A first reported case of metastatic anorectal amelanotic melanoma with a marked response to anti-PD-1 antibody nivolumab: A case report

Anorectal Melanoma: A Rare Cause of Large Bowel Obstruction

Anorectal melanoma is a rare and aggressive malignancy with a challenging diagnosis and management. We present the case of a 69-year-old male with a history of chronic constipation and recent weight loss, who presented with symptoms suggestive of anorectal pathology. Despite initial diagnostic challenges, including an unsuccessful colonoscopy due to inadequate bowel preparation, the subsequent radiographic evaluation revealed a large bowel obstruction secondary to a protruding anorectal mass. Abdominal X-ray demonstrated significant colonic dilation while contrast-enhanced CT scan revealed a large hypodense mass protruding from the anal canal. Surgical intervention led to the excision of the mass, and histopathological examination confirmed malignant melanoma. Immunohistochemistry markers, including HMB 45, Melan A, and S100, supported the diagnosis. This case underscores the importance of considering anorectal melanoma in patients presenting with atypical anorectal symptoms, despite its rarity. Early recognition and intervention, supported by appropriate imaging modalities, are critical for optimizing patient outcomes in such cases.

Inhibition of myeloid PD-L1 suppresses osteoclastogenesis and cancer bone metastasis

Programmed death-ligand 1 (PD-L1) is predominantly expressed in the antigen-presenting cells (APCs) that are originated and are abundant in the bone marrow. The roles of PD-L1 in bone cell differentiation and cancer bone metastasis remain unclear. Here we show that PD-L1 antibody or PD-L1 conditional knockout in the hematopoietic or myeloid lineage suppresses osteoclast differentiation in vitro and in vivo. Bone metastases of breast cancer and melanoma are diminished by PD-L1 antibody or PD-L1 deletion in the myeloid lineage. Transcriptional profiling of bone marrow cells reveals that PD-L1 deletion in the myeloid cells upregulates immune-stimulatory genes, leading to increased macrophage M1 polarization, decreased M2 polarization, enhanced IFNγ signaling, and elevated T cell recruitment and activation. All these alterations result in heightened anti-tumor immunity in the cancer microenvironment. Our findings support PD-L1 antibody as a potent therapy for bone metastasis of breast cancer and melanoma by simultaneously suppressing osteoclast and enhancing immunity.

Oral malignant melanoma with gastric metastasis and hemorrhage: A case report

BACKGROUND

Although the gastrointestinal tract is a relatively common site of melanoma metastases, reports of digestive tract hemorrhage caused by melanoma are very rare. The metastatic route is still unclear, though it is considered as implant metastasis in oral malignant melanoma.

CASE SUMMARY

We report the case of an 88-year-old man who was admitted to our hospital with hematemesis and melena. By endoscopic inspection, he was diagnosed with active hemorrhage caused by primary gastric cancer or gastric stromal tumor. Eventually, he underwent surgical resection treatment and was discharged. At the outpatient review 3 wk postoperatively, it was noted that an oral melanoma which had been overlooked preoperatively had enlarged several times and was eventually considered to be the primary focus of the gastrointestinal melanoma. The patient passed away at home after 1 mo.

CONCLUSION

In the present case, an oral cavity mass was found but not further identified, which caused misdiagnosis. The possibility of malignant melanoma should be considered when encountering a gastrointestinal mass, especially when combined with mucocutaneous melanoma. In patients who have pure cutaneous melanoma, attention should also be paid to their gastrointestinal symptoms, with regular gastrointestinal endoscopy or systemic examination performed.

Trends in the management of anorectal melanoma: A multi-institutional retrospective study and review of the world literature

BACKGROUND

Anorectal melanoma (ARM) is a rare disease with a poor prognosis. Evidence on optimal treatment is limited and surgical management varies widely. We hypothesized that the frequency of abdominoperineal resection used as primary treatment of ARM has decreased over the past several decades.

AIM

To update our understanding of outcomes for patients with ARM and analyze management trends around the world.

METHODS

This is a multi-institutional, retrospective study of patients treated for ARM at 7 hospitals. Hospitals included both large, academic, tertiary care centers and smaller, general community hospitals. Using prospectively maintained institutional tumor registries, we identified 24 patients diagnosed with ARM between January 2000 and May 2019. We analyzed factors prognostic for recurrence and survival. We then used Cox regression to measure overall survival (OS) and melanoma-specific survival. We also performed a literature review to assess trends in surgical management and outcomes.

RESULTS

Of the 24 patients diagnosed with ARM, 12 (50.0%) had local, 8 (33.3%) regional, and 4 (16.7%) distant disease at diagnosis. Median time to recurrence was 10.4 mo [interquartile range (IQR) 7.5-17.2] with only 2 patients (9.3%) not developing recurrence following surgical resection. Median OS was 18.8 mo (IQR 13.5-33.9). One patient is still alive without recurrence at 21.4 mo from diagnosis; no other patient survived 5 years. Primary surgical management with abdominoperineal resection (APR) vs wide excision (WE) did not lead to differences in OS [hazard ratio = 1.4 (95%CI: 0.3-6.8)]. Review of the literature revealed geographic differences in surgical management of ARM, with increased use of WE in the United States and Europe over time and more frequent use of APR in Asia and India. There was no significant improvement in survival over time.

CONCLUSION

There is wide variation in the management of ARM and survival outcomes remain poor regardless of approach. Surgical management should aim to minimize morbidity.

Efficacy and prognosis of surgical treatment in ARMM and its effects on immune and inflammatory profiles

The aim of the present study was to investigate the efficacy and prognosis of surgical treatment in anorectal malignant melanoma (ARMM) as well as its effects on immune and inflammatory profiles. A total of 64 patients with ARMM were enrolled and divided into control group (n=32) and observation group (n=32) based on different therapeutic methods. Patients in the observation group underwent wide local excision, while those in the control group were given non-surgical treatment. The immune function was compared between the two groups after treatment. The expression levels of serum IL-17, IL-23 and vascular endothelial growth factor (VEGF) were compared between the groups before and after treatment. Patients were followed up for 5 years to observe the recurrence and survival rates in the two groups. Compared with those in the control group, the levels of cluster of differentiation (CD)3⁺, CD4⁺ and CD4⁺/CD8⁺ were increased, while the level of CD8⁺ was reduced in the observation group (P<0.05). The levels of serum IL-17, IL-23 and VEGF were significantly lower in both groups at 4, 6 and 8 weeks after treatment than those before treatment, and the decrease was more obvious in the observation group (P<0.05). The observation group exhibited a notably elevated 5-year survival rate and a remarkably decreased recurrence rate in comparison with the control group (P<0.05). For ARMM, surgical treatment is more effective than non-surgical treatment, which has less effect on immune function, is able to reduce serum IL-17, IL-23 and VEGF levels, lower recurrence rate, improve patient survival rate, and plays a certain positive role in prolonging the survival time of ARMM patients.

Primary Rectal Amelanotic Malignant Melanoma: A Rare Case Report

Malignant melanoma of the rectum comprises 0.5%-4% of all anorectal cancers. Malignant melanoma of the rectum is exceptionally a rare disease. It commonly affects the fifth or sixth decade, with nonspecific symptoms such as rectal bleeding or anal pain. After skin and retina, anorectum is the third common site for malignant melanoma. Proper diagnosis is difficult in the majority of cases due to lack of pigmentation and amelanotic histological appearance. Prognosis is very poor with a median survival of 24 months and five-year survival of 10%-15%. Anorectal malignant melanomas disseminate along the submucosal planes, therefore complete resection at the time of diagnosis is usually not possible.

Endoscopic diagnosis of gastrointestinal melanoma

Background: Gastrointestinal (GI) melanoma can be diagnosed by endoscopy combined with biopsy and subsequent pathological examination. However, the disease may be misdiagnosed due to the limited awareness of GI melanoma.Objective: We aimed to describe characteristics of GI melanoma that can be detected by endoscopy and endoscopic ultrasound (EUS).Methods: We retrospectively analyzed patients with GI melanoma diagnosed by endoscopic biopsy or postoperative pathology between August 2008 and January 2017. Images of endoscopic examinations, including endoscopy and EUS, were reviewed to characterize GI melanomas.Results: A total of 21 patients (9 males, 12 females) with GI melanoma were enrolled in this study. Several types of melanoma were identified: anorectal melanoma (n = 15), esophageal melanoma (n = 3), gastric melanoma (n = 2), and melanoma of the small intestine (n = 1). EUS was performed for one case of esophageal melanoma, one case of gastric melanoma, and seven cases of anorectal melanoma.Conclusions: GI melanoma is a rare disease. Most GI melanomas showed typical endoscopic manifestations, including black plaques. EUS is a reliable tool for evaluating the depth of infiltration of GI melanoma.

Treatment Strategies and Survival Trends for Anorectal Melanoma: Is it Time for a Change?

BACKGROUND

Immunotherapy advances for the treatment of cutaneous melanoma question its efficacy in treating anorectal mucosal melanoma (ARMM). We aimed to identify the prevalence, current management, and overall survival (OS) for ARMM.

METHODS

Review of patients with ARMM from 2004 to 2015 National Cancer Database. Factors associated with immunotherapy were identified using multivariable logistic regression. The primary outcome was 2- and 5-year OS. Subgroup analysis by treatment type was performed.

RESULTS

A total of 1331 patients were identified with a significant increase in prevalence (2004: 6.99%, 2015: 10.53%). ARMM patients were older, white, on Medicare, and from the South. The most common treatment was surgery (48.77%), followed by surgery + radiation (11.75%), surgery + immunotherapy (8.68%), and surgery + chemotherapy (8.68%). 16.93% of patients received immunotherapy, with utilization increasing (7.24%: 2004, 21.27%: 2015, p < 0.001). Patients who received immunotherapy had a significantly better 2-year OS (42.47% vs. 49.21%, p < 0.001), and other therapies did not reveal a significant difference. Adjusted analysis showed no difference in 2- and 5-year OS based on therapy type.

CONCLUSION

The prevalence of ARMM has increased. The use of immunotherapy has increased substantially. Some survival benefit with the administration of immunotherapy may exist that has yet to be revealed. A more aggressive treatment paradigm is warranted.

Primary Anorectal Amelanotic Melanoma: The First Case Report from Saudi Arabia

Anorectal melanomas are exceptionally uncommon and only 30% of anorectal melanomas are amelanotic. We report here a case of an anorectal amelanotic melanoma in a female patient. An 84-year-old patient complained of anal mass for 3 months. On examination, there was a 7.0 cm mass prolapsing through the anus that was pale-pink in color. Abdominal, pelvic, and chest computed tomography (CT) showed rectal wall thickening with an eccentric polypoid soft tissue density mass, and left inguinal and presacral lymph node enlargement along with a small nodule in the lower lobe of the left lung, likely representing metastatic deposit. Microscopic examination revealed a piece of skin with hyperplastic squamous epithelium with surface ulceration. The dermis and underlining tissue were showing infiltration by malignant sheets and nests of ovoid and spindle shape cells with prominent nucleolus and high mitotic s. Immuno-staining for HMB-45, S-100, and Melan-A was positive, and it was negative for P63, CK 5/6, and Pan-CK, thus confirming it as an anorectal amelanotic melanoma, and not an epithelial tumor. This is the first case of an amelanotic anorectal melanoma reported from Saudi Arabia.

Multidisciplinary therapy for metastatic primary malignant melanoma of the esophagus: A case report

Standard treatment strategies have not yet been established for primary malignant melanoma of the esophagus (PMME), and far much less for recurrent disease. There are no reports of anti-programmed death-1 antibody treatment of recurrent PMME. A 60-year-old Japanese man was diagnosed with a primary malignant melanoma in the lower esophagus. The patient underwent mediastinoscope-assisted subtotal esophagectomy, and two nodal involvements were detected in the lymph nodes (LN)s along the left gastric artery. Paclitaxel and oral fluoropyrimidine were administered for 2 months as adjuvant treatment based on results of a histoculture drug response assay. Computed tomography at 8 months after following surgery revealed LN metastasis around the celiac axis. The serum level of the tumor marker 5-S-cysteinyldopa was elevated aberrantly. Although treatment with dacarbazine and interferon-β was initiated, metastatic disease progressed. Therefore, we started anti-programmed death-1 antibody therapy. Following 8 treatment courses, the patient demonstrated a partial response; however, after following 4 more treatment courses, the patient demonstrated progressive disease. Next, hypofractionated radiotherapy was targeted at the metastatic LN and resulted in a partial response. Then, ipilimumab, an anti-cytotoxic T-lymphocyte associated antigen 4, was administered at a dose of 3 mg/kg. After the initial administration of ipilimumab, grade 3 peripheral neuropathy was recognized; thereafter, ipilimumab was not administered. A total of 18 months after following treatment for metastatic LNs, the LN decreased in size, and there were no other signs of metastasis to other organs. The patient then underwent laparoscopic celiac axis lymphadenectomy. Pathological examination of the surgical specimens identified no viable melanoma cells. A total of 8 months after following surgery, he is free from evidence of disease recurrence. This is the first reported case of recurrent PMME successfully treated with multidisciplinary therapy including anti-programmed death-1 antibody therapy, radiotherapy and laparoscopic lymphadenectomy.