Primary mucosal melanoma of the nasal cavity

Recurrence in a patient with a 10-year history of sinonasal mucosal melanoma manifesting as facial swelling

Sinonasal mucosal melanoma is a rare tumor that develops slowly and may manifest with non specific signs and symptoms, causing significant delay in diagnosis. Local recurrence is common and usually occurs within the first two years after the initial treatment. Prognosis of recurrent lesions is poor and 5-year survival ranges between 10-47%. We report the clinical, radiographic, histopathological and immunohistochemical findings of a recurrent sinonasal mucosal melanoma which was diagnosed 10 years after the initial treatment, in a patient who presented with unilateral facial swelling and one-sided difficulty in breathing of two years duration. We discuss the causes of late diagnosis and review the negative predictive factors for recurrence and survival. As early diagnosis is of paramount importance for prognosis, we emphasize the signs and symptoms of patients with a history of sinonasal mucosal melanoma which should raise the suspicion for recurrence, in spite of a long time interval since diagnosis. Key words: Mucosal melanoma, nasal cavity, sinus, recurrence.

Primary malignant melanoma of the nasal cavity

Primary malignant melanoma of the nose and paranasal sinus mucosa is a rare disease and seen in less than 1% among all melanomas. Malignant melanomas have 2 origins: cutaneous and mucosal. The mucosal form has a worse prognosis because of its aggressiveness compared with that of the cutaneous form. Mucosal melanomas often occur at a rate of 2% to 3% among all melanomas and are typically found in the nasal cavity and paranasal sinuses. Generally, it is more common in males and in those older than 50 years. In this study, 4 patients were observed at the Cumhuriyet University Faculty of Medicine; 2 of them were a 64-year-old man and an 82-year-old woman who had a malignant melanoma originating from the nasal septal mucosa, 1 patient was a 72-year-old woman whose malignant melanoma originated from the inferior turbinate, and 1 patient was a 77-year-old woman with a sinonasally located melanoma. The conditions of these patients were discussed under the light of literature instructions.

Rhinectomy for the management of nasal malignancies

BACKGROUND

Tumours of nasal skin or mucosa are common, and can usually be treated with limited surgical excision or radiotherapy. This paper highlights a subset of high risk tumours which require rhinectomy for complete oncological clearance.

METHOD

Retrospective case note review of 14 patients undergoing rhinectomy for nasal tumours. Clinical and histological findings, treatment and outcome are reviewed and discussed.

RESULTS

Forty-three per cent of patients had recurrent disease and underwent rhinectomy as a salvage procedure following previous surgery or radiotherapy. Most tumours (79 per cent) were basal cell carcinoma or squamous cell carcinoma. After a mean follow up of 30.1 months (range, zero to 96 months), seven patients (50 per cent) were alive and disease-free. Reconstruction was most commonly with a prosthesis.

CONCLUSION

Rhinectomy is an oncologically sound procedure for the management of high risk nasal malignancies. Prosthetic rehabilitation can be an excellent alternative to surgery, particularly in those patients unsuitable for major reconstruction.

Sinonasal mucosal melanomas

OBJECTIVES

Sinonasal mucosal melanomas account for approximately 1% of all melanomas. These tumors are particularly aggressive, with a recurrence rate between 37 and 54% and a 5-year survival rate between 20 and 46%. Metastases are frequent. The main objective of this study was to analyze all of our cases of sinonasal mucosal melanomas and determine any prognostic factors.

PATIENTS AND METHODS

All our cases of sinonasal mucosal melanoma over a period of 10 years were included. Ten cases were analyzed. The mean age was 71 years (range: 61-85 years) for seven women and three men. The clinical, radiological, anatomopathological, and surgical data as well as the characteristics of disease progression were analyzed. These data were compared to those reported in the literature.

RESULTS

The mean follow-up was 36.3 months (range: 2-96 months). The 5-year overall survival was 40%. Seven patients developed local recurrences after a mean follow-up of 16 months (range: 2-27 months) with associated metastases in three cases. Analysis of the prognostic factors showed that tumors classified as T1 and limited to the nasal fossae had a better prognosis.

CONCLUSION

Sinonasal mucosal melanomas are rare tumors with a high mortality rate. Treatment of these tumors requires extensive surgical treatment associated with external radiotherapy.

Mucosal melanomas

Cutaneous malignant melanoma is a common malignancy and has been increasing at an alarming rate in the United States. Sun exposure is a well-known risk factor related to this disease and much is understood regarding the etiology and epidemiology of cutaneous melanomas. In contrast, primary mucosal melanomas represent an extremely rare malignancy and do not have the same risk factors or behavior patterns. They occur in areas that have no sun exposure and solid predisposing risk factors have not been identified, making this disease very difficult to diagnose or screen for. It is usually diagnosed at a later stage and carries a poor prognosis. Identifying the differences between a primary lesion and a metastatic melanoma is often challenging, because of the lack of definitive criteria, both pathologically and clinically. The rich vascular and lymphatic network surrounding these lesions may be responsible for their aggressive behavior and poor prognosis. In addition, the obscure locations where mucosal melanomas occur are an obvious reason why these lesions often go unnoticed until symptoms develop. Recent literature has raised significant questions regarding recommended treatment strategies. Earlier reports advocated radical surgery as the mainstay of therapy; however, local recurrence and survival were unchanged whether radical surgery or local excision was performed, and the most recent data are favoring the conservative approach when appropriate. Unfortunately, a multitude of adjuvant therapies have been tried without any success. Adjuvant radiotherapy plays a role when combined with surgery, particularly in the head and neck region and female genitalia, but this is reserved for nodal and locoregionally advanced disease and has had no effect when used as a prophylactic method. It is difficult to make significant advances in treatment strategies because of the rarity of the disease. As an example, one in 75 persons born in the year 2000 will develop cutaneous melanoma in his lifetime, compared with four cases per ten million people diagnosed with mucosal melanoma per year in the United States. Possible new therapies based on new biologic and immunologic findings may have future promise on being able to impact this disease. Until then, this aggressive tumor continues to have a poor prognosis, and surgical resection continues to be the mainstay of primary therapy.

Mucosal melanoma of the sinonasal tract

Mucosal melanoma of the sinonasal tract is an uncommon clinical entity, which frequently presents in advanced stages and follows an unpredictable course. We describe a case of a 97-year-old white female who presented with a 5-month history of painless, intermittent epistaxis and who was found to have melanoma involving the right inferior turbinate. She required operative intervention because of chronic epistaxis that had resulted in anemia and weakness. The case is presented along with a review of the pertinent literature. The dilemmas involved in the clinical decision-making process and treatment of malignancy in the elderly patient are discussed. In general, treatment outcomes in cases of mucosal melanoma are poor despite combination therapy, and quality-of-life issues become as important as attempts at complete extirpation.