computed-tomographic-guided fine-needle aspiration biopsy and subsequent autopsy.