Long-term outcome of esophagectomy for primary malignant melanoma of the esophagus: a single-institute retrospective analysis

Comprehensive molecular findings in primary malignant melanoma of the esophagus: A multicenter study

Primary malignant melanoma of the esophagus (PMME) is an extremely rare but highly aggressive malignancy with a poor prognosis. Due to the scarcity of driver gene alterations, there is a need for more clinical data to comprehensively depict its molecular alterations. This study reviewed 26 PMME cases from three medical centers. Hybrid capture-based targeted sequencing of 295 and 1021 genes was performed in 14 and 12 cases, respectively. We found that PMME patients had a relatively low tumor mutation burden (median, 2.88 mutations per Mb) and were simultaneously accompanied by mutations in genes such as KIT (6/26, 23%), TP53 (6/26, 23%), SF3B1 (4/26, 15%), and NRAS (3/26, 12%). KIT, NRAS, and BRAF were mutually exclusive, and SF3B1 co-occurred with KIT mutation and amplification. The most common pathways affected were the mitogen-activated protein kinases and DNA damage response (DDR) pathways. Stage IV was a risk factor for both progression-free survival (hazard ratio [HR] = 5.14, 95% confidence interval [CI] = 1.32-19.91) and overall survival (OS), HR = 4.33, 95% CI = 1.22-15.30). Treatment with immune-checkpoint inhibitors (ICIs) was an independent factor for favorable OS (HR = 0.10, 95% CI = 0.01-0.91). Overall, PMME is a complex malignancy with diverse gene alterations, especially with harboring DDR alterations for potentially response from ICIs.

[Treatment of primary malignant melanoma of the esophagus]

OBJECTIVE

To present treatment of primary esophageal melanoma in a young patient, as well as review of modern data on this issue.

MATERIAL AND METHODS

We describe the results of treatment of a patient with primary melanoma of the esophagus. PubMed, SCOPUS, and elibrary databases were used for the review.

RESULTS

We present a rare case of primary esophageal melanoma and variant of radical surgical treatment. The review is devoted to historical information about this nosology, statistical data, options for diagnosis and treatment.

CONCLUSION

Such a rare clinical case is of great scientific interest due to the rarity of this disease. In our opinion, a certain register of orphan malignant tumors is necessary for diagnosis and treatment of various rare malignancies.

Primary esophageal melanoma: a case report

Primary esophageal melanoma remains a rare entity with less than 350 case reports noted in the current literature. This diagnosis is associated with a poor prognosis and early detection and management remains fundamental. In this report, we examine the case of an 80-year-old female who presented with a 1-year course of progressive dysphagia and weight loss. Investigations revealed a primary esophageal melanoma with no evidence of metastases. Pathology did not identify any targetable markers for systematic therapy and thus the patient successfully underwent a minimally invasive esophagectomy. Her postoperative course involved endoscopic esophageal dilatations due to an anastomotic stricture, as well as primary lung adenocarcinoma treated with radiotherapy but has otherwise remained without evidence of melanoma recurrence after 25 months from her surgery.

The Thousand Faces of Malignant Melanoma: A Systematic Review of the Primary Malignant Melanoma of the Esophagus

Primary Malignant Melanoma of the Esophagus (PMME) is an extremely rare cancer of the esophagus, accounting for 0.1−0.8% of all oro-esophageal cancers and <0.05% of all melanoma subtypes, with an estimated incidence of 0.0036 cases per million/year. We conduct a careful analysis of the literature starting from 1906 to the beginning of 2022, searching the PubMed, Science.gov, Scopus and Web of Science (WoS) databases. A total of 457 records were initially identified in the literature search, of which 17 were duplicates. After screening for eligibility and inclusion criteria, 303 publications were ultimately included, related to 347 patients with PMME. PMME represents a very rare entity whose very existence has been the subject of debate for a long time. Over time, an increasing number of cases have been reported in the literature, leading to an increase in knowledge and laying the foundations for a discussion on the treatment of this pathology, which still remains largely represented by surgery. In recent times, the possibility of discovering greater mutations in gene hotspots has made it possible to develop new therapeutic strategies of which nivolumab is an example. Future studies with large case series, with clinicopathological and molecular data, will be necessary to improve the outcome of patients with PMME.

Clinicopathological Features, Staging Classification, and Clinical Outcomes of Esophageal Melanoma: Evaluation of a Pooled Case Series

Studies that have attempted to validate the staging systems and the predictors of survival for patients with primary malignant melanoma of the esophagus (PMME) have been underpowered given their scarcity and small scale. We aimed to review a large number of PMME cases to know more about its clinicopathological features, TNM staging systems, and survival predictors of PMME. Case reports on PMME were extracted from PubMed/Medline through bibliography search and our center. A total of 287 PMME cases were identified. The majority of the patient population was male (72.08%). The most common location of PMME was the lower esophagus (50.62%) and middle esophagus (35.39%). Among the patients, 82.28% received surgical intervention. The median overall survival (OS) duration was 15 months (0.5–244). The American Joint Commission on Cancer staging classification (AJCC) for the mucosal melanoma of the upper aerodigestive tract with stage IVB and IVC integrated in stage IVA showed better distribution of OS than that for esophageal carcinoma. T stage, N stage, and surgery had significant impacts on OS duration in univariate analysis. However, only T stage and N stage were identified as independent factors for OS duration in the multivariate Cox models. PMME is an aggressive tumor with poor prognosis. The AJCC staging system for mucosal melanoma with stage IVB and IVC integrated in stage IVA may be a better option for staging PMME patients. T stage and N stage are independent factors for OS.

Clinical characteristics and treatment outcomes of primary malignant melanoma of esophagus: a single center experience

Background

Primary malignant melanoma of esophagus (PMME) is an extremely rare disease with poor prognosis. We aimed to determine the clinical characteristics and treatment outcomes of patients with PMME.

Methods

We retrospectively reviewed 17 patients diagnosed with PMME in Samsung Medical Center between 2000 and 2020 with median 34 months of follow-up. Survival outcomes were analyzed with Kaplan–Meier method.

Results

15 patients (88.2%) were male and the most common presenting symptom was dysphagia (9/17, 52.9%). On endoscopy, tumors were mass-forming in 15 patients (88.2%) and diffusely infiltrative in two patients (11.8%). Lesions were melanotic in 13 patients (76.5%) and amelanotic in four patients (23.5%). The most common tumor location was lower esophagus (11/17, 64.7%). The disease was metastatic at the time of diagnosis in four patients (23.5%). As for treatment, 10 patients (58.8%) underwent surgery. In all 17 patients, the median overall survival was 10 months. In surgically treated patients, all patients experienced recurrence and the median disease-free survival was 4 months. There was no statistical difference in overall survival between patients with or without surgery. Patients with diffusely infiltrative tumor morphology had better overall survival compared to those with mass-forming tumor morphology (P = 0.048). Two patients who received immunotherapy as the first-line treatment without surgery showed overall survival of 34 and 18 months, respectively.

Conclusions

As radical resection for patients with PMME does not guarantee favorable treatment outcomes, novel treatment strategy is required. Further large-scale studies are warranted to determine the efficacy of immunotherapy for patients with PMME.

Radical Resection in an Era of Immune Therapy for Primary Esophageal Melanoma

Primary malignant melanoma of the esophagus (PMME) is a rare and aggressive esophageal malignancy, demonstrating poor overall survival. Immunotherapy (IO) is now established as a therapy for aggressive or metastatic cutaneous malignant melanoma. This is the first case series discussing IO for PMME in both the peri-operative and salvage setting for curative intent. IO is changing the treatment approaches for PMME and may lead to long-term salvage and survival.

Results of surgical treatment for primary malignant melanoma of the esophagus: A multicenter retrospective study

OBJECTIVE

Few large-sample research data sets exist on long-term survival and prognostic factors among patients with primary malignant melanoma of the esophagus (PMME), a rare malignancy associated with poor outcomes. We sought to investigate postoperative survival and prognostic factors in patients with PMME.

METHODS

We retrospectively analyzed long-term follow-up results for patients with PMME who underwent surgery at 10 Chinese centers between January 1998 and January 2018. We performed uni- and multivariate analyses to investigate clinicopathologic factors associated with survival.

RESULTS

Median overall survival for the entire group (N = 70 patients) was 13.5 months. Female sex (hazard ratio [HR], 0.352; 95% confidence interval [CI], 0.138-0.900; P = .029), ≥12 lymph nodes dissected (HR, 0.274; 95% CI, 0.133-0.563; P < .001), absence of lymph node metastasis (HR, 0.195; 95% CI, 0.084-0.451; P < .001), and postoperative adjuvant therapy (HR, 0.474; 95% CI, 0.249-0.901; P = .023) were factors of favorable prognosis. Preoperative pathologic diagnosis of PMME was as low as 47.1%. A high proportion of patients had lymph node metastasis, including those with early-stage tumors. Rates of lymph node metastasis were 54.2% (13/24) for pT1, 44.4% (12/27) for pT2, 57.1% (8/14) for pT3, and 100% (5/5) for pT4. Regional lymph node recurrence (N = 43 [61.4%]) was the predominant postoperative pattern of recurrence or metastasis.

CONCLUSIONS

Female sex, pN0, increased number of lymph nodes dissected, and postoperative adjuvant therapy were associated with better outcomes among patients with PMME. Preoperative pathologic diagnosis of PMME was low, patients had lymph node metastasis (even those with early-stage tumors), and regional lymph node recurrence was common.

Clinicopathological presentations and surgical outcomes of esophageal melanoma

Background

Primary malignant melanoma of the esophagus is a rare tumor with a poor prognosis; the optimal treatment strategy has yet to be established. This study aimed to clarify clinical features, courses, and outcomes of patients undergoing surgical resection of primary malignant melanoma of the esophagus.

Methods

Six patients with primary malignant melanoma of the esophagus, in whom the absence of other primary melanomas had been confirmed, were selected from the medical database maintained in Toranomon Hospital. Their clinicopathological characteristics and long-term outcomes were retrospectively reviewed and analyzed.

Results

All 6 patients (five males and one female) underwent radical esophagectomy with three-field regional lymphadenectomy, and none received neoadjuvant therapy. Tumor invasion was classified into T1 in 5 (83%) cases and T3 in one (17%). Four (67%) patients had nodal metastases (one N1, one N2 and two N3). No distant metastatic lesions were detected preoperatively in any of our cases. Postoperative surveillance revealed recurrence in all 6 patients, and 5 (83%) died of the disease. The median overall survival was 24 months. One patient with a T3N3M0 tumor was treated after surgery with a dacarbazine-nimustine-vincristine regimen followed by irradiation for bone recurrence and survived for 87 months postoperatively. Another patient with a T1N3M0 tumor who survived for 27 months after liver and bone recurrence was treated with nivolumab, ipilimumab, and dacarbazine.

Conclusion

Although the courses of patients with primary malignant melanoma of the esophagus were consistently unfavorable, surgical resection with multidisciplinary therapeutic modalities may prolong survival in some cases.

Clinicopathological characteristics and survival of primary malignant melanoma of the esophagus

Primary malignant melanoma of the esophagus (PMME) has been reported to be a rare and highly malignant disease, and to date a standard treatment strategy has not been established due to limited evidence. The aim of the present study was to investigate the clinicopathological characteristics of this extremely rare disease. A total of 6 out of 2,093 patients with PMME treated in our institution between 1995 and 2016 were retrospectively analyzed and their clinicopathological parameters including treatment course and long-term survival were investigated. The major clinicopathological characteristics of patients were that they were >70 years of age, male sex, dysphagia at first diagnosis, and macroscopic black protruding tumors located in the lower third of the thoracic esophagus. Four of the five patients receiving pretherapeutic endoscopic biopsy were correctly diagnosed with PMME, and two patients received preoperative treatment with ineffective histopathological responses. There were two unresectable cases, one was treated with an immune-checkpoint inhibitor and the other received palliative care. Three of the four patients receiving curative surgery developed hematogenous recurrence within two years of surgery and only one patient with pT1aN0M0 achieved long-term survival. The median overall survival of all six patients was 19.6 (6.4–40.5) months. Patients with stage I disease exhibited significantly more favorable prognoses than those with stage II–IV (P=0.025) and surgically-treated patients had significantly better prognoses than those who did not receive surgery (P=0.018). In conclusion, PMME was associated with highly malignant features and tended to develop hematogenous metastases even after radical resection. Early diagnosis appears to be important to cure this refractory disease.

An updated review of mucosal melanoma: Survival meta-analysis

Mucosal melanoma (MM) is a highly lethal variant of melanoma that carries a poor prognosis. Extremely low incidence and survival rates have led to few clinical trials, and a lack of protocols and guidelines. The present study performed a survival meta-analysis for the quantitative synthesis of available evidence to search for key patterns that would help clinicians tailor optimal therapeutic strategies in MM. PubMed, EMBASE, Cochrane, MEDLINE, Google Scholar and other databases were searched. Hazard ratios, in disease-specific and overall survival, were calculated for each of the survival-determining variables. MM was 2.25 times more lethal than cutaneous melanoma (CM). The most significant threats to survival were advanced Tumor-Node-Metastasis stage, sino-nasal location, and old age. Chemotherapy was the most effective form of adjuvant therapy. Disease-specific survival, the primary measure of the effect sizes, can fluctuate depending on the accuracy of the reported cause of mortality. In conclusion, MM is a peculiar type of melanoma, with clinical and molecular profile vastly different from the much-familiar CM. In the wake of the era of precision oncology, further studies on driver mutations and oncogenic pathways would likely lead to improved patient survival.

A case of primary malignant melanoma of the esophagus with a widely expanded surface area

Primary malignant melanoma of the esophagus (PMME) is rare but aggressive. PMME accounts for approximately 0. 1% of all malignant esophageal neoplasms occurring worldwide, and is usually diagnosed during the advanced stage. A 67-year-old man underwent an esophagogastroduodenoscopy (EGD) at our hospital and confirmed 20 mm of black pigmentation in the lower esophagus in the chest area. Pathological biopsy findings of the black-pigmented epithelial tissue revealed the presence of tumor cells with brown granules, leading to the diagnosis of malignant melanoma. Owing to difficulty in accurately diagnosing the range in this PMME case, we performed thoracoscopic esophagectomy. Pathological organisation test results were pT1a-LPM, INFb, pN0, and pM0, which were diagnosed at pStage I. The lesion expanded extensively, measuring > 10 cm in diameter. The tumor cells, which were centrally located in the black-pigmented area, were observed to have proliferated beyond the surrounding brownish area into the mucosa, but no findings were found in the endoscopic examination. As in this case, because PMME may diffusely spread along the basal layer outside the range of pigmentation, endoscopic diagnosis of the extent of disease spread may be impossible; hence, it is important to keep this phenomenon in mind while performing resection to treat PMME.

Malignant melanoma of the esophagus complicated with poorly differentiated mucinous adenocarcinoma of the stomach: A case report

RATIONALE

Primary malignant melanoma of the esophagus (PMME) is a rare malignancy that only accounts for <2% of all primary esophageal tumors. Here, we report the even rarer occurrence of PMME in combination with poorly differentiated mucinous adenocarcinoma of the stomach.

PATIENT CONCERNS

A 64-year-old man was presented to the hospital with >1 month of eating dysphagia. Enhanced computed tomography (CT) scan only found a space-occupying lesion in the lower esophagus with moderate enhancement. However, gastroscope showed not only esophageal masses, but also gastric mucosa changes.

DIAGNOSES

Poorly differentiated mucinous adenocarcinoma and PMME were diagnosed based on pathological biopsy and immunohistochemical methods.

INTERVENTIONS

The patient underwent laparoscopic gastric cancer radical surgery, esophageal resection, and colonic replacement of the esophagus.

OUTCOMES

Abdominal CT and esophagography performed 1 week after surgery showed that it was consistent with postoperative changes without other abnormalities. However, the patient died 3 months after discharge without receiving any other treatment.

LESSONS

This case suggests more attention should be drawn to the diagnosis of multiple primary malignant neoplasms in elder patients, and also highlights the need to fulfill comprehensive examinations before surgery in case of misdiagnosis. Besides, it is challenging to finding a reasonable treatment for such rare condition.

Primary amelanotic malignant melanoma of the esophagus: a case report

Background

Primary amelanotic malignant melanoma of esophagus, which is a subtype of primary malignant melanoma of the esophagus (PMME), is a very rare disease with a poor prognosis. We herein report a case of the amelanotic type of PMME.

Case presentation

An 86-year-old woman was admitted to our hospital with symptoms of dysphagia. An endoscopic examination and constructed radiography revealed an elevated and semipedunculated lesion with an ulcer in the lower thoracic esophagus accompanied by another submucosal lesion of the esophagus. She was diagnosed with esophageal squamous cell carcinoma by a preoperative endoscopic biopsy. We performed thoracoscopy- and laparoscopy-assisted subtotal esophagectomy with lymphadenectomy. Based on the surgical specimens, although there were no melanocytes, we made a diagnosis of a malignant melanoma immunohistochemically; the tumor cells were positive for S-100 protein and HMB45 focally and partially for Melan-A.

Conclusion

We experienced a case of primary amelanotic malignant melanoma, and the patient has remained disease-free for 1 year since the surgery. Since the diagnosis of amelanotic type of PMME is difficult, it should be made by the combination of a morphological examination, pathological examination, and immunohistochemistry.

Clinicopathological characteristics, staging classification, and survival outcomes of primary malignant melanoma of the esophagus

BACKGROUND

Primary malignant melanoma of esophagus (PMME) is a remarkably rare and highly aggressive tumor. Studies related with clinicopathological findings, staging classification, and clinical outcomes are lacking.

METHODS

We reviewed 21 cases of PMME at the Tianjin Medical University Cancer Institute and Hospital from January 2002 to February 2017.

RESULTS

Nineteen patients (90.48%) presented a history of dysphagia for months, and two (9.52%) experienced retrosternal pain. Histologically, tumors were composed of atypical melanocytes with melanocytosis surrounding the tumor. The overall survival was 1-40 months, with the median time of 10 months. The mucosal staging classification for upper aerodigestive tract showed better distribution of overall survival with different stages than that of the American Joint Commission on Cancer staging classification for esophagus, but without statistical difference. Both the clinical and pathological characteristics were not highly consistent with overall survival.

CONCLUSIONS

PMME is a considerably aggressive tumor with poor prognosis. The staging classification of mucosal melanoma of the upper aerodigestive tract may be a good option for PMME patients.

Primary malignant melanoma of esophagus following chemoradiotherapy for esophageal squamous cell carcinoma: report of a case

Primary malignant melanoma of the esophagus (PMME) is a rare neoplasm. We observed a case of PMME that had occurred at an irradiated site in the thoracic esophagus. The patient was a 74-year-old man who had received definitive chemoradiotherapy for esophageal squamous cell carcinoma at the age of 68, and had completely recovered. Six years later, via periodic upper gastrointestinal endoscopy, he had been diagnosed with esophageal tumors. After the patient underwent esophagectomy, the removed esophageal tumors were immunohistologically diagnosed as PMME, and most of the tumor was observed to be located within the irradiated area corresponding to the previous radiotherapy. The patient has been free of recurrence and metastasis and alive for 20 months after the second surgery without any additional treatment. The clinical course of this patient suggests that therapeutic radiation may be a factor in the occurrence of PMME.

A long-term survivor with esophageal melanoma and pulmonary metastasis after single-stage esophagectomy and lobectomy: Case report and literature review

RATIONALE

The optimal therapeutic regimen for primary malignant melanoma of the esophagus (PMME) need to be further elucidated. Besides, the efficacy of surgery for PMME with remote metastasis is uncertain for its rarity.

PATIENT CONCERNS

Herein a previously healthy patient was admitted for dysphagia and fatigue, without significant weight loss.

DIAGNOSES

The pathological and molecular tests revealed his diagnosis of BRAF-mutant, advanced PMME with localized pulmonary metastasis.

INTERVENTIONS

Single-stage Ivor-Lewis esophagectomy and lobectomy were performed successfully, followed by 4 cycles of conventional chemotherapy, and concurrent high-dose interferon lasting for 1 year.

OUTCOMES

The patient survived without logo-regional recurrence or remote metastasis during the follow up of two and a half years up to now.

LESSONS

Timely resection of localized primary and metastatic lesions might deliver a chance to obtain better prognosis for selected PMME patients; however, high-quality trials with longer follow-up are needed.

Primary Malignant Melanoma of the Esophagus: A Case Report and Review of the Literature

BACKGROUND Primary malignant melanoma of the esophagus (PMME) is a rare cancer with a poor prognosis. It is often difficult to differentiate from non-epithelial malignant tumors, and immunohistochemical staining may be needed to diagnose the condition. The mainstay of treatment is usually surgical with curative or palliative intent, since radio- and chemotherapy do not really improve the outcome. The average survival rate after surgery is 34.5 months. At the time of diagnosis, 40-80% of cases have local regional lymph node metastases. CASE REPORT The case of a 67-year-old male patient with PMME is reported. He presented with progressive dysphagia. A computerized tomography was performed in which a polypoid mass was observed in the distal esophagus. It was originally suspected to be an adenocarcinoma, but was subsequently correctly diagnosed by immunohistochemical staining with HMB-45 antibody and by the presence of S-100 protein. A subtotal esophagectomy was performed. CONCLUSIONS Very few cases of PMME have been reported in the literature and there is only limited clinical experience with this disease. Therefore, it is very difficult to establish clear criteria for clinical recognition of this type of melanoma. Early histopathological confirmation of the character is essential for further treatment in case of confirmation of malignancy.