Successful palliation of stenosing anorectal melanoma by intratumoral injections with natural interferon-beta

Surgical Management of Primary Anorectal Melanoma: Is Less More?

PURPOSE

Ano-uro-genital (AUG) Mucosal Melanoma UK guidelines recommended a less radical surgical strategy for anorectal melanoma (ARM) where possible. We report our experience of ARM consistent with that approach including clinical presentation, intervention undertaken and prognosis.

METHODS

We present a retrospective study of 15 consecutive patients with ARM surgically treated between November 2014 and April 2023. Patients were divided into the two surgery types: wide local excision (WLE, n = 9) and abdominoperineal resection (APR, n = 6). Data on demographics, diagnosis, treatment and oncological outcomes were assessed between the groups.

RESULTS

The mean age was 65.3 ± 17.4 years and 6 (40.0%) were female patients. Nine patients (60.0%) were diagnosed with stage I and six patients (40.0%) with stage II disease. R0 margins were achieved in all cases. The overall mean length of stay was lower following WLE compared to APR (2.6 ± 2.4 days versus 14.0 ± 9.8 days, p = 0.032). Two complications were observed in the WLE group compared to four complications after APR (p = 0.605). Five patients (55.5%) developed local/distant recurrence in the WLE group compared to three patients (50.0%) in the APR group (p = 0.707), with a median overall survival of 38.5 (12-83) months versus 26.5 (14-48) months, respectively.

CONCLUSIONS

Achieving clear margins by the least radical fashion may have equivalent oncological outcomes to radical surgery, potentially reducing patient morbidity and preserving function. In our experience, the surgical management of ARM consistent with the 'less is more' approach adhering to AUG guidelines has acceptable outcomes.

Can transrectal ultrasonography distinguish anorectal malignant melanoma from low rectal adenocarcinoma? A retrospective paired study for ten years

BACKGROUND

Anorectal malignant melanoma (ARMM) and low rectal adenocarcinoma (LRAC) have some similarities in clinical behaviors, histopathological characteristics and ultrasonographic findings, diagnostic errors are common. By comparing the transrectally ultrasonographic features between the two tumors, we propose to provide more possibilities in differentiating them.

METHODS

The data of 9 ARMMs and 27 age- and gender-matched LRACs (the lower margin below the peritoneal reflection) in West China Hospital Sichuan University between April 2008 and July 2019 were retrospectively reviewed. The ultrasonic features between the two groups were compared.

RESULTS

Transrectal ultrasonography (TRUS) showed that the length of ARMM was shorter than that of LRAC (28.22 ± 12.29 mm vs. 40.22 ± 15.16 mm), and ARMM had a lower position than that of LRAC (the distance to anal verge was 50.78 ± 11.70 vs. 63.81 ± 18.73 mm). Unlike LRAC, the majority of ARMM in our study was confined to the intestinal mucosa/submucosa (66.67/25.93%) (P < 0.05).

CONCLUSIONS

Based on the data of our study, several ultrasonographic findings (length, invasion depth, and position) of ARMM were significantly different from LRAC. Accordingly, more attention should be paid to masses at anorectal junction with lower position, shorter length, and shallower infiltration depth. Instead of the most common tumor, LRAC, ARMM should be taken into account to avoid a misdiagnosis, which will result in a poorer prognosis.

Clinical and oncological outcomes of surgery in Anorectal melanoma in Asian population: A 15 year analysis at a tertiary cancer institute

INTRODUCTION

Anorectal malignant melanoma (ARMM) is an aggressive malignancy with dismal prognosis and a 5-year survival rate less than 20% in most of the previous studies. The ideal surgical treatment has still remained controversial. This retrospective study aims at analysing the outcome in patients with ARMM treated with curative surgical resection.

PATIENTS AND METHODS

This is a retrospective study of 38 patients of stage I anorectal malignant melanoma treated with curative surgical resection at our tertiary cancer institute.

RESULTS

WLE (Wide Local Excision) was carried out in 12 patients and APR (abdominoperineal resection) was done in 26 patients. The median overall survival of the entire group in this study was 20 months. Although the median overall survival of WLE patients was higher than those with APR (37 months versus 16 months, respectively), this was not a statistically significant event (P=0.317). The 1-, 2-, 3-, 5-year survival rates were similar with both APR and WLE with no significant difference in the 5-year survival rate (P=0.816); overall 5-year survival rate of just 13%. There were 3 long-term survivors in this study group who survived for more than 10 years.

CONCLUSION

Most patients ultimately succumb to the disease regardless of the management. Both APR and WLE have significant roles in the management depending on the subset of patients selected. Local treatment should be preferred wherever possible. Abdominoperineal resection should be offered in nodal disease or in a recurrent setting.

Metastatic anorectal melanomas - An exploratory retrospective analysis on the benefits of systemic therapy versus best supportive care in a resource-limited setting from India

Aim

Data regarding the optimal management of metastatic anorectal melanoma (mARM) is scarce. The primary aim was to evaluate the potential benefits of systemic therapy in mARM.

Materials and Methods

This is a retrospective analysis of all mARM who presented between July 2013 and June 2015 at the Department of GI Medical Oncology, Tata Memorial Hospital.

Results

Of a total of 37 patients, twelve patients were planned for best supportive care (BSC) only while the remaining 25 patients received systemic therapy. The median overall survival (OS) for the whole cohort was 27 weeks. The OS was significantly better in patients who received first-line therapy as compared to those who were offered BSC (median OS: 14 vs. 33 weeks; P = 0.04). Patients with PS of 1 did significantly better than PS of 2 more (OS 70 vs. 17 weeks; P = 0.015).

Conclusion

mARM should be offered chemotherapy, especially in good performance patients. Paclitaxel/Platinum or Capecitabine/Temozolomide regimens can be considered as the preferred regime in the resource-limited setting where immunotherapy may not be a feasible option.

Primary rectal melanoma - a case report

The most common site for malignant melanoma is skin, then eye and third is anorectal region. Primary anorectal malignant melanoma is still very uncommon. It is usually very aggressive and presents with altered bowel habit and rectal bleeding. Proctoscopy shows non-pigmented or lightly pigmented polypoid lesion. Histopathology is confirmatory. Early radical excision is mandatory. A 56 year-old female was presented with malignant melanoma of the lower third of rectum. We report this case for its rarity.

Surgical and radiation therapy management of recurrent anal melanoma

BACKGROUND

Melanoma of the anorectal mucosa is a rare but highly aggressive tumor. Its presenting symptoms are frequently confused with hemorrhoids, thereby causing a delay in diagnosis. Anorectal melanoma carries with it a very poor prognosis. There is a paucity of data investigating management options for anorectal melanoma, and even fewer data reporting recurrent or refractory cases.

CASE PRESENTATION

This case documents a 41-year-old female with a long history of hemorrhoids presenting with anorectal discharge. She was incidentally found have anorectal melanoma following surgical resection. Systemic diagnostic work-up demonstrated PET-avid lymphadenopathy in her right groin. She underwent right groin dissection. However, seven months later she recurred in her right groin and a new recurrent mass was found in her pelvis. She underwent a second groin dissection and resection of the pelvic recurrence. This was followed by a course of hypofractionated radiation therapy then systemic immunotherapy.

DISCUSSION

Surgery has been the mainstay of treatment. However, the extent of surgery has been the topic of investigation. Historically, radical resections have been performed but they result in high rates of post-operative morbidity. Newer studies have compared radical resection with wide local excisions and found comparable outcomes. Anorectal melanoma is frequently a systemic disease. The ideal systemic therapy regimen has not yet been determined but numerous studies show a benefit to multi-agent treatments. Radiation therapy is typically given in the post-operative or palliative setting.

CONCLUSIONS

Anorectal mucosal melanoma is a very rare but aggressive disease with a poor prognosis. The overall treatment goal should strive to optimize quality of life and tumor control while minimizing treatment-related morbidities.

Primary amelanotic melanoma of the rectum mimicking adenocarcinoma

Patient: Male, 55

Final Diagnosis: Melanoma

Symptoms: Worsening constipation • tenesmus • weight loss

Medication: —

Clinical Procedure: Chemoradiation therapy

Specialty: Oncology

Microinvasive melanoma: cutaneous pharmacotherapeutic approaches

Surgical excision is the treatment of choice for primary melanomas and radiation therapy is the accepted alternative for the subset of lesions not amenable to surgery. With the recent rise in melanoma incidence, especially in the elderly, there are a growing number of cases that are neither amenable to surgery nor radiation therapy. In this article, we review pharmacotherapeutic approaches to microinvasive melanoma (invasive radial growth phase melanoma) that might be considered in such circumstances. There are no approved drugs for the treatment of primary melanoma and randomized controlled trials with 5 or more years of follow-up have not been performed. The limited studies and numerous case series in the literature on pharmacologic treatment of primary melanoma have focused on topical therapies. Accordingly, we provide a review of the potential pharmacotherapeutic agents in the treatment of microinvasive melanoma by extrapolating from the available limited literature on the use of fluorouracil, azelaic acid, retinoic acid derivatives, interferon (IFN)-α, imiquimod, and other agents for melanoma in situ, invasive melanoma, and epidermotropic melanoma metastases. Our review indicates that topical fluorouracil and tretinoin are not effective as single agents. The efficacy of azelaic acid, tazarotene, cidofovir, and intralesional IFN-α, interleukin-2, and IFN-β is undefined. Imiquimod is the most studied and promising agent; however, optimal dosage, therapeutic regimen, and survival rates are unknown. In the face of a growing demand for non-surgical treatments, formal clinical trials are needed to ascertain the role of pharmacotherapeutic agents in the treatment of microinvasive melanoma.

Primary anorectal melanoma: A case report with extended follow-up

Background:

Anorectal melanoma is a rare and aggressive disease. The mainstay of treatment is usually surgical with curative or palliative intent, since radio- and chemotherapy do not really improve the outcome. The poor prognosis is attributable to delay in diagnosis and its inherent biologic aggressiveness.

Case Report:

We present a case of anorectal melanoma in a 68-year-old man who underwent solely abdominoperineal amputation and was doing well 30 months after surgery, without any evidence of recurrent disease.

Conclusions:

Treatment of anorectal melanoma should be by the least morbid means possible. Surgical procedure that can achieve a complete local excision and respect the functional aspects and quality of life of the patient remains the best therapeutic approach. No systemic regimen for metastatic anorectal melanoma is considered standard of care.

Management of anorectal melanoma: report of 17 cases and literature review

BACKGROUND

Primary anorectal melanoma is a rare and aggressive disease. It accounts for 0.5% of all rectal tumors. They are very agressive tumors with poor prognosis. The aim of this study is to report the clinical and evolutionary profile and therapeutical approach of these tumors.

PATIENTS AND METHODS

A retrospective study of 17 patients with anorectal melanoma diagnosed between January 1998 and December 2007 was performed. The signs and symptoms, diagnostic study, and surgical and medical treatments were analyzed.

RESULTS

The average age was 58 years. Sex ratio was 12 men per five women. Patients had symptoms present for an average of 6 months. The most common symptom was rectal bleeding. According to Slingluff classification, five patients had stage I (localized tumor), four cases had stage II (regional nodes metastasis), and eight cases had stage III (distant metastasis). Seven patients have radical surgery. Only two patients received adjuvant immunotherapy. Eight patients received palliative chemotherapy based on dacarbazine or cisplatinum. The median survival was 8 months.

CONCLUSION

Prognosis of anorectal melanoma is still very poor. However, some patients when treated by radical resection may experience long-term survival. The use of adjuvant immunotherapy needs large collaborative studies in view of the rarity of the tumor.

Her2 overexpression is a rare event in anorectal melanoma

Anorectal melanomas (AMs) are very rare and highly malignant tumors that are often diagnosed in advanced stages. After the differentiation between cutaneous melanoma (CM) and AM on the molecular level based on the presence of BRAF mutations, further modes of differentiation opened up, such as the recently discovered immunohistologically relevant protein deleted in malignant brain tumors 1 (DMBT1). Over the past several years, increasingly specific therapies have been developed on the basis of new therapy principles. Tyrosin kinase receptors such as Her2 and EGFR have been awarded a large role in this context. The goal of this study was to examine AMs for a possible expression or overexpression of these markers. Expression analyses of Her2 and EGFR were performed immunohistologically on 25 primary AMs. An overexpression of Her2 (score: 3+) was found in one AM from a 68-year-old female patient among these samples. In contrast, EGFR expression was not found in any of the AMs. The results presented here show that isolated cases of AM may benefit from an additive Her2-directed therapy, as the overexpression of Her2 was found in one of our AM patients.

Abdominoperineal resection or local excision? a survival analysis of anorectal malignant melanoma with surgical management

Patients with anorectal malignant melanoma (AMM) generally have an unfavorable prognosis, and surgical managements are still in controversy. The purpose of this study was to evaluate the surgical treatment for AMM in China and to compare the survival of abdominoperineal resection (APR) and local excision (LE) in patients with AMM. Between 1995 and 2007, 54 patients managed with curative surgical resection for AMM were reviewed, 39 patients underwent APR, and 15 patients underwent LE. Life table was carried out and Kaplan-Meier test was used to compare the effects of these two different surgical procedures in survival. The overall 1-year, 2-year, 3-year, and 5-year survival rates after curative operation were 80, 54, 43, and 26%, respectively; LE group were 67, 48, 48, and 16%, and APR group were 84, 57, 42, and 30%, respectively. The median survival for all LE and APR were 25 months, 13 months, and 25 months, respectively. Kaplan-Meier test showed that there was no significant difference between APR and LE in survival (P=0.281); however, a 5-year survival advantage for the patients who underwent APR was found, despite the severity of tumor. Local recurrence after LE was more popular than APR (P=0.020). The prognosis of AMM after curative surgery is poor now, and patients undergoing APR have no significant survival advantage than those underwent LE. Local recurrence after LE was more popular than APR.

Anal melanoma

Anal melanoma is rare and aggressive malignancy. Patients commonly present with advanced, even metastatic disease. Unlike cutaneous melanoma, anal melanoma has no known risk factors. Surgical excision remains the cornerstone of therapy. There are no long-term survivors of stage II or III disease; therefore, early diagnosis and treatment remain crucial. There are no trials definitively proving abdominal perineal resection (APR) or wide local excision (WLE) to yield superior long-term survival. APR may offer a higher rate of local control, whereas WLE offers a much less morbid operation. Adjuvant chemotherapy, interferon, and radiation may offer some benefit.

Effect of misdiagnosis on the prognosis of anorectal malignant melanoma

OBJECTIVE

Anorectal malignant melanoma (AMM) is frequently subjected to misdiagnosis. Here the effect of misdiagnosis on the prognosis of AMM was investigated.

METHODS

Between 1995 and 2007, 79 patients managed for AMM were reviewed; 46 (58.23%) of them had been misdiagnosed during the symptoms, while 33 (41.77%) cases had been diagnosed exactly not more than 1 week after the first visit. Diseases misdiagnosed were categorized as cancer, hemorrhoids, polyps and other diseases. Data were statistically analyzed by using the life tables and Kaplan-Meier curves. The software used was SPSS 16.0 for Windows.

RESULTS

The 1-, 2-, 3- and 5-year survival rates of AMM patients were 58, 33, 24 and 16%, respectively, and the median survival time was 14.0 months; 1-, 2-, 3- and 5-year survival rates of the misdiagnosed patients were 61, 22, 22 and 11%, respectively, and the median survival time was 14.0 months; 1-, 2-, 3- and 5-year survival rates of the patients not misdiagnosed were 55, 44, 25 and 25%, respectively, and the median survival time was 12.0 months. Analyses based on Kaplan-Meier curves revealed no significant effect of misdiagnosis on the survival of AMM patients (P > 0.05). Nevertheless, the diseases misdiagnosed significantly affect the prognosis (P = 0.009); AMM misdiagnosed as hemorrhoids had a poor prognosis, with a 1-year survival rate of only 29% and the median survival of only 6.0 months.

CONCLUSIONS

The misdiagnosed patients had relatively poor prognosis, but the effect of misdiagnosis on the prognosis was not significant; however, misdiagnosis of AMM as hemorrhoids seriously affected the prognosis.

Diffuse anorectal melanoma; review of the current diagnostic and treatment aspects based on a case report

Primary anorectal melanoma is a rare and aggressive disease. Patients commonly complain for changes in bowel habits and rectal bleeding, and proctoscopically they mostly appear as non pigmented or lightly pigmented polypoid lesions. Such a lesion should always raise a high index of suspicion in any gastroenterologist or surgeon to prompt surgery, since early radical excision is the only treatment option.

Herein, we report a case of a 57-year-old man with a diffuse anal canal melanoma and give reference to the current diagnostic and treatment options.

Factors Affecting Survival in Patients with Anal Melanoma

Anal melanoma is an aggressive tumor with a predilection for early infiltration and distant spread, resulting in poor overall survival. Because anal melanoma is rare, only small case series are reported in the literature, making it difficult to draw conclusions about optimal treatment and outcome. The Surveillance, Epidemiology, and End Results database was used to identify patients with anal melanomas from 1973 to 2001. In addition to demographics, disease extent at presentation, treatment administered, overall survival, and survival by decade of diagnosis were collected. A total of 126 patients with a mean age of 69.2 years was diagnosed with anal melanoma. Sixty-one per cent were female. Median follow-up was 22.5 months. Median survival was 10 months for those with distant disease, 13 months for patients with regional spread, and 34 months for patients with local disease (P = 0.0001). Five-year survival was 32 per cent, 17 per cent, and 0 per cent for patients presenting with local, regional, and distant disease, respectively (P = 0.0001). Neither age at diagnosis, operation performed, nor use of radiation significantly affected survival. Anal melanoma remains an uncommon but lethal disease. Extent of disease correlates with overall survival. Survival is improving, but the use and extent of operation are not associated with improved overall survival.

The role of surgery in treatment of stage IV melanoma

The prognosis for patients with melanoma has not improved over the last 30 years. So far, almost without exception, clinical trials conducted with single or multiple agent chemotherapy, biological therapy (interferon-alpha, interleukin-2), and biochemotherapy have failed to demonstrate consistent survival benefit. Without effective alternate treatments, surgery must be considered the primary treatment of melanoma, independent of disease stage. Although surgery is clearly favored as the treatment of localized melanoma, consensus opinion and clinician preference become divided once melanoma progresses beyond its primary site. Many physicians will adopt an attitude of resignation and hesitancy when treating metastatic melanoma. As a result, patients with advanced disease are often treated with medications that produce little survival or palliative benefit at the expense of significant toxicity. Numerous studies have demonstrated clear and durable survival advantages for patients undergoing complete resection of metastatic melanoma. Further, surgical resection can produce an immediate decrease in tumor burden with minimal morbidity and mortality at a reasonable cost.

Therapeutic role of beta-interferons in multiple sclerosis

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS). In the last 12 years, there has been a proliferation of studies elucidating the immune mechanisms that mediate tissue damage in MS. Interferons (IFNs) have an important role in regulating innate and adaptive immune responses. They decrease pro-inflammatory responses such as the autoimmunity in MS, but other autoimmune responses such as systemic lupus erythematosus (SLE) may be exacerbated. This review offers a general overview of the biological properties of IFNs, effects on immune cells, and clinical effectiveness in MS treatment. IFN signaling is complex, from receptor binding events to the generation of effector mechanisms that dampen inflammation. Immune cell function is altered in MS. IFN treatment of MS patients ameliorates immune dysfunction, but not completely. The incomplete resolution of immune dysfunction by IFNs partly explains their significant, but modest therapeutic effects. This observation also suggests that there are immune mechanisms in MS that are resistant to IFN therapy. In MS, abnormalities may exist at several points along the IFN signaling pathway, including molecular defects in the IFN second messenger system. Currently, several studies are ongoing evaluating ways of potentiating IFN effects. IFNs were the first agents to show clinical efficacy in treatment of MS. More than a decade of experience with IFNs has showed continued clinical efficacy over time. In the near future, IFNs will continue to play a major role in MS.

Successful sphincter-saving treatment of anorectal malignant melanoma with electrochemotherapy, local excision and adjuvant brachytherapy

Anorectal malignant melanoma is a rare tumor and there is no consensus on whether aggressive or local management is more appropriate. Local sphincter-saving excision has been shown to have a higher recurrence rate than abdominoperineal resection, although there is no long-term survival difference between the two approaches. Therefore, new adjuvant treatment strategies to permit local sphincter-saving excisions are warranted. In our case, a large anorectal malignant melanoma was successfully treated preoperatively by electrochemotherapy with cisplatin that, by reducing the tumor size, enabled sphincter-saving local excision. Brachytherapy was postoperatively delivered to the excision site. Fourteen months after the beginning of treatment, the patient is without signs of local recurrence and is continent.

[Primary anorectal melanoma]

OBJECTIVE

To specify the clinical and therapeutic aspects of anorectal melanoma.

METHODS

Nine cases of malignant anorectal melanoma were managed in the department of gastroenterology of the Ibn Rochd university hospital in Casablanca between 1984 and 2002.

RESULTS

There were 5 men and 4 women, with a mean age of 61 years. Clinical symptoms were dominated by rectal bleeding (7 cases) and rectal syndrome (5 cases). The tumor was blackish in 4 cases. Extension staging showed metastases in the liver in one patient and in the bones in another. One patient had undergone abdominoperineal resection, two transanal tumor resection, and in one patient radiotherapy was applied. Five patients refused any treatment. The outcome was marked by remission in 2 cases with an event free survival respectively of 10 and 21 months. Three patients died because of visceral metastases. Four patients were lost to follow-up.

DISCUSSION

The prognosis of anorectal melanoma is frightening because of late diagnosis and high malignancy potential. Treatment is based essentially on surgery.

Surgical management of primary anorectal melanoma

BACKGROUND

This aim of this study was to analyse outcome after surgery for primary anorectal melanoma and to determine factors predictive of survival.

METHODS

Records of 40 patients treated between 1977 and 2002 were reviewed.

RESULTS

Twelve men and 28 women of mean age 58.1 (range 37-83) years were included in the analysis. Overall and disease-free survival rates were 17 and 14 per cent at 5 years. Median overall survival was 17 months and disease-free survival was 10 months. The 5-year survival rate was 24 per cent for patients with stage I tumours, and zero for those with stage II or stage III disease. There was no significant difference in overall survival after wide local excision (49 and 16 per cent at 2 and 5 years respectively) and abdominoperineal resection (33 per cent at both time points). In patients with stage I and stage II disease, there was a significant association between poor survival and duration of symptoms (more than 3 months), inguinal lymph node involvement, tumour stage and presence of amelanotic melanoma.

CONCLUSION

Anorectal melanoma is a rare disease with a poor prognosis. Wide local excision is recommended as primary therapy if negative resection margins can be achieved.