Sinonasal Melanoma: A Case Report and Literature Review

From apparent pseudoprogression to durable complete remission of expansile destructive sinonasal mucosal melanoma under pembrolizumab after primary endoscopic resection: A case report

Head and neck mucosal melanoma is a rare but highly aggressive malignant tumor that usually has a poor prognosis. We describe a 53-year-old male patient, having no any medical history, with left maxillary sinus mucosal melanoma causing bilateral lung metastasis. Rapid tumor regrowth was observed on the 49th day after radical tumor resection. Subsequent pembrolizumab immunotherapy initially elicited pseudoprogression, for which add-on radiation therapy was carried out during maintenance pembrolizumab. A gradual decrease in tumor volume and complete remission were observed by a series of magnetic resonance imaging scans and lung windows of a computer tomography scan of chest. At the 29-month follow-up, the patient was rendered disease-free. In conclusion, head and neck mucosal melanoma may regrow rapidly after surgical resection and pseudoprogression could be frightening during immunotherapy. Subsequent single-agent pembrolizumab plus localized radiation therapy aiming to release more tumor antigens may offer the possibility of long-term remission.

Primary Intranasal Melanotic Mucosal Melanoma - A Case Report and Literature Review

Background

Intranasal mucosal melanoma is a rare form of melanoma. Presenting as the features of occult malignancy and rapid in its progression. Presented with nonspecific symptoms. So far, no specific risk factor has been identified. The histopathological and immunohistochemical examination helps to confirm the diagnosis. Here, we present a case of primary intranasal melanotic mucosal melanoma and literature review.

Case Report

The authors present a patient with primary right intranasal melanotic mucosal melanoma.

Conclusion

An endoscopic medial maxillectomy was done, and the patient was linked to the oncology department for radiotherapy.

Evaluation of clinical and imaging features for differentiating rhabdomyosarcoma from neuroblastoma in pediatric soft tissue

Background

In this study, we developed a nomogram predictive model based on clinical, CT, and MRI parameters to differentiate soft tissue rhabdomyosarcoma (RMS) from neuroblastoma (NB) in children preoperatively.

Materials and methods

A total of 103 children with RMS (n=37) and NB (n=66) were enrolled in the study from December 2012 to July 2023. The clinical and imaging data (assessed by two experienced radiologists) were analyzed using univariate analysis, and significant factors were further analyzed by multivariable logistic regression using the forward LR method to develop the clinical model, radiological model, and integrated nomogram model, respectively. The diagnostic performances, goodness of fit, and clinical utility of the integrated nomogram model were assessed using the area under the curve (AUC) of the receiver operator characteristics curve (ROC) with a 95% confidence interval (95% CI), calibration curve, and decision curve analysis (DCA) curves, respectively. Diagnostic efficacy between the model and radiologists' interpretations was examined.

Results

The median age at diagnosis in the RMS group was significantly older than the NB group (36.0 months vs. 14.5 months; P=0.003); the fever rates in RMS patients were significantly lower than in patients with NB (0.0% vs.16.7%; P=0.022), and the incidence of palpable mass was higher in patients with RMS compared with the NB patients (89.2% vs. 34.8%; P<0.001). Compare NB on image features: RMS occurred more frequently in the head and neck and displayed homogeneous density on non-enhanced CT than NB (48.6% vs. 9.1%; 35.3% vs. 13.8%, respectively; all P<0.05), and the occurrence of characteristics such as calcification, encasing vessels, and intraspinal tumor extension was significantly less frequent in RMS children compared to children with NB (18.9% vs. 84.8%; 13.5% vs. 34.8%; 2.7% vs. 50.0%, respectively; all P <0.05). Two, three, and four features were identified as independent parameters by multivariate logistic regression analysis to develop the clinical, radiological, and integrated nomogram models, respectively. The AUC value (0.962), calibration curve, and DCA showed that the integrated nomogram model may provide better diagnostic performance, good agreement, and greater clinical net benefits than the clinical model, radiological model, and radiologists' subjective diagnosis.

Conclusion

The clinical and imaging features-based nomogram has potential for helping radiologists distinguish between pediatric soft tissue RMS and NB patients preoperatively, and reduce unnecessary interventions.

Multimodal treatment and immune checkpoint inhibition in sinonasal mucosal melanoma: real-world data of a retrospective, single-center study

PURPOSE

Local failure and distant metastases occur frequently in sinonasal mucosal melanoma (SNMM). Response rates to chemotherapy are low and targetable mutations are rarely detected. However, there is increasing data indicating efficacy of immune checkpoint inhibition (ICI). The aim of this retrospective monocenter study was to assess the mutational landscape and to evaluate the outcome of surgical treatment and ICI in SNMM in a real-world setting.

METHODS

Thirty-eight SNMM patients being treated between 1999 and 2020 at our institution were retrospectively reviewed. Survival curves were generated according to Kaplan-Meier and compared by the log-rank test.

RESULTS

Local failure was seen in 60% of patients treated in a curative intent. Overall, 24% of all patients suffered from regional and 66% from distant metastases. Next generation sequencing revealed mutations of BRAF, NRAS and KRAS. One out of three patients treated with a primary ICI showed a complete response (CR) and two showed progressive disease. Eleven patients received ICI as a palliative treatment. CR could be observed in three patients and stable disease in one patient. In the whole study population, the 5-year overall survival rate (OS) was 26%. OS was better for patients who received ICI during the course of disease.

CONCLUSIONS

Recurrences and distant metastases are frequent in SNMM. Durable CR could be observed after primary and palliative ICI. Therefore, ICI in a palliative, adjuvant or even neoadjuvant setting might play a promising role in SNMM therapy while targetable mutations are rarely detected.

Advanced Sinonasal Malignant Melanoma; A Case Report

Malignant melanoma of the sinonasal area is a rare tumor that arises from melanocytes in the nasal mucosa and is more aggressive than the cutaneous type with a poor prognosis. We report a 60-year-old female with the initial chief complaint of nasal cavity fullness, continuous epistaxis, and nasal bone deformity in the past two months. In a primary examination, a black mass was found, and in an excisional biopsy, the pathologist reported sinonasal malignant melanoma, which was confirmed after IHC staining. In spindle cell tumors of the head and neck area, we should be aware of mucosal malignant melanoma as a differential diagnosis.

Dramatic response to radiation of a sinus melanoma: A case report

In this report, we shared our experience in the treatment of a patient with unresectable sinonasal melanoma, in whom a complete radiographic response was seen after a course of conventional external beam radiotherapy. Given that local control has an important role in maintaining the quality of life of patients.

Sinonasal Malignant Melanoma Variant: A Case Report

Sinonasal malignant melanoma (SMM) is a rare malignant tumour among head and neck cancers predominantly found in adults 60 years and above. The commonly reported symptoms for sinonasal tumour lesions are nasal obstruction and recurrent, painless epistaxis as the symptoms are non-specific and can delay the diagnosis. Moreover, melanoma has a poor prognosis regardless of its location. We report an 86-year-old female patient presenting with recurrent, painless epistaxis from the nasal cavity. Anterior rhinoscopic examination revealed a bluish-black, bleeding mass completely obstructing the left nasal nare. Contrast-enhanced computed tomography of the nasal cavity and sinus region showed a polypoidal soft tissue attenuation with heterogeneous enhancement completely filling the left nasal cavity. The patient underwent endoscopic excision. Histopathology of the specimen showed a small, round and blue cell tumour which immunohistochemistry found to be positive for S100 and HMB 45. After surgical resection, the patient received chemotherapy and radiotherapy. Sinonasal malignant melanoma is a rare, aggressive tumour that has a very poor prognosis. Contrast-enhanced computed tomography of the nasal cavity and paranasal sinuses is the imaging modality of choice which reveals the enhancing mass. There is no optimal management strategy for SMM. Surgical resection is the first-line treatment but is limited due to the complex anatomy of the sinonasal region.

Exceptional response to oral metronomic chemotherapy in a rare case of sinonasal mucosal melanoma

Sinonasal mucosal melanoma is a rare malignancy with limited treatment options and a poor prognosis. They are usually diagnosed at an advanced stage owing to their late and nonspecific clinical presentation. Here we present a case of relapsed refractory unresectable malignant melanoma involving the right nasal cavity managed with Oral Metronomic Chemotherapy (OMCT). A 75-year-old male patient was diagnosed with unresectable malignant melanoma involving the right nasal cavity and showed radiological progression after initial management with four cycles of Dacarbazine. He was then shifted to OMCT (Cyclophosphamide, Celecoxib and Tamoxifen), as immunotherapy could not be given due to financial constraints, on which he showed approximately 40% reduction in tumour size after 6 months. This result can have important clinical implications in resource constrained settings, where the use of immunotherapy is limited by great financial burden.

Mucosal Melanoma of the Head and Neck: A Retrospective Review and Current Opinion

Introduction: Head and Neck Mucosal Melanoma (HNMM) is an uncommon malignancy that arises in decreasing order in the nasal cavity, the paranasal sinuses, and the oral cavity. Although radical surgery followed by eventual radiotherapy is acknowledged as the mainstay treatment, patients with advanced stages or multi-focal tumors benefit from new systemic therapies. We wish to share our experience with these treatments and review the current literature. Materials and Methods: We present a case review of every patient treated in our center for an HNMM over the past 10 years, including every patient treated in our center for an HNMM over the past 10 years. We analyzed clinical characteristics, treatment modalities, and outcomes. Results: We included eight patients aged from 62 to 85 years old. We found six MM in the nasal cavity, one in the sphenoidal sinus, and one in the piriform sinus. Six patients underwent endoscopic surgery with negative margins, six underwent radiotherapy with variable modalities. Immunotherapy or targeted therapy was given in cases extensive tumors without the possibility of a surgical treatment or in two patient as an adjuvant treatment after R0 surgery. The three-year overall survival was 50%, and three patients (37.5%) are in remission. Conclusions: HNMM is associated with poor oncologic outcomes regarding the concerned patients of our review, as reported in the literature. New treatments such as immunotherapies or targeted therapies have not significantly changed the prognosis, but they may offer new interesting perspectives. Our small series of cases seems to confirm that surgical resection with negative margins improves overall survival.

Impact of adjuvant therapy on survival for sinonasal mucosal melanoma

Background: The optimal treatment modality for sinonasal mucosal melanoma (SNMM) remains controversial.Objectives: To investigate the impact of adjuvant therapy on SNMM.Material and methods: Ninety-two patients were retrospectively analyzed and were grouped into surgery alone (SA), surgery plus radiotherapy (SR), surgery plus chemotherapy (SC) and surgery plus radiochemotherapy (SRC) groups. Survival outcomes among different treatment modalities were analyzed using the Kaplan-Meier method and log-rank test.Results: Twenty-nine patients (31.5%) developed local recurrence, 10 patients (10.9%) had nodal metastasis, and 41 patients (44.6%) had distant metastasis. The overall survival time (OS) for SA, SR and SRC were 16, 29 and 27 months, respectively, and the disease-free survival time (DFS) were 10, 16 and 16 months, respectively. Significant differences were found between SA and SR (OS: p = .003; DFS: p = .016) and SA and SRC (OS: p = .002; DFS: p = .008). Superior outcomes were also found in SRC group compared to that in SA group for both OS (15 vs. 27 months, p = .012) and DFS (10 vs. 20 months, p = .017) in endoscopic approach.Conclusions and significance: SNMM had poor prognosis with high rates of local recurrence and metastasis. Adjuvant therapy improved survival outcomes for SNMM.

Magnetic resonance features of sinonasal melanotic mucosal melanoma

A 67-year-old man presented to ear, nose and throat department complaining of nasal congestion and recurrent epistaxis for 5 months. Nasal endoscopy revealed a pigmented polyp obstructing the right nasal cavity. MRI with contrast agent showed a right nasal cavity polypoid mass with hyper signal intensity (SI) both in non-enhanced T1-w and diffusion imaging, marked hypo SI in T2-w sequences and avidly contrast enhancement characterised by rapid wash-in without significant wash-out on dynamic perfusion imaging. Histological specimen showed epithelioid and spindle cells with focal intense pigmentations and immunohistochemical features compatible with primary melanotic sinonasal mucosal melanoma (SNM). As melanotic SNM shows MRI pathognomonic high non-enhanced T1-w SI, this case underlines the crucial role of MRI not only in assessing the local tumour extension/recurrence but also in increasing the diagnostic confidence of detecting melanotic SNM. Thus, MRI should be always performed in case of clinical-endoscopic suspicion of SNM.

The evaluation of malignant mucosal melanoma of nasal cavity with a rare occasion

Malignant mucosal melanoma is an uncommon disease with a low rate of survival. Malignancies of nasal mucosa which usually presents with nasal obstruction, epistaxis and back drip are difficult to treat and often have poor prognosis. The present case had presented to our clinic with classic symptoms and diagnostic findings of nasal polyposis. Consistently, the patient had previously been diagnosed with and treated for nasal polyposis in another ENT clinic. Physical examination, rhinoscopic examination, computed tomography (CT) scan of the head did not reveal any findings which might imply malignant formations. The operation had been planned for nasal polypectomy and taking deep biopsy specimens. The incised mass showed characteristic features of malignant tissues and the pathology report of the biopsy samples revealed that the specimen showed the histological signs of malignancy. Based on physical examination, CT findings and pathology reports the case was diagnosed as nasal mucosal melanoma. Following an oncosurgical operation, postoperative radio-therapy and chemotherapy were given to the patient and PET/CT examination of the patient did not indicate distant metastases.

Recurrence in a patient with a 10-year history of sinonasal mucosal melanoma manifesting as facial swelling

Sinonasal mucosal melanoma is a rare tumor that develops slowly and may manifest with non specific signs and symptoms, causing significant delay in diagnosis. Local recurrence is common and usually occurs within the first two years after the initial treatment. Prognosis of recurrent lesions is poor and 5-year survival ranges between 10-47%. We report the clinical, radiographic, histopathological and immunohistochemical findings of a recurrent sinonasal mucosal melanoma which was diagnosed 10 years after the initial treatment, in a patient who presented with unilateral facial swelling and one-sided difficulty in breathing of two years duration. We discuss the causes of late diagnosis and review the negative predictive factors for recurrence and survival. As early diagnosis is of paramount importance for prognosis, we emphasize the signs and symptoms of patients with a history of sinonasal mucosal melanoma which should raise the suspicion for recurrence, in spite of a long time interval since diagnosis. Key words: Mucosal melanoma, nasal cavity, sinus, recurrence.