Mucosal melanoma of the head and neck: 32-year experience in a tertiary referral hospital

Oral Melanoma in Older Adults: Epidemiology, Molecular Landscape, and Treatment Strategies

Oral melanoma is an aggressive neoplasm arising from melanocytes in the mucosal epithelium, accounting for 0.2%-0.8% of all melanomas. Unlike cutaneous melanoma, it is not associated with UV exposure, and its pathogenesis involves complex genetic and molecular alterations. This neoplasm predominantly affects older adults (≥ 60 years). Clinically, lesions often present as macular or nodular with an exophytic growth pattern, sometimes ulcerated, and exhibit varied pigmentation. Diagnosis is further complicated by non-pigmented (amelanotic) variants that can resemble other oral pigmentations. Wide surgical excision remains the mainstay treatment, often combined with chemotherapy; however, recurrence and distant metastasis remain high. While immunotherapy has shown promise in other melanoma subtypes, its efficacy in oral melanoma remains uncertain. Treatment in older adults is particularly challenging due to comorbidities and treatment-related morbidity. This review summarizes the epidemiology, clinical features, and current treatment strategies for oral melanoma in older adults. Key advances in the molecular mechanisms underlying this neoplasm are also outlined. As a strategic approach, integrating oral melanoma screening into routine geriatric dental care, supported by diagnostic algorithms, may improve early detection, prognosis, and survival outcomes in this vulnerable population.

Role of Postoperative Radiotherapy in the Management of Localized Head and Neck Mucosal Melanoma

BACKGROUND/OBJECTIVES

To evaluate the role of postoperative radiotherapy (PORT) in the management of localized head and neck mucosal melanoma (HNMM).

METHODS

We retrospectively reviewed 33 patients who underwent surgery for localized HNMM between 2006 and 2023. PORT was delivered to affected anatomical structures, and elective nodal irradiation was not performed. Treatment outcomes, including local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS), were analyzed.

RESULTS

After surgery, 14 patients (41.4%) received PORT. During follow-up, 87.9% of patients experienced recurrence, with local and distant failures being the most common. PORT significantly improved LRFS (p = 0.047) but did not impact PFS or OS. PORT (HR 0.14, p = 0.005) and resection margin status (HR 8.71, p < 0.001) were significantly associated with LRFS in multivariable analysis.

CONCLUSIONS

PORT for localized HNMM improved local control. Regional recurrence was rare (one patient, 3.4%) even though ENI was not performed. PORT without ENI could improve clinical outcomes for localized HNMM.

Primary Sinonasal Mucosal Melanoma: A Narrative Review

Mucosal melanomas (MMs) are under-researched tumors with a poor prognosis that arise from melanocytes found in the mucous membranes at different anatomical locations throughout the body. MMs are an uncommon yet highly aggressive tumor that typically develops on mucosal surfaces, predominantly in the head and neck region. MM of the head and neck occurs in 8-10% of all head and neck melanomas. It most commonly affects the mucosa of the nasal cavity and paranasal sinuses (75%), followed by the oral cavity mucosa (25%). A family history and the presence of mucosal nevi are associated with the occurrence of MM. Inhaled and dietary carcinogens are also linked to the development of sinonasal melanoma, much like other malignancies of the nasal cavity. Overexpression of the C-KIT gene is found in more than 80% of all primary mucosal melanomas, with somatic mutations in 10-30% of cases. The presence of these genetic alterations is also reflected in recent clinical studies of specific gene inhibitors that have proven efficiency in the systemic therapy of melanoma. There are various treatment modalities for MM. Surgical therapy involves en bloc surgical resection with a macroscopically visible and palpable mucosal margin of 1.5-2 cm. Partial resection of the maxilla may be considered if it ensures adequate tumor-free margine. Because of its rarity, outcome data for locally advanced head and neck MM is limited and primarily derived from retrospective studies with small case numbers. This review aims to update and summarize findings from clinical trials, prospective observational studies, and retrospective studies, while also exploring future directions for multimodal treatment approaches in this area.

Primary mucosal malignant melanoma (PMMM) of nasal cavity: A report of two cases

ABSTRACT

Primary mucosal malignant melanoma of the nasal cavity is a rare tumor with aggressive behavior and a dismal prognosis. An extremely rare tumor that accounts for 0.7% to 1% of all melanomas in Caucasian populations and between 4% and 8% of malignant tumors of the nasal cavity and paranasal sinuses. Taking into account the rarity, it is important to note that malignant melanoma should be considered when making a differential diagnosis of tumors of the nose and paranasal sinuses. Two cases of primary malignant melanoma of the nasal cavity both arising in females, one in a 60-year-old and the other in a 64-year-old, both of whom presented with nasal obstruction and brief symptomatic epistaxis are being presented here. The diagnosis being confirmed by a histopathological examination along with an immunohistochemical analysis by using S100 and HMB45.

A nomogram for predicting overall survival of patients with sinonasal melanoma: A population-based study

Objective

Sinonasal melanoma (SMM) is a rare but aggressive malignancy with 5-year overall survival (OS) rates below 40% in published studies. However, the clinicopathological predictors of the prognosis of SMM remain undefined. We aimed to establish a model to predict the survival outcomes of SMM.

Methods

We searched the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed with SMM between 1975 and 2016. Data on patient demographics, treatment modalities, and survival outcomes were retrieved. Risk factors for OS were evaluated by survival and Cox regression analyses. We also developed and validated a nomogram for OS, and compared its performance with that of conventional staging systems.

Results

Overall, 305 SMM patients were included in this population-based study. Multivariate Cox regression showed that primary site, American Joint Committee on Cancer stage, radiotherapy, and surgery were significant risk factors for survival. A nomogram was established using the regression model. The C-indices, areas under the receiver operating characteristic curves, calibration plots, and decision curve analysis demonstrated reliable performance of the nomogram.

Conclusion

The nomogram predicting survival outcomes of SMM patients based on clinical information showed good discriminative ability and prognostic accuracy compared with conventional stage classifications. Our nomogram could be used to predict the survival probabilities for SMM patients at different timepoints.

Level of Evidence

2b.

Primary mucosal melanoma of the larynx: systematic review of the literature and qualitative synthesis

PURPOSE

Primary mucosal melanoma of the larynx (PLM) is a rare entity among head and neck cancers. Due to its rarity, clear protocols of management are not available. A deeper knowledge of the clinical and biological behaviour of PLM is strongly needed.

METHODS

According to PRISMA process, we searched through electronic databases case reports, case series and review articles providing relevant clinical data. The survival analysis was performed with Kaplan-Meier survival curves, using disease free survival (DFS) and overall survival (OS) as endpoints.

RESULTS

1074 articles were initially screened, of which 37 studies describing 44 PLM cases were selected and included in the analysis. Mean age was 59.7 years with a mean follow-up time of 25.4 months. The most common symptom at presentation was hoarseness (52%), while the most involved laryngeal subsite was supraglottic region (62%). Most patients presented with an advanced stage. Tumour (T) and node (N) status at presentation did not influence OS nor DFS, whereas distant metastases (M) status resulted significantly associated with the reduction of OS and DFS time (Mantel-Cox: p < 0.0001 and p = 0.001, respectively). The laryngeal subsite and the type of surgery performed did not significantly impact on OS and DFS.

CONCLUSIONS

Treatment for PLM remains debated. Surgery with safe margins is recommended due to the high rates of local recurrence. Systemic therapy is advised for metastatic disease. However, the prognosis remains poor even after radical resection or targeted therapy.

Adjuvant Therapy and Prognosticators of Survival in Head and Neck Mucosal Melanoma

OBJECTIVES/HYPOTHESIS

To identify prognosticators and determine the efficacies of surgery with adjuvant radiotherapy (SR) and surgery with immunotherapy (SI) of head and neck mucosal melanoma (HNMM).

STUDY DESIGN

Retrospective database study.

METHODS

The 2004 to 2017 National Cancer Database was queried for HNMM patients. Cox proportional hazards and Kaplan-Meier analyses evaluated prognosticators of mortality and survival benefits conferred by SR, SI, or surgery with adjuvant radiotherapy and immunotherapy (SRI). Logistic regression identified predictors of adjuvant radiotherapy or immunotherapy use.

RESULTS

Overall, 1,910 cases (845 surgery, 802 SR, 51 SI, 101 SRI) were analyzed, with 50.3% females and an average age of 68.6 ± 13.8 years. SI was associated with greater overall survival (OS) than surgery (hazard ratio [HR] 0.672; P = .036). SI (HR 0.425; P = .024) and SRI (HR 0.594; P = .045) were associated with superior OS than SR. Older age (HR 1.607; P < .001), female sex (HR 0.757; P = .006), paranasal sinus localization (HR 1.648; P < .001), T4 classification (HR 1.443; P < .001), N1 classification (HR 2.310; P < .001), M1 classification (HR 3.357; P < .001), and positive surgical margins (HR 1.454; P < .001) were survival prognosticators. Adjuvant radiotherapy use was negatively correlated with older age, oral cavity localization, and M0 or T3 tumors (all P < .05). Adjuvant immunotherapy use was positively correlated with younger age and M1 tumors (all P < .05).

CONCLUSIONS

Although SR did not confer survival benefits in HNMM patients, SI and SRI yielded greater OS than surgery alone. SRI was associated with superior survival outcomes than SR. Certain demographic and clinical factors were associated with increased mortality risk. Patient age and certain tumor characteristics were predictors of adjuvant radiotherapy or immunotherapy use.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

A nomogram for predicting survival of head and neck mucosal melanoma

Objectives

We aimed to understand the clinical characteristics and better predict the prognosis of patients with mucosal melanoma of the head and neck (MMHN) using a nomogram.

Methods

Three hundred patients with nometastatic MMHN were included. Multivariable Cox regression was performed to analyze independent prognostic factors for overall survival (OS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRRFS), and these factors were used to develop a nomogram. Concordance indexes (C-indexes), calibration plots, and receiver operating characteristic (ROC) analysis were performed to test the predictive performance of the nomogram in both the primary (n = 300) and validation cohorts (n = 182).

Results

The primary tumor site, T stage and N stage were independent risk factors for survival and were included in the nomogram to predict the 3- and 5-year OS, DFS, DMFS, and LRRFS in the primary cohort. The C-indexes (both > 0.700), well-fit calibration plots, and area under the ROC curve (both > 0.700) indicated the high diagnostic accuracy of the nomogram, in both the primary and validation cohorts. The patients were divided into three groups (high-risk, intermediate-risk, and low-risk groups) according to their nomogram scores. The survival curves of OS, DFS, DMFS, and LRRFS were well separated by the risk groups in both cohorts (all P < 0.001).

Conclusions

The nomogram can stratify MMHN patients into clinically meaningful taxonomies to provide individualized treatment.

Hyperspectral imaging as a diagnostic tool to differentiate between amalgam tattoos and other dark pigmented intraoral lesions

The goal of this project is to identify any in-depth benefits and drawbacks in the diagnosis of amalgam tattoos and other pigmented intraoral lesions using hyperspectral imagery collected from amalgam tattoos, benign, and malignant melanocytic neoplasms. Software solutions capable of classifying pigmented lesions of the skin already exist, but conventional red, green and blue images may be reaching an upper limit in their performance. Emerging technologies, such as hyperspectral imaging (HSI) utilize more than a hundred, continuous data channels, while also collecting data in the infrared. A total of 18 paraffin-embedded human tissue specimens of dark pigmented intraoral lesions (including the lip) were analyzed using visible and near-infrared (VIS-NIR) hyperspectral imagery obtained from HE-stained histopathological slides. Transmittance data were collected between 450 and 900 nm using a snapshot camera mounted to a microscope with a halogen light source. VIS-NIR spectra collected from different specimens, such as melanocytic cells and other tissues (eg, epithelium), produced distinct and diagnostic spectra that were used to identify these materials in several regions of interest, making it possible to distinguish between intraoral amalgam tattoos (intramucosal metallic foreign bodies) and melanocytic lesions of the intraoral mucosa and the lip (each with P < .01 using the independent t test). HSI is presented as a diagnostic tool for the rapidly growing field of digital pathology. In this preliminary study, amalgam tattoos were reliably differentiated from melanocytic lesions of the oral cavity and the lip.

Head and neck mucosal melanoma: The United Kingdom national guidelines

The United Kingdom head and neck mucosal melanoma guideline development group used an evidence-based systematic approach to make recommendations in key areas of uncertainty in the field, including accurate diagnosis and staging; the appropriate treatment pathway including surgery, adjuvant radiation and new systemic treatments, such as targeted agents and immunotherapy; and the surveillance of patients after treatment. The guidelines were sent for international peer review and have been accredited by the National Institute for Health and Care Excellence. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website (https://melanomafocus.com/activities/mucosal-guidelines/mucosal-melanoma-resources/).

Nasal mucosal melanoma as a cause of epistaxis

A 43-year-old woman presented with an 8-week history of fatigue and recurrent right sided nasal bleeds progressing to significant pain and swelling on the right side of her face. Clinical examination revealed a friable mass in her right nasal passage. A biopsy and staging positron emission tomography-CT scan confirmed the diagnosis of a T4 N1 M1 BRAF wild type mucosal melanoma. The melanoma had metastasised to the right paranasal sinuses, right and left neck nodes, right submental node, right upper breast, liver, the subcutaneous fat of the left buttock and the right iliac bone as well as cerebral metastasis with further disease progression. Combination immunotherapy was started but initially suspended due to an adverse reaction to nivolumab and restarted in due course. Surgical debulking was carried out for symptomatic relief. This case report explores the delay in diagnosis of mucosal melanoma with its subsequent consequences and the lack of understanding of associated risk factors and optimal treatment.

[Nasal cavity mucosal melanoma with skin extension mimicking a malignant lentigo with mucosal extension]

Mucosal melanoma is a rare malignant disease developed from melanocyte. We report the case of a patient with nasal cavity mucosal melanoma with a primary clinical and histological diagnosis of malignant lentigo with mucosal spreading. The presence of a c-Kit mutation, in a second lecture and the evolving nature of the lesion, reorientated the diagnosis of malignant lentigo to mucosal melanoma with skin extension. Extensive surgical resection and foramen free flap with costal graft reconstruction may have a local control of the disease. Yet, after one year, a regional evolution involving a parapharyngeal node was treated by stereotaxic radiotherapy. After 5 years, the patient was considered in clinical and radiological remission. Malignant lentigo with mucosal extension is a very rare situation, this diagnoses must be evoqued after setting mucosal melanoma diagnosis.

Amalgam tattoo versus melanocytic neoplasm - Differential diagnosis of dark pigmented oral mucosa lesions using infrared spectroscopy

Background

Dark pigmented lesions of the oral mucosa can represent a major diagnostic challenge. A biopsy is usually required to determine the nature of such intraoral discolorations. This study investigates the potential use of infrared spectroscopy for differential diagnosis of amalgam tattoos versus benign or malignant melanocytic neoplasms.

Materials and methods

For this retrospective study, formalin-fixed paraffin-embedded tissue (FFPE) specimens of dark pigmented lesions concerning the oral mucosa or the lip were investigated using mid infrared spectroscopy. The samples were chosen from patients who had undergone a mucosal biopsy at the University Hospital Innsbruck (Austria) between the years 2000 and 2017. Principal component analysis was used for data exploration. Evaluation was based on the superimposition of the recorded spectra and the corresponding histologic slides.

Results

In total, 22 FFPE specimens were analyzed. Clear differences were found between amalgam and non-amalgam samples. A general weakening of the penetrating infrared radiation allowed for unspecific discrimination between these two classes. An overall accuracy in predicting the correct class of 95.24% was achieved.

Conclusion

Infrared spectroscopy appears to be a suitable technique to differentiate between amalgam tattoos and melanocytic lesions in FFPE samples. It could potentially be applied in vivo, too, serving as a non-invasive diagnostic tool for intraoral dark pigmented lesions.

Whole-exome sequencing of oral mucosal melanoma reveals mutational profile and therapeutic targets

Oral mucosal melanoma (OMM) is a rare and aggressive subtype of melanoma with little known about its pathogenesis or carcinogenesis. We therefore performed whole-exome sequencing (WES) on 19 matched OMM tumor/normal pairs in order to gain insight into potential genetic drivers of tumor formation. For the first time, we describe the comprehensive mutational profile of OMM. Our data suggest that the genetic background of OMM differs from those of other melanoma subtypes. We identified recurrent mutations involving KIT, POLE, PTPRD, PTCHD2, and DMXL2. Notably, copy number analysis revealed recurrently amplified regions of 12q14 (57.9%, containing CDK4) and 5p15 (47.4%, containing TERT). CNV analysis in a separate cohort of 15 samples validated the frequent CNV in CDK4 and TERT. We also observed that the melanocyte development and pigmentation signaling pathway is frequently altered in OMM. Furthermore, our data suggest several altered genes that may be amenable for targeted therapy. We identified one patient with metastatic OMM in our cohort who was identified to harbor a targetable KIT mutation using our WES results. This patient was able to achieve complete remission following implementation of KIT-targeted therapy. These findings provide further insight into the genetic underpinnings of OMM development and suggest that patients with OMM may benefit from WES analysis to identify potential targetable genetic mutations. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Failure patterns and prognostic factors of patients with primary mucosal melanoma of the nasal cavity and paranasal sinuses

OBJECTIVES

To analyse the failure patterns and prognostic factors influencing survival in patients with primary mucosal melanoma of the nasal cavity and paranasal sinuses.

MATERIALS AND METHODS

Fifty-one patients were analysed retrospectively. Forty-eight, 33, 10, and 13 patients underwent surgery, radiotherapy, chemotherapy, and immunotherapy, respectively. Failure events, including local recurrence, regional relapse, distant metastases, and death, were examined.

RESULTS

During follow-up (median: 59.0 months), 36 patients experienced failure after treatment, including local (n = 17), regional (n = 8), and distant organ (n = 23) metastases. The median failure times for local, regional, and distant metastases were 13.0, 14.0, and 8.0 months, respectively. The median survival times from local, regional, and distant failure to death were 10.5, 8.0, and 4.0 months, respectively. The 5-year overall survival rates of patients with and without distant organ metastases were 14.4% and 72.6%, respectively (p < .001). Multivariate analyses showed that radiotherapy increased local recurrence-free and regional relapse-free survival. Patients with stage IV tumours had reduced distant metastasis-free and overall survival compared to patients with stage I-III tumours.

CONCLUSIONS

Distant metastasis was mainly owing to failure. Radiotherapy and the disease stage were prognostic factors for survival.

Clinical Patterns of Melanoma in Asians: 11-Year Experience in a Tertiary Referral Center

BACKGROUND

Malignant melanoma is a relatively common malignancy in the West, but has a significantly lower incidence in Asians. Stark contrast in clinicopathological characteristics and prognosis has been observed between the 2 populations, yet data are limited. Here, we evaluate 106 Asian patients from a tertiary referral center in Hong Kong during an 11-year period. The purpose of this study was to collectively review all types of melanomas to analyze the clinicopathological characteristics of this poorly understood condition in an Asian population.

METHODS

A total of 106 patients diagnosed with malignant melanoma from 2002 to 2012 were retrospectively reviewed. Demographics, clinical presentations, pathological subtypes, treatments, and survival outcomes were evaluated.

RESULTS

Cutaneous melanomas dominated with 46 (43.4%) cases, followed by mucosal (39.6%), ocular (9.4%), and melanomas of unknown primary (7.5%); 43.3% patients presented in stage I, 36.7% in stage II, 18.9% in stage III, and 1.1% in stage IV. Acral lentiginous melanoma was the commonest subtype of cutaneous melanomas (60.9%). When types of melanomas were reviewed collectively, the median overall survival, disease-specific survival, and recurrence-free survival were 37, 45, and 48 months, respectively. Cutaneous melanoma had the best median overall survival of 59 months, followed by ocular melanoma (58 months), mucosal melanoma (18 months), and melanoma of unknown primary (2 months). Similar patterns were observed for disease-specific survival and recurrence-free survival.

CONCLUSIONS

Melanoma among Asians remains poorly understood. There is a clear distinction in the clinical patterns between Asians and whites and the difference is not solely accounted for by the lower incidence of cutaneous melanoma. Certain subtypes, such as mucosal melanoma and is acral lentiginous melanoma, seemed to have disproportionately high incidences. Further studies are warranted to elucidate these observations. The poor survival outcomes reflected the need for better awareness and understanding of the condition by both the general public and the physicians.

The Utility of Sentinel Node Biopsy for Sinonasal Melanoma

Objective  Report two positive sentinel node biopsies for sinonasal melanoma. Design  Retrospective review. Setting  Academic tertiary care center. Participants  Patients who underwent sentinel node biopsy for sinonasal melanoma between November 1, 2014 and November 1, 2015. Main Outcome Measures  Clinical course. Results  Two patients were identified. Patient 1 (83M) presented with a sinonasal melanoma anterior to the left inferior turbinate and was clinically N0 neck. Lymphoscintigraphy revealed two sentinel nodes in the ipsilateral and three in the contralateral cervical basins. The left level I sentinel node was positive for melanoma and lymphadenectomy showed no additional metastases. Patient 2 (71F) presented after incomplete resection of a sinonasal melanoma of the left posterior maxillary sinus wall and was clinically N0 neck. Lymphoscintigraphy with single-photon emission computed tomography (SPECT/CT) localization revealed one sentinel node in the parapharyngeal space and another in the ipsilateral cervical basin. Metastatic melanoma was found in both nodes and completion lymphadenectomy was negative for additional disease. Both patients developed distant metastasis in less than 1 year after surgical resection but responded well to adjuvant immunomodulatory chemotherapeutic agents. Conclusion  Sentinel node biopsy for sinonasal melanoma can provide crucial clinical evidence of regional metastasis prior to overt clinical signs and symptoms. This intraoperative tool has the potential to improve detection of regional metastasis and improve long-term outcomes of this aggressive malignancy.

Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Mucosal Melanomas

The updated edition of The World Health Organization Classification of Tumours of the Head and Neck includes discussions on mucosal melanoma of both the sinonasal and oral cavity. Since the prior edition, sinonasal origin is now recognized as the most common site of occurrence of mucosal melanoma in the head and neck (66%) with oral cavity representing 25% of cases. Histologic features of mucosal melanomas vary widely from spindled, epithelioid, and pleomorphic to rhabdoid, plasmacytoid and undifferentiated. Additionally, mucosal melanomas are commonly amelanotic (or minimal pigmentation) (~50%) leading to overlapping features and diagnostic challenges in differentiating mucosal melanomas from other small cell/undifferentiated sinonasal tumors. Since the last edition, formal staging of head and neck mucosal melanomas was added to the American Joint Committee on Cancer entities, though the traditional histologic features that have prognostic significance in cutaneous melanomas fail to stratify mucosal melanomas (i.e. tumor thickness, ulceration). Interestingly, while melanomas of all sites are a malignancy derived from melanocytes, mucosal melanomas are now recognized to have distinct molecular alterations compared to cutaneous or uveal melanomas. BRAF V600E mutations are rare (<6%) in mucosally derived melanomas compared to a rate of 50% in cutaneous melanomas. CD117 (C-Kit) mutations are the most common alteration encountered (~25%) in mucosal sites with potential therapeutic targetability. The recognition of the distinct genetic changes in this subgroup of melanomas means that therapy advances in cutaneous melanomas may not translate to head and neck mucosal melanomas and clinical trials specific to this subgroup of patients are needed.

The presentation and outcomes of mucosal melanoma in 695 patients

BACKGROUND

Most data on sinonasal mucosal melanoma come from small institutional studies, and therefore optimal treatment methods are not well understood. The purpose of this study was to analyze the association between treatment and survival in sinonasal mucosal melanoma.

METHODS

Six hundred ninety-five patients diagnosed with sinonasal mucosal melanoma between 2004 and 2010 were identified from the National Cancer Data Base. Treatment modalities and overall survival rates were determined.

RESULTS

The 5-year overall survival was 21.7%, with a mean survival of 38.4 ± 1.7 months. The majority of patients were treated with surgery alone (31.5%) or surgery with adjuvant radiotherapy (41.4%). There was no statistical difference between survival with surgery alone and surgery with adjuvant radiation therapy (25.1% vs 25.1%, p = 0.93). Between the surgery and surgery-with-adjuvant-therapy groups, there was no difference in the number of patients with positive margins (p = 0.54), regional lymph node metastases at diagnosis (p = 0.55), morbidity scores (p = 0.58), insurance status (p = 0.13), age > 60 years (p = 0.24), or treatment at academic centers (p = 0.12).

CONCLUSIONS

Based on this large review of patients with sinonasal mucosal melanoma, adjuvant radiation therapy may not provide a survival benefit as patients tended to do poorly regardless of adjuvant radiation status.

The Prognostic Role of the Surgical Approach and Adjuvant Therapy in Operable Mucosal Melanoma of the Head and Neck

Objectives

The aim of this study was to investigate the prognostic impact of the surgical approach and adjuvant treatment in operable malignant melanoma of head and neck (MMHN).

Methods

Retrospective reviews of 31 patients who underwent surgery-based treatment with curative intent, either by the endoscopic or external approach, for MMHN were performed to analyze recurrence patterns, salvage modalities, and oncological outcomes (disease-specific survival and disease-free survival).

Results

Overall recurrence rate was 61% (19/31). In stage III patients (n=24), 50% (12/24) developed recurrences with a median recurrence-free period of 6.0 months, and 30% (4/12) of them was successfully salvaged by reoperation with adjuvant radiotherapy. On the contrary, all stage IVA patients (n=7) developed recurrences with a median recurrence-free period of 4.4 months. Distant metastasis was the most common pattern of failure and no patients were salvaged. Among variables, age and T classification, not the surgical approach, were significant prognosticators for disease-free survival and disease-specific survival. Adjuvant radiotherapy was associated with a lower rate of local failure, compared to surgery alone (hazard ratio, 0.02; 95% confidence interval, 0.06 to 0.75; P=0.02). However, adjuvant systemic therapy was not effective in reducing the risk of failures for any pattern.

Conclusion

Our data suggested that meticulous surgical resection, either by the endoscopic or external approach, with adjuvant radiotherapy increases the local control rate in MMHN.

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.

Sinonasal mucosal melanoma: A 12-year experience of 58 cases

BACKGROUND

Sinonasal mucosal melanoma is a rare malignancy with poor prognosis.

METHODS

Patients with sinonasal malignant melanoma who underwent surgery by different approaches were included in this study. Overall survival (OS) and event-free survival were calculated, and statistically significant variables by univariate analysis were entered in a multivariate Cox regression model.

RESULTS

Pathological staging was pT3, pT4a, and pT4b in 30 cases (51.7%), 17 cases (29.3%), and 11 cases (19.0%). At 3 and 5 years, OS was 43.5% and 29% and event-free survival was 23.6% and 12.4%, respectively. At univariate analysis, OS was significantly influenced by male sex, advanced pT classification, positive margins, and surgical approach; event-free survival was affected by positive margins. At multivariate analysis, the risk of death was independently associated with male sex (hazard ratio [HR] = 2.27; p = .04) and positive margins (HR = 2.32; p = .03).

CONCLUSION

Male sex and positive margins were negative prognostic factors. Endoscopic resection did not show an increased risk of death compared with more extensive surgical approaches. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1737-E1745, 2016.

Primary malignant mucosal melanoma of the upper lip: a case report and review of the literature

Background

Malignant melanoma of oral cavity is a rare condition, accounting for 0.5 % of all oral malignancies and about 1–2 % of all melanomas. Oral melanomas have extremely poor prognosis with 5 years survival rate of 12.3 %. The poor prognosis compared to cutaneous melanoma may be attributed to delay in reporting by patient and diagnosis, and apt to become ulcerated due to repeated trauma. The ‘chameleonic’ presentation of a mainly asymptomatic condition, the rarity of these lesions, the poor prognosis and the necessity of a highly specialized treatment are factors that should be seriously considered by the involved health provider.

Case presentation

We present a case of 32 years old male of Han ethnicity with mucosal melanoma of upper lip, comparing his clinical presentation and histological findings at his first visit and following the recurrence. The patient complained of black discoloration on the left side of upper lip since 4 years which gradually increased in size and later involved the skin of the lip. Excision with 5 mm safety margin was performed but the patient presented with the similar lesion after three and half years of the treatment. So, again wide excision with 2 cm safety margin was performed followed by reconstruction of the lip.

Conclusion

This case provides an example of aggressive behavior of mucosal melanoma and emphasizes on the fact that any pigmented lesion detected in the oral cavity may exhibit potential growth and should be submitted to biopsy to exclude malignancy. It also exemplifies of how the time of diagnosis and the evolution of a disease could be seriously influenced by patient’s behavior.

Mucosal melanoma of the head and neck: recurrence characteristics and survival outcomes

OBJECTIVE

The aim of this study was to review oncologic outcomes and recurrence characteristics of head and neck mucosal melanomas (HNMMs) managed at a tertiary referral center.

STUDY DESIGN

Clinical records of 10 patients who were managed for HNMMs between 2001 and 2013 were retrospectively analyzed.

RESULTS

The median age was 66 years (range 28-76 years) and male/female (M/F) ratio was 1:5. The 3-year disease-free survival (DFS) rates and overall survival (OS) rates were 11.7% and 35%, respectively; and the 5-year DFS rates and OS rates 11.7% and 23.3%, respectively. The median DFS and OS periods were 12 months (range 2-36 months) and 17 months (range 7-96 months), respectively. The rates of development of local, regional, and systemic recurrences were 20%, 50%, and 80%, respectively. Lungs were involved in all patients who had distant metastasis.

CONCLUSIONS

This study shows that HNMMs has a very aggressive course and that distant metastases are common. For this reason, systemic control of the disease is an important aim of treatment.

Treatment outcomes of sinonasal malignant melanoma: a Korean multicenter study

BACKGROUND

The aim of this work was to evaluate factors that influence local recurrence and survival after surgical resection of sinonasal malignant melanoma, using a large population-based multicenter study in Korea.

METHODS

Retrospective analysis was performed for 155 newly diagnosed sinonasal malignant melanoma patients gathered from 15 university hospitals throughout Korea. Demographic data, tumor characteristics, surgical approach, adjuvant treatment, recurrence, and outcomes were analyzed.

RESULTS

Three-year and 5-year overall survival rates were 48.8% and 40.1%, respectively. Local recurrence rate was 46.6%, with a mean recurrence time of 15.5 months. On multivariate analysis, patients who underwent surgery that included an endoscopic approach showed decreased local recurrence rate (p = 0.042) and increased survival rate (hazard ratio [HR], 1.702; 95% confidence interval [CI], 1.007 to 2.875; p = 0.047) compared to those who underwent an external approach. Patients with postoperative radiotherapy showed a decreased local recurrence rate (p = 0.001), but without impact on survival rate. Male gender, tumor beyond the nasal cavity, and presence of distant metastasis were associated with poor survival.

CONCLUSION

An endoscopic-including surgical approach was associated with improved local control and survival in sinonasal malignant melanoma patients. Postoperative radiotherapy helped increase the local control rate.

Primary Malignant Melanoma of the Lip: A Report of 48 Cases

PURPOSE

Lip melanoma (LM) is a rare malignant tumor and well-established treatment protocols for it are in short supply. The objective of this study was to evaluate the outcome of treatment modalities and explore the prognostic factors.

PATIENTS AND METHODS

A retrospective chart review was performed on 48 patients with primary LM treated in the authors' hospital from January 1992 to November 2013. The clinical characteristics and treatment modalities were identified and correlated with the outcomes.

RESULTS

The 5-year overall survival (OS) rate was 56.1%, and the rate of cervical lymph node (CLN) metastasis was 46% (22 of 48). A tumor of at least 4 cm (P = .001), nodular types (P = .003), and CLN (P < .0001) were independent prognostic factors for OS. Twenty-five patients died during follow-up, mainly from to neck recurrence (14 of 25). Chemotherapy significantly improved the 5-year OS rate in patients with stage IV LM (P = .03), but not in those with stage III (P = .8).

CONCLUSIONS

LM has a lower CLN and distant metastasis rate and a better prognosis than other oral mucosal melanomas. A long history of melanin pigmentation is a dangerous sign for all patients, and smoking seems to be associated with LM in male patients. Tumor size (≥4 cm), nodular type, and CLN positivity are poor prognostic factors. A wide excision with close observation is advocated as the primary treatment for stage III LM. Adjuvant chemotherapy is useful for patients with stage IV cancer, but not for those with stage III.

The role of radiation therapy in melanoma

Although melanoma was historically thought to be radiation resistant, there are limited data to support the use of adjuvant radiation therapy for certain situations at increased risk for locoregional recurrence. High-risk primary tumor features include thickness, ulceration, certain anatomic locations, satellitosis, desmoplastic/neurotropic features, and head and neck mucosal and anorectal melanoma. Lentigo maligna can be effectively treated with either adjuvant or definitive radiation therapy. Some retrospective and prospective randomized studies support the use of adjuvant radiation to improve regional control after lymph node dissection for high-risk nodal metastatic disease. Consensus on the optimal radiation doses and fractionation is lacking.

Mucosal melanoma of the nasal cavity and paranasal sinuses

Mucosal melanoma of the nasal cavity and paranasal sinuses is a rare disease, but its incidence appears to be increasing. The mean age at diagnosis is between 65 and 70 years. Unilateral nasal obstruction and epistaxis are the most common presenting complaints. Melanoma arises in the septum or lateral wall of the nasal cavity in the great majority of cases. The histological diagnosis is based on specific immunohistochemical labelling and is usually established at an advanced stage of disease: stage T3 or T4 tumours according to the 7th edition of the American Joint Committee on Cancer (AJCC) classification of tumours. First-line treatment consists of surgery. The place of intranasal endoscopic surgery remains controversial due to the difficulty of controlling surgical margins and should be reserved for experienced teams. Adjuvant radiotherapy is usually performed due to its efficacy on local and regional disease control. Five-year overall survival of mucosal melanoma of the nasal cavity and paranasal sinuses in the most recent series does not exceed 40%. Local recurrence is observed in about 50% of cases and metastatic disease is common. The quality of initial tumour resection with negative surgical margins is the most important prognostic factor for tumours confined to the nasal cavity. Hopes for improvement of survival are based on early diagnosis, progress in radiotherapy techniques and cell and gene therapy that are currently under evaluation.

Targeted local simultaneous iontophoresis of chemotherapeutics for topical therapy of head and neck cancers

The objective was to investigate the feasibility of using buccal iontophoresis for the simultaneous delivery of chemotherapeutic agents with a view to developing a new approach to treat head and neck cancers. Short duration cathodal iontophoresis of 5-fluorouracil (5-FU; 20mM) and leucovorin (LV; 10 mM) at 1 mA/cm(2) for 10 or 20 min from aqueous solution and a 2% hydroxyethyl cellulose gel at pH 7.6 was evaluated using bovine mucosa in vitro. Iontophoresis resulted in a statistically significant increase in the mucosal deposition of both drugs as compared to passive diffusion (Student's t-test, α=0.05); in each case, drug delivery was selective for deposition with no permeation being observed. After 20 min of iontophoresis, there was an ~ 8-fold enhancement for 5-FU (1.46 ± 0.86 and 11.93 ± 3.81 μg/cm(2), respectively) and a 3-fold increase for LV (8.31 ± 2.44 and 25.08 ± 6.89 μg/cm(2), respectively) when using aqueous solutions. The same trend was observed when the gel was applied for 10 min; passive delivery of 5-FU from the gel resulted in non-detectable levels in the mucosa, while 4.62 ± 1.76 μg/cm(2) were deposited in the mucosa following iontophoresis. Similarly, iontophoretic delivery of LV from the gel resulted in ~ 3-fold higher deposition as compared to passive diffusion (6.71 ± 1.36 and 21.12 ± 9.94 μg/cm(2), respectively). No drug permeation was observed in either case. In conclusion, iontophoresis can be used for targeted topical delivery of chemotherapeutics to the buccal mucosa and may enable less invasive local therapy of head and neck cancers.

Pigmented lesions of the oral cavity: an update

Oral pigmentation may be focal, multifocal, or diffuse. The lesions may be blue, purple, brown, gray, or black. They may be macular or tumefactive. Some are localized harmless accumulations of melanin, hemosiderin, or exogenous metal; others are harbingers of systemic or genetic disease; and some can be associated with life-threatening medical conditions that require immediate intervention. The differential diagnosis for any pigmented lesion is extensive, and can include examples of endogenous and exogenous pigmentation. Although biopsy is a helpful and necessary aid in the diagnosis of focally pigmented lesions, with diffuse presentations lesions require a thorough history and laboratory studies to establish a definitive diagnosis.