Mucosal melanoma of the head and neck

Radiation Therapy in the Management of Head and Neck Mucosal Melanoma

Mucosal melanoma of the head and neck (HNMM) is a rare but highly aggressive malignancy, often diagnosed at an advanced stage with poor prognosis. This review discusses current treatment strategies, emphasizing the role of radiotherapy in managing this challenging disease. A comprehensive analysis of 33 studies provides updated information on techniques and outcomes, highlighting the consistent benefit of adjuvant radiation in improving local control. Advances in conformal techniques, such as intensity-modulated radiotherapy (IMRT), have significantly reduced toxicity rates. Preliminary data on proton and carbon ion therapies suggest the potential for further enhancement of the therapeutic ratio, despite limited availability. Although recent studies report 3-year local control rates as high as 90%, overall survival within the same time frame remains well below 50-60%, underscoring the need for continued improvement in systemic therapies to address the persistent issue of distant metastases.

Mucosal Melanomas of the Oral Cavity: A Tertiary Care Centre Experience of Surgically Treated Cases

Mucosal melanoma of oral cavity (MMO) is a relatively rare tumour comprising of 40% of all head and neck mucosal melanomas. This study assessed the treatment outcomes and factors affecting prognosis in oral cavity mucosal melanomas. The clinical case records of 25 cases of oral cavity mucosal melanomas treated in our institution during 2003-2013 were retrospectively reviewed. Various clinicopathological parameters were taken into consideration and statistical analysis done by Kaplan-Meier method and Cox's proportional hazards model. The most common sites of MMO were upper alveolus and hard palate (64%) followed by lower alveolus (28%). 57.1% mucosal melanomas of hard palate and upper alveolus had associated metastatic lymph nodes whereas all cases of MMO of lower alveolus had lymph node metastasis. Disease failure at distant sites was higher than that at primary site or lymph nodes. The most common site of distant metastases was brain. The 5-year OS for treated cases was 23.8% and among subsites, MMO of hard palate and upper alveolus had the highest survival. Metastasis to lymph nodes and bone infiltration by tumour significantly decreased the survival. Recurrence at primary site had the worst prognosis. MMO with lymph nodal involvement and bone erosion had poor prognosis. Due to high chances of lymph node metastases and disease recurrence in lymph nodes following treatment, it is essential to do an elective neck dissection for all cases of MMO. Disease failure at primary site was an independent predictor of outcome in MMO.

Oral Amelanotic Melanoma: A Systematic Review of Case Reports and Case Series

Oral amelanotic melanoma (OAM) is a rare, non-pigmented mucosal neoplasm representing less than 2% of all melanoma. The present study analyses the available data on OAM and describes its clinicopathological features, identifying potential prognostic factors. Online electronic databases such as PubMed-Medline, Embase, and Scopus were searched using appropriate keywords from the earliest available date till 31st March 2021 without restriction on language. Additional sources like Google Scholar, major journals, unpublished studies, conference proceedings, and cross-references were explored. 37 publications were included for quantitative synthesis, comprising 55 cases. The mean age of the patients was 59.56 years, and the lesions were more prevalent in males than in females. OAM's were most prevalent in the maxilla (67.2%) with ulceration, pinkish-red color, nodular mass, and pain. 2 patients (3.36%) were alive at their last follow-up, and 25 were dead (45.4%). Univariate survival analysis of clinical variables revealed that age older than 68 years (p = 0.003), mandibular gingiva (p = 0.007), round cells (p = 0.004), and surgical excision along with chemotherapy & radiation therapy (p = 0.001) were significantly associated with a lower survival rate. Oral Amelanotic Melanoma is a neoplasm with a poor prognosis, presenting a 6.25% possibility of survival after 5 years. Patients older than 68 years, lesions in the mandibular gingiva, round cells, and surgical excision along with chemotherapy and radiotherapy, presented the worst prognosis. However, they did not represent independent prognostic determinants for these patients.

Amelanotic Malignant Mucosal Melanoma of the Nasal Cavity: Case Report and Literature Review

Sinonasal malignant melanoma is a rare but aggressive tumor of the head and neck area. It has a poor prognosis. Common symptoms are nasal obstruction, epistaxis, or purulent rhinorrhea. Diagnosis relies on histopathology with immunohistochemistry (IHC) studies. Surgery is the essential treatment, most often supplemented by radiotherapy or immunotherapy. A 63-year-old female patient, with a history of right dacryocystorhinostomy and Parkinson's disease, consulted for symptoms of right nasal obstruction with increasing intensity accompanied by two episodes of mild unilateral epistaxis. Rigid optic examination showed a white-pinkish right obstructive supra-centimetric endonasal tumor. CT revealed an extensive tissue process of the right nasal cavity invading the maxillary sinus, the inferior and middle conchas. A biopsy of the lesion was conducted under local anesthesia. The immunohistochemical study has shown undifferentiated tumor with positive antibody anti PS100 and anti-melan A evoking malignant sinonasal melanoma. The patient underwent two surgeries for maxillectomies as she presented a first local recurrence. She was started on adjuvant radiotherapy. At one year of follow-up, she does not present any local or general signs of disease. Sinonasal melanoma is a particular entity of head and neck mucosal melanomas. The highest incidence is described to be in the seventh and eighth decades of life with no sex difference. IHC profiling of different melanoma subtypes showed the importance of alterations in the KIT gene, this genetic data may constitute a therapeutic target. After surgery, the important local recurrence rates and regional failure justify adjuvant radiotherapy also for resections in free margins. Most authors consider that prophylactic neck dissection is not necessary. Preoperative imaging features (CT scan) are characteristic and helpful for diagnosis. IHC is essential, has a high sensitivity for differentiating achromic melanomas from other neoplasms. Sinonasal achromic melanoma is a very uncommon tumor, invasive, and frequently associated with distant metastasis. Paraclinic examinations are essential for staging and guiding therapeutic management. Immunotherapy is a promising ground of research as it comes to metastatic and advanced disease.

Nasal and paranasal sinus mucosal melanoma: Long-term survival outcomes and prognostic factors

OBJECTIVE

To determine prognostic factors and survival patterns for different treatment modalities for nasal cavity (NC) and paranasal sinus (PS) mucosal melanoma (MM).

METHODS

Patients from 1973 to 2013 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier method and multivariable cox proportional hazard modeling were used for survival analyses.

RESULTS

Of 928 cases of mucosal melanoma (NC = 632, PS = 302), increasing age (Hazard Ratio [HR]:1.05/year, p < 0.001), T4 tumors (HR: 1.81, p = 0.02), N1 status (HR: 6.61, p < 0.001), and PS disease (HR: 1.50, p < 0.001) were associated with worse survival. Median survival length was lower for PS versus NC (16 versus 26 months, p < 0.001). Surgery and surgery + radiation therapy (RT) improved survival over non-treatment or RT alone (p < 0.001). Adding RT to surgery did not yield a survival difference compared with surgery alone (p = 0.43). Five-year survival rates for surgery and surgery + RT were similar, at 27.7% and 25.1% (p = 0.43).

CONCLUSION

Surgery increased survival significantly over RT alone. RT following surgical resection did not improve survival.

Complete remission in metastatic primary malignant melanoma of the esophagus with nivolumab: a case report

Background

Primary malignant melanoma of the esophagus is a rare form of mucosal melanoma with a poor prognosis. While immune checkpoint inhibitors have recently extended overall survival in metastatic melanoma, data on their effects on primary malignant melanoma of the esophagus are limited because of its rarity. Here, we report the first case of long-term complete remission of metastatic primary malignant melanoma of the esophagus after nivolumab monotherapy.

Case presentation

A 79-year-old Asian man with a history of prostate cancer, gallbladder cancer, deep vein thrombosis, hypertension, and diabetes mellitus presented with gross hematuria. Cystoscopy revealed a solitary tumor on the right posterior wall of the bladder, and transurethral resection of bladder tumor was performed. Pathology was consistent with metastatic melanoma. A pigmented submucosal tumor-like growth in the esophagus was discovered on esophagogastroduodenoscopy. Computed tomography showed widespread metastases. The patient was diagnosed as having primary malignant melanoma of the esophagus with metastases to the stomach, subcutaneous tissue, lung, bladder, pleura, and peritoneum. Complete remission was achieved after seven cycles of triweekly nivolumab monotherapy. While nivolumab was discontinued because of kidney injury, the patient has remained tumor-free for over 4 years without further treatment.

Conclusion

Immune checkpoint inhibitors may have astonishing curative effects in selected populations. More research is warranted to identify factors that increase the likelihood of achieving complete remission in primary malignant melanoma of the esophagus as well as in other melanomas.

Surgery alone versus post-operative radiotherapy for sinonasal malignant melanoma: a meta-analysis

OBJECTIVE

Sinonasal malignant melanoma is a relatively rare malignancy with poor prognosis, and effective treatments remain elusive. This analysis aimed to explore whether post-operative radiotherapy conferred any survival advantages in patients with this disease when compared with surgery alone.

METHODS

Published studies were identified by searching four electronic databases. The endpoints evaluated were: rates of overall survival, disease-free survival and local control.

RESULTS

Twenty-eight studies including 1392 patients were identified. The results indicated that post-operative radiotherapy led to a significantly better three-year overall survival rate (p = 0.02), and suggested a borderline significant benefit for five-year overall survival (p = 0.05), when compared with surgery alone. However, no statistical advantage was found for disease-free survival, local control or one-year overall survival.

CONCLUSION

This meta-analysis indicated that adjuvant radiotherapy prolonged survival, but showed no benefit for disease-free survival or local control.

Efficacy and safety of primary surgery with postoperative radiotherapy in head and neck mucosal melanoma: a single-arm Phase II study

Background

There still remains no well-established treatment strategy for head and neck mucosal melanoma (HNMM). We aim to evaluate the effectiveness and safety of primary surgery with postoperative radiotherapy for this disease.

Patients and methods

A single-arm, Phase II clinical trial was conducted at Sun Yat-Sen University Cancer Center. Patients with nonmetastatic, histologically proven HNMM were prospectively enrolled. Patients received primary surgery followed by intensity-modulated radiotherapy with an equivalent dose at 2 Gy per fraction of 65–70 Gy to CTV1 (high-risk regions including tumor bed) and 50–55 Gy to CTV2 (low-risk regions). Additional use of adjuvant chemotherapy (AC) depended on consultation from a multidisciplinary team. This trial is registered with ClinicalTrials.gov, number NCT03138642.

Results

A total of 33 patients were enrolled and analyzed between July 2010 and November 2016. There were 18 (54.5%) patients with T3 disease and 15 (45.5%) patients with T4a disease. The median age at diagnosis was 58 years (range 27–83 years), and 61% of the cohort were males. The overall median follow-up duration was 25.3 months (range 5.3–67.1 months). The 3-year overall survival (OS), local relapse-free survival (LRFS), regional relapse-free survival (RRFS), and distant metastasis-free survival (DMFS) rates were 44.4, 91.7, 78.1, and 41.7%, respectively. Patients with T4a disease showed significantly inferior OS (P=0.049) and DMFS (P=0.040) than those with T3 disease. Prophylactic neck radiation (PNR) was nearly associated with superior RRFS (P=0.078). However, there was no significant difference in OS, LRFS, RRFS, and DMFS for patients treated with or without AC (P>0.05 for all). Toxicities were generally mild to moderate.

Conclusion

Primary surgery with postoperative radiotherapy yielded excellent local control and acceptable toxicity profile for HNMM. Nevertheless, high rates of distant metastases resulted in limited survival.

Analysis of KIT gene mutations in patients with melanoma of the head and neck mucosa: a retrospective clinical report

Unlike their cutaneous counterparts, head and neck mucosal malignant melanomas (HNMM) are more aggressive, and their prognostic markers have not been fully elucidated. This study, comprising 28 patients with HNMM, aimed to establish the relationship between different mutations and outcome, define the incidence of KIT mutations in HNMM, and identify the correlation among therapeutic options, histopathological findings, demographic data, and clinical response. Clinical analysis included patient characteristics, staging, primary and palliative treatments, and disease-free survival and overall survival (OS). Progression-free survival and OS were analyzed. Paraffin blocks were selected following histologic analyses, enabling DNA extraction. PCR amplification of exons 9, 11, 13, and 17, with different DNA concentrations, was performed. Patients were predominantly females (57%) and aged 27–85 years. All patients underwent surgery; 17 received adjuvant radiotherapy, and recurrences occurred in 82% patients. Oncologic mutations in KIT were found in 7 of 7 tumors, 3 in exon 9, 3 in exon 11, and 1 in exon 13. Predictive factors for recurrence were mitotic rate, vascular invasion, and perineural spread. There were no significant differences in DFS and OS according to KIT mutation. Our study results suggest that some patients might benefit from appropriate targeted therapy with kinase inhibitors.

Contemporary Treatment Approaches to Sinonasal Mucosal Melanoma

Sinonasal mucosal melanoma (SNMM) is a rare oncological entity that comprises most head and neck mucosal melanomas. SNMM has distinctive genetic background, different from cutaneous melanoma. Survival outcomes among SNMM patients are poor; while there is no clear consensus on the optimal management of SNMM, the primary treatment modality is generally considered to be wide surgical excision, and radiation therapy (RT) is often used in the postoperative adjuvant setting to improve locoregional control. Systemic therapies have demonstrated little or no survival benefit, and most SNMM patients die of distant metastatic disease. Owing to the rarity of the disease, the literature describing treatment approaches for SNMM is lacking and largely limited to isolated case reports and retrospective series. Here, we describe contemporary diagnostic and therapeutic approaches to SNMM based on the most recent molecular and outcome data.

Prognostic factors in head and neck mucosal malignant melanoma

OBJECTIVE

Primary mucosal malignant melanoma of the head and neck (HN-PMMM) is an aggressive and uncommon neoplasm. Herein, we present a series of 33 patients and the results of treatment, and aimed to determine prognostic factors in HN-PMMM.

METHODS

Patients who were diagnosed as having HN-PMMM in our reference hospital, between 2005 and 2014 were evaluated. Thirty-three of these patients who had follow-up data were included. Surgical margin status was extracted from the original pathology reports. Archived materials were retrieved for the histopathologic findings: ulceration, necrosis, lymphovascular invasion, perineural invasion, pigmentation, and presence of an in situ component. Mitotic activity was evaluated using phosphohistone H3 (PHH3) immunohistochemical staining.

RESULTS

We found an association of PHH3 mitotic activity with overall survival in a univariate analysis and to our knowledge, this is the first report among the available case series of HN-PMMM to evaluate mitotic activity using immunohistochemical staining. We also investigated the relationship between multicentricity and locoregional recurrence, which the authors believe is also a first.

CONCLUSION

PHH3 mitotic activity can be used a prognostic factor for head and neck mucosal malignant melanoma.

Local control in sinonasal malignant melanoma: Comparing conventional to hypofractionated radiotherapy

BACKGROUND

The purpose of this study was to analyze the effect of fractionation schedule on local control in postoperative radiotherapy (RT) for sinonasal malignant melanoma.

METHODS

Sixty-three patients who were treated with surgery and postoperative RT in 4 accredited head and neck cancer centers in the Netherlands between 1998 and 2013 were retrospectively studied. Outcomes with conventional fractionation (2-2.4 Gy per fraction; n = 27) were compared to hypofractionation (4-6 Gy per fraction; n = 36). The primary endpoint was local control and the secondary endpoint was toxicity.

RESULTS

Comparable local control rates were found after 2 and 5 years (63% vs 64% and 47% vs 53%; P = .73 for, respectively, conventional fractionation vs hypofractionation). Local recurrences were predominantly present ipsilateral (92%) and within the irradiated volume (88%). Late toxicity grade ≥ 3 was observed in 2 of 63 patients, 1 patient in both groups.

CONCLUSION

Radiotherapy fractionation schedule did not influence the local control rate or the incidence of late toxicity in patients treated with surgery and RT for sinonasal malignant melanoma in this retrospective analysis. Due to this retrospective nature and the limited number of patients, strong recommendations cannot be made. Expected toxicity, patient convenience, and workload may be taken into account for the choice of fractionation schedule until conclusive evidence becomes available.

Positron Emission Tomography in Mucosal Melanomas of Head and Neck: Results from a South Asian Tertiary Cancer Care Center

To evaluate the accuracy of fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in staging and restaging of patients with mucosal melanomas (MM) of head and neck. Patients who underwent PET/CT at our institution, with a biopsy proven diagnosis of MM of the head and neck between March 2006 and December 2013 were included in the study. Nineteen patients with MM of the nasal cavity, paranasal sinuses, and oral cavity were included, of which 12 were for staging and seven for restaging. PET/CT had 100% sensitivity (SN), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) for detection of the primary. SN of 91.7%, SP of 100%, PPV of 100%, and NPV of 87.5% were seen for nodal metastases. For distant metastases, SN of 85.7%, SP of 100%, PPV of 100%, and NPV of 92.3% were noted. The disease was upstaged from loco-regional to metastatic in 32% leading to treatment change in 25% in the staging group and 43% in the restaging group. PET/CT demonstrates good overall accuracy in evaluation of patients with MM of the head and neck. The main strength of PET/CT lies in detection of distant metastatic disease due to extended whole-body field of view.

Comparative study between two different staging systems (AJCC TNM VS BALLANTYNE'S) for mucosal melanomas of the Head & Neck

Background

Mucosal melanoma (MM) of head and neck (H &N) is a rare entity with a quite poor prognosis. Ballantyne’s staging system has been commonly used since 1970. In the 7th edition of the AJCC Staging Manual a new chapter for the staging of TNM Classification system for mucosal melanoma (MM) of the head and neck (H &N) has been introduced to reflect the particularly aggressive biological behavior of this neoplasm. The aim of this study was to analyze and compare among Ballantyne’s staging system vs TNM H &N in terms of overall survival (OS) and disease-free survival (DFS) in a consecutive population of patients with MM in a cancer centre.

Material and Methods

Descriptive analysis of demographic, clinical and pathological variables of MM of the Head & Neck were performed. We compared the survival curves for both systems according to the Kaplan-Meier method using the Log-rank test.

Results

An up-staging migration effect from Ballantyne’s localized disease to moderately and very advanced disease according to AJCC staging system. The 5-year DFS and OS for Ballantyne’s Localized Disease and AJCC Stage III were 31% and 36% vs. 47% and 50%, respectively. For locoregional disease the 5-year DFS / OS were 5% / 10% for Bal-lantyne’s system vs. 13.8% / 17.8% and 0 / 0% for AJCC Stages IVA and IVB, respectively.

Conclusions

In this series, the TNM staging system for MM of the H &N predicted better the prognosis of the disease when comparing with Ballantyne’s system.

Key words:Head and neck, mucosal melanoma, AJCC TNM, Ballantynes´s staging system.

A study of mucosal melanoma of the oral cavity in India: a rare tumor

Malignant melanomas involving the mucosa are rare and aggressive lesions. Their rarity has made the formulation of staging and treatment protocols very difficult, as most of the available information comes from case reports and small case series. We conducted a retrospective study to analyze the behavior of melanomas of the oral mucosa in patients who were treated at Tata Memorial Hospital in Mumbai, a tertiary care referral center for malignancies and one of the largest cancer centers on the Indian subcontinent. During the 22-year period from January 1986 through December 2007, we found only 13 such cases, which had occurred in 8 men and 5 women, aged 26 to 70 years (mean: 37.5). All patients had been offered surgery with curative intent. Mucosal melanomas have exhibited a greater tendency for distant recurrence than for local treatment failure, which is why adjuvant radiation therapy has not been shown to confer any consistent benefit. In our study, only 3 of the 13 patients (23.1%) remained alive 2 years after diagnosis, despite aggressive treatment. Tumor staging, optimal treatment, and prognostic factors for oral mucosal melanoma are far from clear, and further research is needed. Despite the small number of patients in this study, it still represents one of the largest series of oral mucosal melanoma patients in India.

Localized sinonasal mucosal melanoma: Outcomes and associations with stage, radiotherapy, and positron emission tomography response

BACKGROUND

Sinonasal mucosal melanoma is a rare neoplasm with a poor prognosis.

METHODS

Retrospective analysis was conducted on 78 patients with localized sinonasal mucosal melanoma treated at Memorial Sloan Kettering Cancer Center (MSKCC from 1998-2013). Demographic, tumor, imaging, and treatment factors were recorded and survival and disease-control outcomes were analyzed.

RESULTS

Median overall survival (OS) and disease-specific survival (DSS) were 32 and 50 months, respectively. Median locoregional recurrence-free survival (LRFS) and distant recurrence-free survival (DRFS) were 43 and 12 months, respectively. Multivariate analysis demonstrated greater OS in nasal cavity tumors and earlier T classification. Radiotherapy (RT) was associated with significantly greater LRFS (5-years; 35% vs 59%; p = .01), but no difference in OS. Post-RT positron emission tomography (PET) response was associated with greater OS.

CONCLUSION

Distant metastasis is the predominant mode of recurrence in sinonasal mucosal melanoma, but local recurrence remains common. RT is associated with improved local control, but no survival benefit. The prognostic value of post-RT PET imaging warrants further investigation. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1310-1317, 2016.

Survival Outcomes of Mucosal Melanoma in the Head and Neck: Case Series and Review of Current Treatment Guidelines

PURPOSE

Malignant mucosal melanoma of the head and neck (MMHN) is an aggressive and rare neoplasm with poor long-term outcomes. The aim of this study is to evaluate the outcomes of patients treated by a single-institution head and neck multidisciplinary team.

MATERIALS AND METHODS

In this retrospective case series, all MMHN cases treated at the Royal Melbourne Hospital from 1990-2015 were retrospectively reviewed. Patient demographic characteristics (eg, age), treatment offered, pathology, and outcomes were collected, tabulated, and correlated with outcomes. Survival outcomes were calculated by the Kaplan-Meier method. Comparison was made between oral and sinonasal melanomas.

RESULTS

A total of 16 cases were identified. Two were excluded because of inaccessible data. Of the 14 remaining cases, 8 were sinonasal melanomas and 6 were oral cavity melanomas. Sinonasal tumor patients presented with epistaxis or visual impairment. Oral melanoma patients presented with pigmented lesions or ulceration. Follow-up ranged from 4 months to 11 years. In 2 patients, locoregional recurrences developed that were successfully re-excised. Six patients died of distant metastases despite clear surgical margins. Two patients with sinonasal melanomas died of extensive local disease with intracranial invasion. One patient died 4 years after diagnosis without disease. There were no failures in the neck. The 2- and 5-year overall survival rates were 63.3% and 31.7%, respectively, by the Kaplan-Meier method. The difference in survival between oral and sinonasal melanomas was not statistically significant.

CONCLUSIONS

Despite clear surgical margins, MMHN has a poor prognosis and most deaths are due to distant metastases. Systemic therapies such as those used in cutaneous melanoma treatment might be used in the future for MMHN.

Primary mucosal melanoma of the oral cavity: current therapy and future directions

BACKGROUND

Primary mucosal melanoma of the oral cavity is a highly aggressive malignancy of melanocytic origin. The aim of this study is to report a case series of oral mucosal melanomas (OMMs) and provide a review of the literature with regard to treatment guidelines for and prognosis of this pathologic entity.

STUDY DESIGN

We report three cases of OMMs treated in our institutions and the results of a literature review, in which the words "oral" and "mucosal melanoma" were used as the main keywords.

RESULTS

Surgical resection of the primary tumor with wide resection margins appears to be the recommended primary treatment modality with the aim to achieve tumor-free margins. Elective neck dissection and adjuvant radiotherapy have been advocated for locoregional control. Chemotherapy has not been shown to improve survival and is mainly used for palliative purposes. Immunotherapy and biochemotherapy seem to significantly improve survival and could open new therapeutic horizons.

CONCLUSIONS

The prognosis of OMMs remains poor despite treatment. Early diagnosis and aggressive surgical resection followed by adjuvant therapies could be the key to improving survival. Multicenter randomized clinical trials, which may be difficult to conduct because of the rarity to the lesion, would aid in the development of new strategies.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

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.

Oral malignant melanoma: A report of two cases with BRAF molecular analysis

Primary oral malignant melanoma is a rare condition, accounting for 1.3–1.4% of all melanomas, usually presenting with an aggressive clinical behavior. The present study reports the clinicopathological findings of two cases of oral malignant melanoma and discusses the epidemiology, diagnosis and current therapeutic approaches for this uncommon condition. In the first case the patient presented with a pigmented lesion located on the lower mucosal lip. The patient showed no nodal metastases and therefore, underwent a wedge resection. After seven months, the patient presented with neck lymph nodes and multiple visceral metastases. Molecular analysis of BRAF, using a pyrosequencing approach, revealed the presence of BRAF V600E mutation. The patient developed multiple visceral metastases, but refused treatment and was lost to follow-up. In the second case, no BRAF V600E mutation was found, but the patient exhibited a pigmented patch in the lower gingival mucosa, which was excised by surgical treatment. The patient was followed up by an oncologist, but did not undergo an additional therapy and is currently alive with no evidence of visceral metastases at one year following the diagnosis.

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.

Primary mucosal melanoma: report of two cases

Primary mucosal malignant melanoma is of unusual occurrence and poor prognosis. We report two cases of primary mucosal melanoma, one in a 70-year-old male in the palate and the other in a 73-year-old female in the maxillary sinus. Early diagnosis and proper clinical and cytologic evaluation is necessary to institute therapeutic intervention. These cases are reported on account of their rarity of occurrence and difficulty of treatment.

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.

Mucosal melanomas of the head and neck: the role of postoperative radiation therapy

Objectives. Mucosal melanomas are rarer than their cutaneous counterparts and are associated with a poorer prognosis. We report the clinical outcomes of patients with mucosal melanomas of the head and neck region generally treated with definitive surgery followed by postoperative radiation therapy (RT). Methods. We reviewed the records of 17 patients treated at the University of Miami in 1990-2007. Patients generally received conventionally fractionated RT regimens to the postoperative bed. Elective nodal RT was not routinely delivered. Eight patients received adjuvant chemotherapy or immunotherapy. Results. Median followup was 35.2 months (range 5-225). As the first site of failure: 3 patients recurred locally, 2 regionally and 2 distantly. All 3 patients who recurred locally had not received RT. Of the 5 locoregional recurrences, 4 were salvaged successfully with multimodality therapy with no evidence of disease at last followup. Overall survival was 64.7% at 2 years and 51.5% at 5 years. Conclusions. Patients with mucosal melanoma of the head and neck are best treated with surgery to achieve negative margins, followed by postoperative RT to optimize local control. Elective nodal irradiation may not be indicated in all cases, as regional failures were not predominant. Distant metastases were fewer when compared to historical data, potentially due to advancements in adjuvant therapies as well as aggressive multi-modality salvage at time of failure.

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.

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.