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

Primary lacrimal sac melanoma: a case report describing the novel use of fine needle aspiration cytology (FNAC) for diagnosis, together with literature review and immunotherapy treatment update

Primary lacrimal sac melanoma (PLSM) is exceedingly rare and associated with high morbidity and mortality. Unfortunately, PLSM often presents insidiously resulting in delayed detection and poor prognosis. A 69-year-old Black man was suspected of having a lacrimal sac tumour following presentation with a left sided watery eye, bloody tears, and a lacrimal mass. Due to the patient's implantable pacemaker, defibrillator, and high anticoagulation, an ultrasound-guided FNAC was performed instead of incisional biopsy, revealing a PLSM. Diagnosis was confirmed following complete tumour resection with free flap reconstruction and neck dissection. Unfortunately, disease progression ensued despite further neck dissection and three cycles of both pembrolizumab and iplimumab. This is the first description of FNAC to accurately diagnose PLSM and highlights its use as an accurate, rapid, and minimally invasive technique that may allow an earlier screening diagnosis of lacrimal sac tumours. We also discuss the outcome of immunotherapy in recent similar cases.

Mucosal melanoma of the head and neck: a retrospective analysis of 34 cases in Japan

PURPOSE

Mucosal melanoma of the head and neck (MMHN) is a rare condition. This study aimed to investigate oncological outcomes of surgical intervention in patients with MMHN.

MATERIALS AND METHODS

The study included 34 patients with MMHN who underwent surgical resection as initial treatment at 10 institutions in Japan between July 2005 and June 2015. Results: The 5-year overall survival (OS), local control rate (LCR), disease-free survival (DFS), and disease-specific survival (DSS) rates were 48.7%, 53.4%, 32.4%, and 55.1%, respectively. Based on multivariate analysis, no independent prognostic factors for the 5-year OS and DSS were found. Based on univariate analysis, the 5-year LCR was worse in patients with lesions in the nasal cavity and paranasal sinuses than in the oral cavity and pharynx. However, no differences in oncological outcomes were identified in relation to primary sites, and postoperative radiotherapy (PORT) and adjuvant systemic therapy did not contribute to improvements in the 5-year OS.

CONCLUSIONS

No independent prognostic factors for the 5-year OS or DSS were identified. Regional or distant recurrences are often identified, regardless of local control with surgical resection. Difficult control of MMHN with conventional therapeutic strategies, such as surgical intervention, PORT, and systemic therapy, has been suggested.

Clinical outcomes and patterns of failure of head and neck mucosal melanoma treated with multiple treatment modalities

OBJECTIVES

The study aims to analyze the clinical characteristics of head and neck mucosal melanoma (MMHN) and the effects of multiple treatment modalities on distant metastasis, recurrence and survival rates to provide a reference for the individualized treatment of MMHN.

METHODS

We retrospectively reviewed 262 patients with stage III-IVb MMHN treated from March 1986 to November 2018 at our cancer center.

RESULTS

The median follow-up time was 34.0 months (range 1-262 months). The 5-year overall survival (OS), distant metastasis-free survival (DMFS) and disease-free survival (DFS) probabilities were 37.7%, 30.2%, and 20.3%, respectively. The 5-year OS rates for patients with stage III, stage IVA, and stage IVB MMHN were 67.0%, 24.1% and 8.3%, respectively (P < 0.001). A total of 246 (93.9%) patients received surgery, 149 (56.9%) patients received chemotherapy, and 69 (26.3%) patients received immunologic/targeted therapy. A total of 106 (40.5%) patients were treated with radiotherapy: 9 were treated with preoperative radiotherapy, 93 were treated with postoperative radiotherapy, and 4 were treated with radiotherapy alone. In the multivariate Cox regression analysis, primary tumor site, T stage, and immunologic/targeted therapy were independent factors for OS (all P < 0.05). Irradiation technique, T stage, and N stage were independent prognostic factors for DMFS (all P < 0.05). T stage, N stage, and surgery were independent prognostic factors for DFS (all P < 0.05). Distant metastasis was observed in 107 of 262 patients (40.8%), followed by local [74 (28.2%)] and regional [52 (19.8%)] recurrence.

CONCLUSIONS

The main reason for treatment failure in MMHN is distant metastasis. Immunologic/targeted therapy and surgery are recommended to improve the survival of MMHN. The American Joint Committee on Cancer (AJCC) 8th edition staging system for MMHN does stage this disease effectively.

Outcomes of endoscopic and open resection of sinonasal malignancies: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy of endoscopic and open resection of sinonasal malignancies.

METHODS

The search was performed using PubMed (1950-2020), Embase (1974-2020), the Cochrane library, and the website clinicaltrials.gov. The hazard ratio, HR, 95% confidence interval, CI, of the rates of overall survival and disease-free survival and the demographic characteristics of the included studies were extracted and analyzed. Pooled analysis was conducted with the studies' individual patient data, using log-rank test, Kaplan-Meier survival, and Cox regression analysis.

RESULTS

Of 1939 articles retrieved, 23 articles were included. Overall, 1373 cases were incorporated into the final analysis, 653 (47.56%) of which underwent the surgery through an endoscopic approach, whereas 720 (52.44%) cases utilized the open approach. The overall survival was comparable between endoscopic and open resection (HR = 0.84 [95% CI: 0.65-1.07], p = 0.16; random effects analysis). Pooled analysis with Cox regression revealed signifcant differences in overall survival (HR = 0.568 [95%CI:0.380-0.849], p = 0.006) and disease-free survival (HR = 0.628 [95%CI:0.424-0.929], p = 0.02) between endoscopic and open approaches.

CONCLUSION

The aggregated evidence suggests the survival outcome of endoscopic resection is comparable or greater than that of open resection of sinonasal malignancies.

Melanoma of the oral cavity: A silent killer

Melanoma of the mouth is a rare entity of cancer. It has a bad prognosis. We report two cases of mouth melanoma. In the first case, 68 years old man developed a mandibular gingival tumor. Head and neck MRI scans showed an aggressive tumor process in the mouth with bone extension and in the deep spaces. The patient was free of cervical lymph nodes. The second case is a 75-years-old male with heavy tobacco smoke. The man felt a burgeoning mass on the right palate. The neck palpation found a firm mobile non-tender mass at the left upper jugular region. The anatomopathological study of the biopsies assigned both cases to malignant melanoma. Because of the rarity and delays in diagnosis, case reports are an invaluable source of information.

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Melanoma of the mouth is a rare entity of cancer with a bad prognosis.

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Tobacco and alcohol use are two of the most important risk factors for oral cavity and oropharyngeal cancers.

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Maxillofacial surgeons and physicians who treat oral lesions must be conscious of the need for early diagnosis of melanoma.

Surgical Treatment of Sinonasal Mucosal Melanoma in Patients Treated with Systemic Immunotherapy

Objective  Surgical resection is widely accepted as a critical component for definitive treatment of sinonasal mucosal melanoma. Systemic immunotherapy, including multiple newer agents, has been used to treat metastatic or unresectable disease. In this study, we examine its efficacy in locoregional control when used in conjunction with surgical resection for primary mucosal lesions. Design  Present study is a retrospective review of all patients at a tertiary academic medical center with primary sinonasal mucosal melanoma and distant metastatic disease. Results  A total of four patients were identified. In all cases, patients were treated with a combination of surgical resection of the primary tumor and systemic immunotherapy. Three patients were initially treated with surgery at the primary site followed by immunotherapy for distant metastases. Response to immunotherapy at the sites of primary and metastatic disease was seen in two patients. All four patients developed progression or recurrence at the primary site following initiation of immunotherapy for which they underwent surgical resection. One patient remains in follow-up without evidence of disease 20 months after initial treatment; three succumbed to the disease at 135, 37, and 16 months after initial treatment. Conclusion  Surgical resection for local control plays a critically important role in the treatment of sinonasal mucosal melanoma regardless of the presence of metastases and whether immunotherapy will be given. This case series suggests that, though immunotherapy may demonstrate efficacy in managing distant disease, surgery should remain the first-line treatment for the primary site.

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.

Open Versus Endoscopic Approach for Sinonasal Melanoma: A Systematic Review and Meta-analysis

Background

Open resection (OR) of sinonasal mucosal melanoma (SNM) traditionally has been the gold standard for treatment. However, endoscopic resection (ER) has recently become a surgical alternative. The aim of this study was to compare survival outcomes between OR and ER of SNM.

Methods

A literature search encompassing PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and Google Scholar was performed. Two reviewers independently screened for original studies comparing survival outcomes between OR and ER for SNM. Data were systematically collected on study design, patient demographics, outcomes, and level of evidence. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Meta-analysis of overall survival and disease-free survival was performed using random-effects models.

Results

The initial search yielded 2078 abstracts, of which 9 cohort studies were included for a total of 510 patients from 6 different countries. The average quality of all included studies using the NOS was 7.7 stars. Six out of 7 studies reported no differences in the stages of SNM between patients receiving ER versus OR. Overall survival was longer in the ER group versus OR group (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.49–0.95). There was no significant difference in disease-free survival between groups (HR: 0.59, 95% CI: 0.28–1.25).

Conclusion

Based on the available literature, an endoscopic approach for SNM resection has survival outcomes that are similar or greater compared to an open approach.

Oral malignant melanoma: History of malignant degeneration of a pigmented lesion

Introduction: Oral malignant melanoma (OMM) is a rare malignant lesion of the oral mucosa. It accounts for 0.5% of oral cavity cancers and less than 1% of all melanomas. Most cases arise on the palate or gingiva. OMM is caused by unknown factors. Benign pigmentation may precede the neoplasm by several years. The malignant transformation of benign melanosis is poorly understood. Observation: The aim of this work is to present a new clinical case of oral malignant melanoma which appeared on benign melanosis with a brief review of the literature. A 37-year-old woman presented with a blackish pigmented plaque that covered the hard palate and vestibular maxillary gingiva and a soft, friable 2 cm nodule with ulcerated surface next to the 11, 12 and 13. Fifteen years ago, the patient underwent a biopsy that was in favor of benign melanosis. Unfortunately, the patient was followed for one year and then was lost. Recently, in front of the rapidity of the extension of the lesion, she came again. After biopsy, a final diagnosis of OMM is retained. Commentaries: OMM is often asymptomatic. It presents usually as a 1.5–4 cm, blackish grey, irregular, flat or nodular lesion. The neoplasm can appear on apparently normal oral mucosa and may be preceded by benign pigmented lesions. Few articles discussed malignant transformation of benign melanosis. OMM is characterized by its poor prognosis. The treatment of choice for OMM remains surgery with wide clear margins. Conclusion: Close monitoring is needed to detect signs of transformation and to early diagnose melanoma.

Contemporary Treatment Approaches to Sinonasal Mucosal Melanoma

Sinonasal mucosal melanoma (SNMM) is a rare oncological entity that comprises most head and neck mucosal melanomas. SNMM has distinctive genetic background, different from cutaneous melanoma. Survival outcomes among SNMM patients are poor; while there is no clear consensus on the optimal management of SNMM, the primary treatment modality is generally considered to be wide surgical excision, and radiation therapy (RT) is often used in the postoperative adjuvant setting to improve locoregional control. Systemic therapies have demonstrated little or no survival benefit, and most SNMM patients die of distant metastatic disease. Owing to the rarity of the disease, the literature describing treatment approaches for SNMM is lacking and largely limited to isolated case reports and retrospective series. Here, we describe contemporary diagnostic and therapeutic approaches to SNMM based on the most recent molecular and outcome data.

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.