Role of adjuvant chemotherapy in malignant mucosal melanoma of the head and neck

Failure Patterns Within Different Histological Types in Sinonasal Malignancies: Making the Complex Simple

OBJECTIVE

To analyze the failure patterns in patients with different histological subtypes of sinonasal malignancies (SNMs).

STUDY DESIGN

Retrospectively gathered data.

SETTING

Academic university hospital.

METHODS

Patients with SNMs treated at a tertiary referral center between January 1999 and January 2019 were included. We assessed the failure patterns within different histological subtypes.

RESULTS

The study included 897 patients. The median follow-up time was 100 months. Adenoid cystic carcinoma (ACC) had a moderate risk of developing local recurrence (LR) and distant metastasis (DM). Compared with ACC, squamous cell carcinoma (SCC), adenocarcinoma (AC), soft tissue sarcoma (STS), and mucosal melanoma (MM) were classified as a high LR risk group. For DM, neuroendocrine carcinoma (NEC), STS, and MM were in the high-risk group.

CONCLUSIONS

ACC had intermediate local and distant failure risks, while SCC, AC, STS, and MM were at high LR risks. NEC, STS, and MM were at high DM risk.

The Role of Hedgehog Signaling in the Melanoma Tumor Bone Microenvironment

A crucial regulator in melanoma progression and treatment resistance is tumor microenvironments, and Hedgehog (Hh) signals activated in a tumor bone microenvironment are a potential new therapeutic target. The mechanism of bone destruction by melanomas involving Hh/Gli signaling in such a tumor microenvironment is unknown. Here, we analyzed surgically resected oral malignant melanoma specimens and observed that Sonic Hedgehog, Gli1, and Gli2 were highly expressed in tumor cells, vasculatures, and osteoclasts. We established a tumor bone destruction mouse model by inoculating B16 cells into the bone marrow space of the right tibial metaphysis of 5-week-old female C57BL mice. An intraperitoneal administration of GANT61 (40 mg/kg), a small-molecule inhibitor of Gli1 and Gli2, resulted in significant inhibition of cortical bone destruction, TRAP-positive osteoclasts within the cortical bone, and endomucin-positive tumor vessels. The gene set enrichment analysis suggested that genes involved in apoptosis, angiogenesis, and the PD-L1 expression pathway in cancer were significantly altered by the GANT61 treatment. A flow cytometry analysis revealed that PD-L1 expression was significantly decreased in cells in which late apoptosis was induced by the GANT61 treatment. These results suggest that molecular targeting of Gli1 and Gli2 may release immunosuppression of the tumor bone microenvironment through normalization of abnormal angiogenesis and bone remodeling in advanced melanoma with jaw bone invasion.

Neoadjuvant checkpoint inhibitor immunotherapy for resectable mucosal melanoma

Background

Neoadjuvant checkpoint inhibition (CPI) has recently demonstrated impressive outcomes in patients with stage 3 cutaneous melanoma. However, the safety, efficacy, and outcome of neoadjuvant CPI in patients with mucosal melanoma (MM) are not well studied as MM is a rare melanoma subtype. CPI such as combination nivolumab and ipilimumab achieves response rates of 37-43% in unresectable or metastatic MM but there is limited data regarding the efficacy of these agents in the preoperative setting. We hypothesize that neoadjuvant CPI is a safe and feasible approach for patients with resectable MM.

Method

Under an institutionally approved protocol, we identified adult MM patients with resectable disease who received neoadjuvant anti-PD1 +/- anti-CTLA4 between 2015 to 2019 at our institution. Clinical information include age, gender, presence of nodal involvement or satellitosis, functional status, pre-treatment LDH, tumor mutation status, and treatment data was collected. Outcomes include event free survival (EFS), overall survival (OS), objective response rate (ORR), pathologic response rate (PRR), and grade ≥3 toxicities.

Results

We identified 36 patients. Median age was 62; 58% were female. Seventy-eight percent of patients received anti-PD1 + anti-CTLA4. Node positive disease or satellite lesions was present at the time of treatment initiation in 47% of patients. Primary sites of disease were anorectal (53%), urogenital (25%), head and neck (17%), and esophageal (6%). A minority of patients did not undergo surgery due to complete response (n=3, 8%) and disease progression (n=6, 17%), respectively. With a median follow up of 37.9 months, the median EFS was 9.2 months with 3-year EFS rate of 29%. Median OS had not been reached and 3-year OS rate was 55%. ORR was 47% and PRR was 35%. EFS was significantly higher for patients with objective response and for patients with pathologic response. OS was significantly higher for patients with pathologic response. Grade 3 toxicities were reported in 39% of patients.

Conclusion

Neoadjuvant CPI for resectable MM is a feasible approach with signs of efficacy and an acceptable safety profile. As there is currently no standard approach for resectable MM, this study supports further investigations using neoadjuvant therapy for these patients.

Effects of Para-Toluenesulfonamide on Canine Melanoma Xenotransplants in a BALB/c Nude Mouse Model

The pharmacological pathway of para-toluenesulfonamide (PTS) restricts the kinase activity of the mammalian target of rapamycin, potentially leading to reductions in cell division, cell growth, cell proliferation, and inflammation. These pathways have a critical effect on tumorigenesis. We aimed to examine the antitumor effect of PTS or PTS combined with cisplatin on canine melanoma implanted in BALB/c nude mice by estimating tumor growth, apoptosis expression, inflammation, and metastasis. The mice were randomly divided into four groups: control, cisplatin, PTS, and PTS combined with cisplatin. Mice treated with PTS or PTS combined with cisplatin had retarded tumor growth and increased tumor apoptosis through the enhanced expression of cleaved caspase 3 and extracellular signal-regulated kinase phosphorylation, decreased inflammatory cytokine levels, reduced inflammation-related factors, enhanced anti-inflammation-related factors, and inhibition of metastasis-related factors. Mice treated with PTS combined with cisplatin exhibited significantly retarded tumor growth, reduced tumor size, and increased tumor inhibition compared with those treated with cisplatin or PTS alone. PTS or PTS combined with cisplatin could retard canine melanoma growth and inhibit tumorigenesis. PTS and cisplatin were found to have an obvious synergistic tumor-inhibiting effect on canine melanoma. PTS alone and PTS combined with cisplatin may be antitumor agents for canine melanoma treatment.

Comparative analysis of postoperative adjuvant therapy for head and neck mucosal melanoma in China

BACKGROUND

Head and neck mucosal melanoma is a rare malignant disease with no clear and effective treatment to control the prognosis of patients.

AIM

To analyze the effects of different postoperative adjuvant treatments on the survival and prognosis of patients.

MATERIAL AND METHODS

A retrospective analysis of 163 patients which were divided into five groups: no adjuvant therapy, postoperative radiotherapy, postoperative chemotherapy, postoperative chemotherapy and radiotherapy, and postoperative immunotherapy. Kaplan-Meier method and Cox regression analysis were used to analyze the prognosis in the different groups.

RESULTS

Postoperative radiotherapy had statistically significant effects on local recurrence, distant metastasis, overall survival, progression-free survival (PFS) and recurrence-free survival (RFS); Postoperative chemotherapy and postoperative chemotherapy/radiotherapy had effects on distant metastasis, overall survival, PFS and RFS. However, postoperative immunotherapy did not show any significant effects. For patients with limited lesions who underwent endoscopic surgery, receive postoperative radiotherapy and postoperative chemotherapy/radiotherapy seem to have better prognosis.

CONCLUSIONS AND SIGNIFICANCE

For the head and neck mucosal melanoma, different types adjuvant therapy can prolong the survival of patients to varying degrees compared with no postoperative treatment, but immunotherapy as a single adjuvant therapy does not show any advantages. We recommended that patients should receive radiotherapy and/or chemotherapy after surgery.

Importance of Margins, Radiotherapy, and Systemic Therapy in Mucosal Melanoma of the Head and Neck

OBJECTIVES/HYPOTHESIS

The ideal strategy in the treatment of mucosal melanoma of the head and neck (MMHN) remains unclear. Our objective was to evaluate the importance of surgical margins, radiotherapy, and systemic therapy in MMHN.

STUDY DESIGN

Retrospective Single Institutional Review.

METHODS

Retrospective review of patients with MMHN treated at a tertiary care oncology center between 1999 and 2016.

RESULTS

Seventy-six patients were included, 60 of whom were treated with curative intent. Negative or close margins compared with positive margins were associated with higher 3-year overall survival (OS) (62% vs. 29% vs. 13% P = .012), disease-free survival (33% vs. 29% vs. 4% P = .003), and distant control (48% vs. 29% vs. 22% P = .039). Cases with pre-/postoperative radiotherapy had a marginally higher locoregional control versus without (69% vs. 59%, P = .117). Immunotherapy for recurrent and/or metastatic disease was associated with an increase in 3-year OS (15% vs. 3% P = .01).

CONCLUSION

Achieving negative surgical margins is relevant in disease control. Despite small sample size, our data suggest that radiotherapy may enhance surgical outcomes. Immunotherapy has therapeutic benefit.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Survival of oral mucosal melanoma according to treatment, tumour resection margin, and metastases

Because of the poor prognosis and of oral mucosal melanoma, and patients' short survival, large, randomised, clinical studies are difficult. We have investigated its demographic characteristics and analysed the effect of treatment, resection margins, and metastases on survival. We recorded age, sex, site of primary tumour, and types of treatment, survival, and metastases in 74 patients treated at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. Survival was analysed based on bony invasion, depth of invasion, and resection margins, and we found that it varied depending on the primary site (p=0.002), and declined with liver (p=0.001) or brain (p=0.033) metastases. The two-year survival according to the primary site was as follows: palate 85% (n=32), anterior maxillary gingiva 53% (n=13), mandible 58% (n=13), and posterior maxillary gingival 74% (n=10) and buccal mucosa 50% (n=4). The two-year survival was 34% (n=8) in patients with liver metastases and 23% (n=7) in patients with brain metastases. In cases of bony invasion (p=0.005), depth of invasion (p=0.042), unclear resection margin (p=0.023), or higher T stages (p=0.009), the survival declined considerably. Neck dissection did not affect survival (p=0.343). Survival of the patients given chemotherapy was significantly lower (p=0.013) and the two-year survival was 54.0%. The patients given radiotherapy showed no significant difference in survival compared with those not given radiotherapy (p=0.107). In conclusion, primary site, bony invasion, resection margins, depth of invasion and systemic metastases were critical to predict prognosis and selection of treatment of oral mucosal melanoma.

Malignant Mucosal Melanoma of the Eustachian Tube With Extension Into the Ipsilateral External Ear Canal: A Case Report and Review of the Literature

Mucosal melanoma arising in the middle ear or eustachian tube is uncommon. We present a patient with hearing loss and otalgia found to have mucosal melanoma which occurred in the eustachian tube with extension into the middle ear cavity and external ear canal. Otologic clinics was consulted and biopsy of the mass located at the external canal was performed to ascertain the pathological diagnosis. The patient refused immunotherapy and surgery instead of undergoing radiotherapy and died from hepatic metastasis 8 months later. The mucosal melanoma originated from the eustachian tube with extension into the external ear canal is exceedingly rare, and the differential diagnosis should be considered for tumors in external ear canal.

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).

An updated review of mucosal melanoma: Survival meta-analysis

Mucosal melanoma (MM) is a highly lethal variant of melanoma that carries a poor prognosis. Extremely low incidence and survival rates have led to few clinical trials, and a lack of protocols and guidelines. The present study performed a survival meta-analysis for the quantitative synthesis of available evidence to search for key patterns that would help clinicians tailor optimal therapeutic strategies in MM. PubMed, EMBASE, Cochrane, MEDLINE, Google Scholar and other databases were searched. Hazard ratios, in disease-specific and overall survival, were calculated for each of the survival-determining variables. MM was 2.25 times more lethal than cutaneous melanoma (CM). The most significant threats to survival were advanced Tumor-Node-Metastasis stage, sino-nasal location, and old age. Chemotherapy was the most effective form of adjuvant therapy. Disease-specific survival, the primary measure of the effect sizes, can fluctuate depending on the accuracy of the reported cause of mortality. In conclusion, MM is a peculiar type of melanoma, with clinical and molecular profile vastly different from the much-familiar CM. In the wake of the era of precision oncology, further studies on driver mutations and oncogenic pathways would likely lead to improved patient survival.

Mucosal melanoma of the cranio-facial region: Surgical challenges and therapeutic options

OBJECTIVE

Although current therapeutic options for cutaneous melanoma (CM) are constantly improving survival, mucosal melanoma (MM) remains a rare tumor disease with a poor clinical outcome. While radical surgery is the gold standard, clear margin resections in the head and neck area are particularly critical due to high density of vulnerable structures. Adjuvant therapeutic options increases local control and data on the effect of systemic agents is sparse. The aim of this study was to elucidate surgical challenges in the craniofacial area and to evaluate the effect of local and systemic therapy in Head and Neck Mucosal Melanoma (HNMM).

METHODS

In total, 21 patients with nasal mucosal malignant melanoma were included in this study over the course of 20 years in two German tertiary referral centers. Patient characteristics and conducted therapy as well as clinical outcomes were analyzed retrospectively.

RESULTS

By performing survival analysis for multimodal therapies, we observed a superiority effect of interferon therapy compared to surgery with radiation and surgery alone in the first therapeutic approach. However, patients treated with surgery alone in a recurrent setting showed the best outcome.

CONCLUSION

Both, Interferon and radiation as adjuvant therapies, demonstrated survival benefits in initial treatment compared to surgery alone. Analysis after recurrence, however, revealed salvage surgery as a reliable and powerful tool to prolong post-recurrence survival without exposing palliative patients to the risk of severe adverse events from systemic therapies.

Combination therapy improves immune response and prognosis in patients with advanced oral mucosal melanoma: A clinical treatment success

OBJECTIVE

This study was undertaken to analyze disease response and immune response to assess treatment effectiveness and success in patients with advanced oral mucosal melanoma treated with cytokines injection, cryosurgery, and adoptive cell transfer therapy.

STUDY DESIGN

Ten patients were enrolled in the study, and the relevant characteristics and immunologic differences were evaluated.

RESULTS

All patients achieved an objective clinical response according to the Response Evaluation Criteria in Solid Tumors, including 7 cases of continuing complete remission (55, 27, 87 + , 58⁺, 58 + , 45 + , and 37 + months) and 3 cases of partial remission (30, 12, and 9 months). Five responders are currently alive. After combination therapy, we observed that the proportion of CD3+ lymphocytes and the secretion of interferon-γ increased, whereas interleukin-10 decreased. In the assay of improved cytokine-induced killer cells, CD4+CD25+ regulatory T cells declined, and natural killer cells upregulated. Meanwhile, the proliferation rate of in vitro cultured improved cytokine-induced killer cells improved after courses of therapy.

CONCLUSIONS

Combination therapy of cytokine injection, cryosurgery, and transfer of improved cytokine-induced killer cells may be a promising approach for patients with oral mucosal melanoma.

Role of Adjuvant Treatment in Sinonasal Mucosal Melanoma

Purpose  Sinonasal mucosal melanoma (SNMM) is a locally aggressive tumor. This study aimed to define the role of adjuvant treatment and its association with survival outcomes of SNMM. Methods  This retrospective study investigated 152 patients with SNMM treated between 1991 and 2016 in MD Anderson Cancer Center. Patients were divided into the following treatment groups: surgery alone, surgery with postoperative radiotherapy (PORT), surgery with postoperative chemoradiation (POCRT), and induction chemotherapy followed by surgery and PORT. Overall survival (OS), disease-specific survival, and relapse-free survival were compared. Survival between the groups was compared using univariate and multivariate analyses. Results  The median follow-up was 28 months (range: 2-220 months). Five-year OS rates were 39, 42, 47, and 27% for the surgery only, PORT, POCRT, and neoadjuvant chemotherapy groups, respectively (log rank p  = 0.73). Distant metastasis was the most common form of treatment failure and occurred in 59 (39%) patients. Five-year distant metastasis rates were 51, 45, and 58% for patients treated with surgery alone, PORT, and POCRT, respectively (log rank p  = 0.21) but unable to be estimated in the neoadjuvant chemotherapy group due to low OS rates. Multivariate analysis demonstrated tumor site (hazard ratio [HR] = 2.32, 95% confidence interval [CI] = 1.24-4.15) and smoking status (HR = 1.77, 95% CI = 1.02-3.1) to be significant prognostic factors for survival. Conclusion  Tumor site and smoking status were significant prognosticators in SNMM. A high rate of distant metastatic disease suggests that further investigation into novel, systemic therapies is required to improve outcomes in this disease entity.

Oral mucosal melanoma treated with carbon ion radiotherapy: a case report

BACKGROUND

Oral mucosal melanoma is a rare disease with a relatively poor prognosis. Carbon ion radiotherapy has been shown to be effective against radiotherapy-resistant tumors owing to its excellent dose concentration and high biological effect.

CASE PRESENTATION

Our patient was a 66-year-old Japanese man with oral mucosal melanoma of his right maxillary gingiva (T4aN0M0). He received carbon ion radiotherapy at 57.6 Gy (relative biological effectiveness) in 16 fractions for 4 weeks. Concomitant chemotherapy (dacarbazine + nimustine + vincristine) was administered at the same time as carbon ion radiotherapy initiation. Two courses of adjuvant chemotherapy were given after carbon ion radiotherapy. Although he experienced grade 2 acute oral mucositis, his symptoms improved within a few weeks of undergoing carbon ion radiotherapy. He was alive at the time of reporting, 35 months after treatment, without any recurrence. Late toxicity has not been observed.

CONCLUSIONS

Carbon ion radiotherapy for oral mucosal melanoma resulted in a good local effect.

Prognostic significance of nestin in primary malignant melanoma of the oral cavity

Several studies have examined the correlation between nestin expression and the degree of tumor invasion in cutaneous melanoma. However, no information has been reported on nestin in primary mucosal melanoma of the head and neck. The present study examined the expression and prognostic significance of nestin in patients with primary mucosal melanoma of the oral cavity. Nestin expression was examined immunohistochemically in 39 patients (six oral melanoma in-situ cases and 33 invasive oral melanoma cases) and analyzed for association with disease progression. Age, sex, anatomic site, stage, level of invasion, regional lymph node metastasis, surgical margin involvement, and treatment modality were also analyzed. In the 33 invasive melanoma cases, invasion depth correlated significantly with prognosis in univariate and multivariate analyses. High-intensity nestin staining was observed in 14 of the 33 cases and a high proportion of nestin-positive cells was observed in 16 cases. In stage III oral melanoma cases, nestin expression was not significantly associated with disease progression. However, in stage IV cases, both the intensity and the proportion of nestin expression were significantly associated with disease progression (P=0.022 and 0.005, respectively). In all 33 invasive cases, multivariate analyses showed that both the intensity and the proportion of nestin were significantly associated with a poor prognosis (P=0.014 and 0.009; hazard ratio, 3.59 and 4.05; 95% confidence interval, 1.29-9.98 and 1.42-11.56, respectively). In conclusion, nestin can be a valuable prognostic indicator in the advanced-stage (stage IV) cases of oral mucosal melanoma.

Biopanel identifies expression status of targetable proteins in sinonasal melanoma

BACKGROUND

Advanced stage at presentation, lack of BRAF mutations and overall rarity pose unique challenges to the therapy and trial design in sinonasal melanoma.

METHODS

Here, we assessed the expression status of 12 proteins in two independent cohorts of sinonasal melanoma (n = 20).

RESULTS

Each case showed expression of at least one protein (KIT, TP53, MYC, HER2, EGFR, MET, VEGFR, BRAF V600E and/or MDM2), whereas lack of ALK, FLI1 and PDGFRα expression underscores differences to cutaneous melanoma. Comparison of marker frequencies to a metareview of the literature indicates that MYC, HER2, EGFR and MET had not been previously assessed.

CONCLUSION

Expression of at least one potentially targetable protein per case illustrates proteome pathway profiling as one starting point for marker stratified trial design.

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.

Outcomes of mucosal melanoma of the head and neck

INTRODUCTION

Mucosal melanoma of the head and neck is a rare disease with limited data available on outcomes; therefore, we reviewed our institutional experience.

METHODS

An institutional database was queried and 38 patients with head and neck mucosal melanoma were identified. Charts were abstracted and local control (LC), progression-free survival (PFS) and overall survival (OS) were calculated.

RESULTS

Most patients had T4 disease (86%), although nodes were positive in 11%. En bloc or endoscopic resection was performed on 93%. Adjuvant or definitive radiotherapy to a median dose of 60 Gy was utilized in 90%. Chemotherapy was given in 21%, and 16% received interferon. Three-year LC, PFS and OS were 90%, 48% and 59%, respectively. Median OS was 4.6 years. Site of first failure was distant in 52% of cases.

CONCLUSION

With aggressive therapy median OS was 4.6 years in this cohort. Distant recurrence remains the primary mode of failure. It may be reasonable to include mucosal melanoma patients in trials of systemic agents along with high-risk cutaneous melanomas.

Efficacy and safety of image-guided interstitial single fraction high-dose-rate brachytherapy in the management of metastatic malignant melanoma

PURPOSE

Computed tomography (CT) or magnetic resonance imaging (MRI) guided brachytherapy provides high tumor control rates in hepatocellular carcinoma (HCC) and colorectal liver metastases. In contrast to thermal ablation methods such as radiofrequency ablation (RFA), much less restrictions apply with respect to tumor location or size. In this study, we determined the efficacy and safety of CT- or MRI-guided brachytherapy in metastatic melanoma.

MATERIAL AND METHODS

Fifty-two metastases of malignant melanoma in 14 patients were included in this retrospective study. Local tumor control and safety were evaluated as primary and secondary endpoints. Furthermore, we evaluated overall survival and progression free survival. Tumor locations were liver (n = 31), lung (n = 15), adrenal (n = 3), lymph nodes (n = 2), and kidney (n = 1). Treatment planning was performed using three-dimensional CT or MRI data acquired after percutaneous applicator positioning under CT or open MRI guidance. Subsequently, single fraction high-dose-rate (HDR) brachytherapy was applied using a (192)Iridium source. Clinical and cross-sectional follow-up were performed every 3 months post intervention.

RESULTS

The median diameter of treated lesions was 1.5 cm (range: 0.7-10 cm). Doses between 15 and 20 Gy were applied (median dose: 19.9 Gy). The mean irradiation time ranged between 7-45 minutes. After treatment, there was one patient with a cholangitis. After a median follow up of five months, the median local tumor control was 90%. The median overall survival of the patients was 8 months. The median progression free survival of the patients was 6 months.

CONCLUSIONS

Image-guided HDR brachytherapy is a safe and effective treatment procedure in metastatic malignant melanoma.

Epidemiology and survival outcomes of ocular and mucosal melanomas: a population-based analysis

Extracutaneous melanomas are poorly characterized tumors that include ocular (OM), mucosal (MM) and leptomeningeal melanomas, often lacking standardized staging and treatment guidelines. We analyzed cases of cutaneous melanoma (CM, N = 219,890), OM (N = 7,069) and MM (N = 2,755) of different anatomical origins, diagnosed between 1988 and 2010, recorded in the Surveillance Epidemiology and End Results (SEER) database. Relative survival was studied in patients grouped by summary stage classification (localized, regional or distant disease) and in multivariate models adjusting for varying distribution of baseline factors. Unlike in CM, the incidence rate in MM increased exponentially with age. Five-year relative survival was significantly worse for OM (78%) and for most mucosal sites (aggregate 34%, range 3-69%) compared with CM (89%). The differences between primary sites were particularly pronounced in localized disease, with a hazard ratio of 5.7 for OM, 4.3-9.0 for external genital or oral cavity MM and 19.8-90.4 for other mucosal locations. Melanomas of the pharynx, gastrointestinal, urinary tract and vagina had poor outcomes regardless of clinical stage. In contrast to CM, there was no evidence of improved survival in OM and MM during the study period. A substantial proportion of patients with operable OM or MM underwent radical organ resections (13-88% depending on site and stage) or perioperative radiotherapy (0-66%). In conclusion, extracutaneous melanomas have a markedly worse survival than CM and aggressive locoregional management appears to be insufficient for their control. Because of poor outcomes in MM, studies of systemic therapy are warranted regardless of the extent of disease at presentation.

Oral desmoplastic melanoma mimicking inflammatory hyperplasia

INTRODUCTION

Desmoplastic melanoma (DM) arising in the oral cavity is a rare neoplasm that may be confused with a variety of non-melanocytic benign or malignant lesions.

OBJECTIVES

To present a case of DM in the oral mucosa mimicking fibrous inflammatory hyperplasia, discusses the difficulties involved in the diagnosis and offers a literature review on the clinicopathologic and immunohistochemincal aspects of this neoplasm.

CASE REPORT

A 62-year-old white male, smoker, was referred with a chief complaint of pain and swelling in the palate. The oral examination revealed multiple brown-to-black patches and a non-pigmented sessile nodule located on the mucosa of the hard palate. The clinical diagnosis of the pigmented lesions was either oral melanosis or melanoma. The nodular lesion was clinically diagnosed as fibrous inflammatory hyperplasia. Incisional biopsy was performed on the pigmented lesion and the microscopic sections revealed a melanotic macule. The nodular lesions histologically revealed an amelanotic desmoplastic melanoma.

CONCLUSIONS

Reactive lesions close to a pigmented area should be investigated with great care.

Mucosal melanomas of the head and neck: new aspects of the clinical outcome, molecular pathology, and treatment with c-kit inhibitors

Approximately 50% of mucosal melanomas affect the head and neck region representing approximately 9% of all malignant head and neck tumors. The pathogenesis of this disease is unknown. Mucosal melanomas are characterized by an aggressive biological behavior, leading to a 5-year survival rate of less than 25%. Data for this review were identified by searches of Medline, Current Contents, PubMed, and references from relevant articles using the terms 'mucosal melanoma,' 'head and neck melanoma,' 'c-kit mutation in melanoma,' and 'c-kit inhibitors'. Therapy aims for the complete surgical excision of the primary tumor, whereas sentinel node biopsy is not established and present data do not support the addition of radiotherapy. Mutilating operations of larger tumors should be avoided, as they do not inhibit the frequent development of distant metastasis. C-kit mutations and amplifications are found in approximately 15-30% of mucosal and acral-lentiginous melanomas. Therefore, the use of so-called targeted therapies addressing molecular structures in mucosal melanomas seem to represent new promising treatment tools. In this study, we review the literature regarding epidemiology, molecular pathology, and therapy of mucosal melanomas of the head and neck emphasizing c-kit protein inhibiting treatment modalities for tumors carrying c-kit mutations.