Anorectal Melanoma: A Case Report

Anorectal mucosal melanoma (AMM) is an infrequent and highly aggressive form of mucosal melanoma. Its rarity makes it challenging to clinically diagnose, and its initial symptoms are typically nonspecific such as rectal/anal bleeding (the most common symptom), anal pain, or the presence of an anal mass. The prognosis for this condition is generally poor, and its incidence appears to be increasing each year. AMMs often go undetected and/or are already metastasized at the time of diagnosis. We present a case report of a patient who initially presented with nonspecific symptoms of anemia and blood per rectum, and was later found to have stage IV melanoma of the anorectal region. There is a notable scarcity of literature on this disease, resulting in a lack of a comprehensive understanding of its nature. Most available information consists of isolated case reports rather than comprehensive studies. Although surgical resection remains the primary treatment approach, the majority of patients (over 80%) will die due to distant metastasis within five years after undergoing surgery. The five-year survival rate for anorectal melanoma is estimated to be between 6% and 22%.

Early-Stage Primary Rectal Melanoma: A Case Report

Malignant primary rectal melanomas (PRM) are rare tumors. Their diagnosis is frequently delayed as these lesions are often mistaken for benign diseases, resulting in extremely poor overall survival. Histological evaluation with special immunohistochemical (IHC) stains is often indispensable for a definitive diagnosis. The main treatment for this condition involves surgical resection. Adjuvant therapy has also been long recommended. We discuss the case of a 60-year-old woman who presented with changes in bowel habits, anal pain, and perineal burning with no bleeding. A digital rectal examination revealed a nodular mass extending 5 cm from the anal verge. Rectosigmoidoscopy demonstrated an ulcerated polypoid tumor extending 4 cm from the anal verge and over 5 cm into the lower rectum. Biopsy and IHC tests confirmed the diagnosis of rectal melanoma. The patient was successfully managed with surgery followed by external beam radiotherapy and a complete response was achieved after 10 months of follow-up.

Primary Gastric Mucosal Melanoma: A Rare Etiology of Iron Deficiency Anemia

Iron deficiency anemia is a concerning finding, particularly in males and post-menopausal females, and can have numerous underlying causes. When evaluating potential sources of gastrointestinal blood loss, bidirectional endoscopy is often necessary. We report the case of an 89-year-old female with multiple comorbidities, including atrial fibrillation treated with apixaban, who presented with symptomatic iron deficiency anemia. Extensive dermatological and radiological assessments ruled out a primary source, and subsequent endoscopy identified a rare etiology: primary gastric mucosal melanoma. This case highlights the importance of thorough evaluation in identifying uncommon causes of iron deficiency anemia such as unsuspected malignancies, hereditary conditions, and different autoimmune conditions amongst other etiologies.

Melanoma in the Vulva of a 71-Year-Old Patient: A Case Report

Mucosal melanomas (MM) are a rare type of melanomas commonly found in the vulvovaginal, anorectal, and respiratory tract. In this case report, a 71-year-old female presented to her OB/GYN clinic with dark raised mass on her right labial region adjacent to the perineum. Past medical and surgical history of note included third-degree uterine prolapse, senile vaginitis, fibrocystic changes of the breasts bilaterally, hypothyroidism, hypertension, as well as a past hysterectomy and anterior colporrhaphy. Upon further workup, the 2.7 x 1.8 x 2 cm polyploid mass was biopsied and was found to be consistent with malignant melanoma. The patient then underwent a wide local excision confirming that the lesion was a nodular vulvar melanoma with superficial ulcerations and lymphovascular invasion of the vulvar region. Post-wide local incisions were found to be healed well after the procedure and the patient was referred to a gynecological oncologist for continuous monitoring. The purpose of this case report is to bring awareness of melanomas arising in atypical regions. While MMs are rare in comparison to cutaneous melanomas (CM), the prognosis can be poor if not caught early.

Primary Malignant Melanoma of the Genitourinary System: A Systemic Review and Report of Eight Cases

Malignant melanoma (MM) of mucosal membranes (excluding anus and head-neck) is a rare but aggressive disease with poor outcomes. The knowledge of this tumor's development, etiology, and management is scarce, mainly due to the low case numbers. We presented eight cases and performed a comprehensive literature review on mucosal MM (between 1970 and 2020). We identified 47 manuscripts on 55 patients with primary mucosal MM (limited to urothelium and vagina) and reviewed demographics, tumor specifications (morphology, stage, etc.), management, and survival. We identified 10 manuscripts discussing treatment in 1595 mucosal and non-mucosal MM and extracted the data regarding the non-surgical treatment modalities of mucosal MM patients. In 63 cases, 48 tumors primarily occurred in the urothelium (urethra: 47, bladder: 1) and 15 in the vagina. Molecular studies in a subset of cases revealed alterations in c-KIT, NRAS, BRAF (non-V600E and V600E), TP53, and NF1. Fifty-three patients underwent surgery (with additional chemotherapy, immunotherapy, and radiotherapy in 19, eight, and eight patients, respectively). The outcome was available in 52 cases, showing 21 deaths, 10 without recurrence, two alive with disease, and five lost to follow-up. Shared genetic signatures in mucosal and skin MM suggest a similar development mechanism; however, unlike skin MM, there are less BRAF mutations and more PI3K/AKT/mTOR pathway alterations in mucosal MM. Prolonged chemotherapy (i.e., methotrexate) and immune-modulating agents (i.e., natalizumab) may be risk factors. The stage at diagnosis and proper surgical extirpation are keys to the prognosis and survival of patients.

Prolapsed anorectal malignant melanoma presenting as hemorrhoids

Rectal bleeding in a patient with a history of hemorrhoids should not be ignored. It is often benign and resolves spontaneously without treatment. Here we present a case of anorectal malignant melanoma that presented with rectal bleeding and a prolapsed rectal mass.

Malignant Melanoma of the Female Genital Tract: Experience of an Oncology Center in Pakistan

Introduction

Malignant melanoma, which arises from melanocytes or pigment cells, is one of the most common forms of epithelial cancer. Cutaneous and noncutaneous melanomas differ clinically and genetically. Mucosal melanomas are rare. In the female genital tract, the most frequent location of melanoma is the vulva, whereas the vagina is seldom affected. The occult nature of their anatomical location contributes to the late presentation and late diagnosis of vaginal melanoma, resulting in an exceedingly poor patient prognosis. The present study describes the incidence, symptoms, management, and prognosis of women in Pakistan with malignant melanoma of the vulva, vagina, and cervix.

Materials and methods

The Hospital Information System of Shaukat Khanam Memorial Cancer Hospital and Research Center was searched electronically to identify patients diagnosed with malignant melanoma from January 1995 to December 2017. Patients with cutaneous malignant melanoma, multiple primary tumors, and metastases to the female genital tract from primary tumors located elsewhere were excluded. All included patients had been diagnosed with primary malignant melanoma of the female genital tract.

Results

The search of medical records identified 271 patients with malignant melanoma, of whom 13 had primary malignant melanomas of the female genital tract. Of these 13 patients, nine, three, and one had primary vaginal, vulvar, and cervical melanomas, respectively. Median age at presentation was 60 years (range, 30-70 years), with 10 patients being post-menopausal. The most common presentations were per-vaginal bleeding and per-vaginal discharge (five patients each). The mean duration of symptoms was 7.46 months. Seven patients underwent wide local excision. Six patients had nodular type malignant melanoma, two had superficial spreading type, and five were unclassified. Nine patients had pathological T4 disease, and two had pathological T3. Mean Breslow depth was 5.4 millimeters (mm), with 10 patients having tumor depth >4 mm. Eight patients were positive for the microscopic involvement of margins. The mean time to recurrence was 11.8 months (range, 1-24 months), and the mean time to metastasis was 17.6 months (range, 2-44 months). The median survival after surgery was 25 months (range, 2-75 months).

Conclusion

This study is the first to report the incidence, symptoms, management, and prognosis of patients in Pakistan with malignant melanoma of the female genital tract. Meta-analyses and prospective multicenter studies are needed.

Amplification and attenuation of lung metastases depending on glucocorticoid dosage implicating long-acting activated memory cells induced by nivolumab against malignant melanoma

Firstly, glucocorticoids such as prednisolone can attenuate the effect of anti-PD-1 antibody nivolumab. Secondly, malignant melanoma cells survived latently and unnoticeably in places other than those of previous metastatic lesions. Thirdly, effector T cells activated by nivolumab sustained their memory to attack malignant melanoma cells for several months.

Long-term outcomes after carbon-ion radiotherapy for oral mucosal malignant melanoma

Oral mucosal malignant melanoma (OMM) is extremely rare and has a poor prognosis. Owing to its rarity, it has not yet been possible to establish an optimal treatment modality. The objective of this study was to evaluate the long-term efficacy of carbon-ion radiotherapy (C-ion RT) for OMM. Between 1997 and 2013, 19 patients with OMM were treated with C-ion RT alone. Patient ages ranged from 44 to 84 years (median, 69 years). Nine men and 10 women were included. OMMs were restaged in accordance with the seventh edition of the tumour/node/metastasis (TNM) Staging System of the International Union Against Cancer. Before treatment, 14 patients had T3 disease and 5 had T4a disease. Three patients were classified as having N1 disease. All patients were classified as having M0. The hard palate was the most frequently involved oral subsite. All patients were treated with 57.6 Gy (relative biological effectiveness) in 16 fractions. The median follow-up period was 61 months (range, 8-190 months). The 5-year local control, overall survival and progression-free survival rates were 89.5%, 57.4% and 51.6%, respectively. For local control and overall survival, T classification was found to be a significant prognostic factor. Grade 2 and 3 osteoradionecrosis was observed in three and four patients, respectively. The presence of teeth within the planning target volume was a significant risk factor for developing osteoradionecrosis. C-ion RT was an effective treatment option with acceptable toxicity for OMM.

Usefulness of 11C-methionine-PET for predicting the efficacy of carbon ion radiation therapy for head and neck mucosal malignant melanoma

The aim of this study was to determine whether l-methyl-[¹¹C]-methionine (MET) positron emission tomography (PET) allows the prediction of outcomes in patients with head and neck mucosal malignant melanoma treated with carbon ion radiation therapy (CIRT). This was a retrospective cohort study involving 85 patients who underwent a MET-PET or MET-PET/computed tomography (CT) examination before and after CIRT. MET uptake in the tumour was evaluated semi-quantitatively using the tumour-to-normal tissue ratio (TNR). Local recurrence, metastasis, and outcome predictions were studied in terms of TNR before CIRT (TNRpre), TNR after CIRT (TNRpost), and the TNR change ratio. Kaplan-Meier curves revealed significant differences between patients with higher TNRpre values and those with lower TNRpre values in regard to local recurrence, metastasis, and outcome (log-rank test P<0.0001 for all three). There were also significant differences in metastasis rates and outcomes between patients with higher and lower TNRpost values (log-rank test P=0.0105 and P=0.027, respectively). The Cox proportional hazards model revealed TNRpre to be a factor significantly influencing the risk of local recurrence (hazard ratio (HR) 29.0, P<0.001), risk of metastasis (HR 2.67, P=0.024), and the outcome (HR 6.3, P<0.001). MET-PET or MET-PET/CT is useful for predicting the outcomes of patients with head and neck mucosal malignant melanoma treated with CIRT.

Lack of correlation between microvascular density and pathological features and outcomes in sinonasal and oral mucosal melanomas

Unlike its cutaneous counterpart, prognostic markers for primary mucosal malignant melanoma have not been well elucidated. It has been recently demonstrated that microvascular density (MVD) in cutaneous malignant melanoma has a significant negative correlation with survival; however, this has not been well-studied in mucosal malignant melanoma of the head and neck. This study explores the potential association between MVD, various histological parameters, and the outcome of a series of sinonasal and oral mucosal melanomas. Nineteen such cases were immunostained with CD31 and the MVD was calculated by using Bioquant Image Analysis Software (R and M Biometrics, Nashville, TN). These cases included 16 sinonasal and 3 oral cavity tumors. The 1, 2, 3, 4 and 5 years overall survival rates were 75, 57, 61, 46 and 46%, respectively. The MVD of the tumors ranged from 25.7 to 732 vessels/mm(2) (mean 142.8 vessels/mm(2); median 84.7 vessels/mm(2)). There was no significant correlation between the MVD and the different clinicopathological features seen within the tumors. There was also no correlation between the MVD and relapse free and overall survival. The results of this study suggest that MVD does not correlate with outcome in mucosal melanoma of the head and neck as seen in cutaneous melanomas. Further larger studies are needed to identify predictive and prognostic markers in such melanomas.