Single-center retrospective series of fourteen patients with mucosal melanoma of the nasal cavity and paranasal sinuses

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.

Sinonasal Mucosal Melanoma: An Update and Review of the Literature

ABSTRACT

Primary sinonasal mucosal melanoma (SNMM) is an aggressive tumor with high metastatic potential and poor outcomes. Presenting symptoms are nonspecific, and the nasal cavity is the most common site of origin followed by the maxillary and ethmoid sinuses. Histopathologically, SNMMs are pleomorphic and predominantly composed of epithelioid cell type. Identifying these tumors requires a high index of suspicion for melanoma and the use of a panel of immunohistochemical markers when typical histopathological features are missing. Not infrequently, these tumors are undifferentiated and/or amelanotic. Currently, SNMM falls into 2 different staging systems proposed by the American Joint Committee on Cancer, one for carcinoma of the nasal cavity and sinuses and the other for head and neck melanoma. Although therapeutic standards do not exist, surgical resection with adjuvant radiotherapy and/or systemic therapy may offer the best outcome. Lymphadenectomy including possible parotidectomy and neck dissection should be considered in patients with regional lymph node metastasis. However, the role of elective lymph node dissection is controversial. Genetic profiling has identified a number of recurrent gene mutations that may prove useful in providing targets for novel, emerging biological treatments. In this article, we provide an update on clinicopathological features, staging, molecular discoveries, and treatment options for SNMM.

What is the role of the surgeon in the management of head and neck mucosal melanoma in the immunotherapy era?

INTRODUCTION

The advent of immunotherapy has impacted both the management and, to a lesser extent, the outcomes for patients with head and neck mucosal melanoma. As a consequence, one might expect that the role of the surgeon would be limited to the diagnostic work-up and that systemic therapies would be the mainstay of treatment.

METHODS AND RESULTS

Here, we present the surgical aspects of the recently published United Kingdom Head and Neck Mucosal Melanoma Guideline to highlight the continued role of surgeons in the management of this disease. We highlight key areas where surgeons remain the lead clinician and reinforce the multidisciplinary requirement for exemplary patient care.

CONCLUSIONS

Despite the advent of immunotherapy, surgeons continue to have a key role to play in this disease. When indicated, it is essential that appropriate surgery is offered by a suitably experienced team.

Survival benefits from concomitant chemoradiotherapy before radical surgery in stage IVA sinonasal mucosal melanoma?

BACKGROUND

The aim of the study was to review a local treatment protocol for sinonasal mucosal melanoma (SNMM) focusing on triple modality treatment (TMT), that is, neoadjuvant concomitant chemoradiotherapy (CRT) and surgery.

METHODS

In a retrospective design, data on clinical presentation, treatment, and survival were retrieved for 22 consecutive patients from a tertiary referral center.

RESULTS

The mean overall survival (OS) for all patients (3 stage III, 16 stage IVA, and 3 stage IVB) was 62 months, and the 5-year OS rate 50%. Four of the 22 patients received treatment with palliative intention. Of the 18 patients who received treatment with curative intention, patients with stage IVA disease who received TMT (n = 10) had a 5-year OS of 70% and 10-year OS of 20%. The median disease-free survival for these patients was 51 months compared with 9 months for stage IVA not receiving TMT (n = 4).

CONCLUSION

A seemingly favorable survival outcome for a disease with characteristically poor prognosis was observed. The lead finding was a high survival rate (70% 5-year OS) for stage IVA patients who received neoadjuvant TMT. The observations suggest the possibility that patients with advanced SNMM (stage IVA) might benefit from concomitant CRT before surgery by delaying the onset of local recurrences and distant metastases.

LEVEL OF EVIDENCE

Level 4, case series (with or without comparison).

Sinonasal melanoma: a systematic review of the prognostic factors

The objective was to evaluate the available published data on sinonasal melanoma and analyse its clinical features, treatment modalities, and prognostic factors. An electronic search was undertaken in March 2018 in multiple databases. Eligibility criteria included publications with sufficient clinical, histological, and immunohistochemical information to confirm the diagnosis. Seventy-three publications (439 cases) were included. The lesion was more prevalent in females than in males. There was a higher prevalence in the seventh and eighth decades of life. The lesions mainly presented as epistaxis and commonly involved the nasal cavity. Age (>67.6 years; P=0.0012), primary location (middle turbinate; P=0.0112), disease stage (advanced disease stage; P=0.0026), treatment (radiotherapy; P=0.0111), recurrence (recurrence presented; P=0.0137), and distant metastasis (distant metastasis presented; P=0.0011) were independently associated with a lower survival rate. Recurrence was significantly correlated with age (>67.6 years; P=0.0021), sex (males tended to present a higher recurrence rate than females; P=0.0051), disease stage (stages III and IV presented a higher recurrence rate than stages I and II; P=0.0331), and histological type (amelanotic lesions presented a higher index of recurrence than melanotic lesions; P=0.0095). In conclusion, sinonasal melanoma is a neoplasm with a poor prognosis, presenting a 30.69% possibility of survival after 5 years.

Recurrent amelanotic melanoma of nasal cavity: Biological variability and unpredictable behavior of mucosal melanoma. A case report

The aim of this report is to present a case of a patient with a recurrent nasal cavity amelanotic melanoma (AM), with emphasis on diagnosis and therapy options of this clinical entity. A 65-year-old female patient presented with pain in the right cheek region and nasal obstruction. In 2013, she was diagnosed with mucosal melanoma (MM) of the left nasal cavity. After endoscopic surgery and radiotherapy, the patient was followed by the oncology team. Five years after the initial diagnosis, rhinoscopy showed a tumorous formation in the right nasal cavity. The tumor mass was without black discoloration and was the same color as the surrounding nasal mucosa. Microscopic examination after biopsy of the tumor confirmed amelanotic MM. The patient underwent an additional endoscopic surgery. A complete standard diagnostic workup for MM found metastases in head and neck lymph nodes, on both sides. MMs of head and neck are uncommon malignancies. Unique biology of MM cells causes a high rate of recurrences. This report presents an example of recurrent AM of the nasal cavity, in treatment with checkpoint inhibitor (pembrolizumab), which could provide a good therapy option for patients with MM.

Surgery alone versus post-operative radiotherapy for sinonasal malignant melanoma: a meta-analysis

OBJECTIVE

Sinonasal malignant melanoma is a relatively rare malignancy with poor prognosis, and effective treatments remain elusive. This analysis aimed to explore whether post-operative radiotherapy conferred any survival advantages in patients with this disease when compared with surgery alone.

METHODS

Published studies were identified by searching four electronic databases. The endpoints evaluated were: rates of overall survival, disease-free survival and local control.

RESULTS

Twenty-eight studies including 1392 patients were identified. The results indicated that post-operative radiotherapy led to a significantly better three-year overall survival rate (p = 0.02), and suggested a borderline significant benefit for five-year overall survival (p = 0.05), when compared with surgery alone. However, no statistical advantage was found for disease-free survival, local control or one-year overall survival.

CONCLUSION

This meta-analysis indicated that adjuvant radiotherapy prolonged survival, but showed no benefit for disease-free survival or local control.

Radiotherapy alone as a method of treatment for sinonasal mucosal melanoma: A report based on six cases and a review of current opinion

Objectives

Radiotherapy in patients with sinonasal mucosal melanoma (SNMM) was given as alternative treatment to surgery in cases with advanced, inoperable tumors or those not eligible for surgery. We presented the outcomes for patients with SNMM treated with radiotherapy alone.

Material and methods

The retrospective review of 6 consecutive SNMM (nasal cavity - 4 pts. and paranasal sinus - 2 pts.) patients (3 males and 3 females at mean age 64 years) treated between 2008 and 2016 was presented. The stage of disease was: T3 (1 pt.), T4a (3 pts.), T4b (2 pts.); with N0 and M0 in all patients. All patients underwent definitive primary photon radiotherapy (IMRT) alone; dose 66-72 Gy was delivered in 22-24 fractions given in 5 fractions (3 Gy) a week.

Results

The complete remission was observed in all our patients but only one patient survived 5 years without disease. Five patients died due to multiple distant metastases; two of those patients developed associated local recurrence 7-8 months after radiotherapy.

Conclusion

SNMM has a poor prognosis due to its high metastatic potential. Based on our numerically small report and data from literature we concluded that primary radiotherapy alone assured complete remission and even 5-year disease-free survival in only a few individual patients.