MR imaging features of primary mucosal melanoma of the eustachian tube: report of 2 cases

MRI-based radiomics for prognosis of pediatric diffuse intrinsic pontine glioma: an international study

Background

Diffuse intrinsic pontine gliomas (DIPGs) are lethal pediatric brain tumors. Presently, MRI is the mainstay of disease diagnosis and surveillance. We identify clinically significant computational features from MRI and create a prognostic machine learning model.

Methods

We isolated tumor volumes of T1-post-contrast (T1) and T2-weighted (T2) MRIs from 177 treatment-naïve DIPG patients from an international cohort for model training and testing. The Quantitative Image Feature Pipeline and PyRadiomics was used for feature extraction. Ten-fold cross-validation of least absolute shrinkage and selection operator Cox regression selected optimal features to predict overall survival in the training dataset and tested in the independent testing dataset. We analyzed model performance using clinical variables (age at diagnosis and sex) only, radiomics only, and radiomics plus clinical variables.

Results

All selected features were intensity and texture-based on the wavelet-filtered images (3 T1 gray-level co-occurrence matrix (GLCM) texture features, T2 GLCM texture feature, and T2 first-order mean). This multivariable Cox model demonstrated a concordance of 0.68 (95% CI: 0.61–0.74) in the training dataset, significantly outperforming the clinical-only model (C = 0.57 [95% CI: 0.49–0.64]). Adding clinical features to radiomics slightly improved performance (C = 0.70 [95% CI: 0.64–0.77]). The combined radiomics and clinical model was validated in the independent testing dataset (C = 0.59 [95% CI: 0.51–0.67], Noether’s test P = .02).

Conclusions

In this international study, we demonstrate the use of radiomic signatures to create a machine learning model for DIPG prognostication. Standardized, quantitative approaches that objectively measure DIPG changes, including computational MRI evaluation, could offer new approaches to assessing tumor phenotype and serve a future role for optimizing clinical trial eligibility and tumor surveillance.

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.

Primary Middle Ear Mucosal Melanoma: Case Report and Comprehensive Literature Review of 21 Cases of Primary Middle Ear and Eustachian Tube Melanoma

OBJECTIVE

To present a case of primary middle ear mucosal melanoma and perform a comprehensive literature review of middle ear and eustachian tube mucosal melanoma.

PATIENT

A 61-year-old female presented with no prior history of melanoma and 3 months of aural fullness. A middle ear mass demonstrated primary mucosal melanoma. The mass extended from mesotympanum into hypotympanum, epitympanum, protympanum, eustachian tube, and mastoid antrum. Additionally, a nonenhancing expansile lesion of the petrous apex was noted on magnetic resonance imaging.

INTERVENTION

Subtotal temporal bone resection with transotic approach to the petrous abnormality was performed. Postoperative adjuvant radiation and immunotherapy were given.

RESULTS

Five months postoperatively, the patient developed an isolated cutaneous metastatic focus treated with wide local excision and has had no further evidence of recurrence to date. Upon comprehensive literature review, patients with primary middle ear melanomas (n = 10) present with otorrhea (50%), aural fullness (40%), and hearing loss (30%) most commonly, while hearing loss (81.8%) and aural fullness (54.5%) were the most common presenting symptoms for eustachian tube melanomas (n = 11). Patients were treated with combinations of surgery, radiation, and/or chemotherapy. Middle ear melanoma demonstrated particularly poor outcomes, with 70% mortality, 20% local recurrence, and 50% distant metastasis, whereas eustachian tube origin demonstrated 9.1%, 18.2%, and 36.4%, respectively.

CONCLUSIONS

Middle ear and eustachian tube mucosal melanomas are exceedingly rare, with middle ear melanomas demonstrating a worse prognosis. Multimodality therapy is commonly used; however, outcomes are poor, with high mortality among affected patients.

Mucosal Melanoma Originating From the Eustachian Tube

A 77-year-old man was referred with a 4-month history of hearing impairment and ear fullness of the left ear. Otoscopic examination revealed an effusion in the left middle ear, and nasal endoscopic examination revealed a dark polypoid lesion at the opening of the left Eustachian tube. In addition to the lesion of the Eustachian tube, a dark mucosal lesion was seen at the posterior choana and the posterior end of the nasal septum. Endoscopic biopsy was done and pathologic result was consistent with malignant melanoma. Wide surgical excision with postoperative radiotherapy was performed; multiple metastases were detected 4 months after the treatment. Mucosal melanoma originating from nasopharynx was extremely rare, but careful examination of nasopharyngeal area should be considered when the patient presents with unilateral middle ear effusion, especially in older age.

Primary mucosal melanoma arising from the eustachian tube with CTLA-4, IL-17A, IL-17C, and IL-17E upregulation

Primary malignant melanoma arising from the eustachian tube is extremely rare. We report the case of a 63-year-old white man who presented with a 1-month history of left-sided hearing loss and aural fullness. Flexible fiberoptic laryngoscopy detected a blue-purple mass that appeared to arise from the left lateral nasopharynx. Computed tomography demonstrated an enhancing mass arising from an orifice of the left eustachian tube. The tumor was debulked endoscopically and was confirmed to have originated in the left eustachian tube. Histologically, the tumor was made up of heavily pigmented pleomorphic spindle cells with frequent mitoses. The tumor cells were immunohistochemically positive for S-100 protein, HMB-45, Melan-A, and PNL-2. The final diagnosis was a mucosal malignant melanoma. We also performed a nested polymerase chain reaction assay for several genes of interest, including CTLA-4, IL-17A, IL-17B, IL-17C, IL-17D, IL-17E, IL-17F, PLZF, Foxp3, RORγt, CD27, and CD70. These genes have been studied mainly in cutaneous melanomas, especially for the development of immunotherapy, but only very limited studies have been done on mucosal melanomas. Our investigation found upregulation of CTLA-4, IL-17A, IL-17C, and IL-17E. Based on our finding of CTLA-4 upregulation, it may be suggested that our patient might have had low antitumor immunity and that he might have benefited from CTLA-4 blockade. On the other hand, upregulation of IL-17A and IL-17E might reflect increased antitumor immunity, which could suggest that patients with a mucosal melanoma might benefit from immunomodulators associated with the effect of Th17. These genes also have great potential to help melanoma patients obtain tailored treatment, and they can be used as biomarkers for predicting prognosis.

Imaging finding of malignant melanoma of Eustachian tube with extension to middle ear cavity: case report

We report a case of malignant melanoma of Eustachian tube with extension to the middle ear cavity and nasopharynx in a 51-year-old woman who presented with right ear fullness. Computed tomography showed a soft tissue mass in the middle ear cavity and causedthe widening and eroding of the bony eustachian tube. Magnetic resonance imaging showed well enhancing mass in eustachian tube extending nasopharynx to middle ear cavity. A biopsy of the middle ear cavity mass revealed a malignant amelanotic melanoma.

Primary tumors and tumor-like lesions of the eustachian tube: a systematic review of an emerging entity

Eustachian tube (ET) primary tumors and tumor-like lesions are rare diseases presenting with common ear, nose and throat symptoms. Pathology can range from developmental anomalies to high malignant neoplasms. Hence this review aimed at suggesting a classification and outline relevant aspects of ET primary tumors and tumor-like lesions, describing clinical findings, diagnostic management and therapeutic approaches. MEDLINE, CINAHL, OVIDSP, HIGHWIRE, and GOOGLE databases were searched from inception to July 2011 for relevant studies. Further papers were identified by examining the reference lists of all included. Sixty-five papers met the inclusion criteria, enclosing 78 cases. Case reports are increasing in the past few years. Benign lesions and tumor-like lesions of ET have been reported. Moreover, melanomas, carcinomas, and sarcomas can affect the ET as a primary site.

Functional MR imaging of the eustachian tube in patients with clinically proven dysfunction: correlation with lesions detected on MR images

OBJECTIVES

To visualise the function of the Eustachian tube by MRI and assess the effect of surrounding lesions.

METHODS

Using 1.5 T MRI, 32 Eustachian tubes of 16 patients with clinically proven dysfunction (clinical symptoms, such as autophonia and fullness and non-opening at tympanometry) were investigated. For depiction of the anatomy and associated abnormalities, coronal and axial T2-weighted turbo spin echo sequences and a T1-weighted-2D-gradient echo sequences were acquired. Eustachian tube opening was analysed with real time turbo-gradient echo sequences during a Valsalva manoeuvre.

RESULTS

Dysfunction, that is, failure of opening of the Eustachian tube as shown by MRI, correlated in all patients with tympanometry. Lesions detected included nasopharyngeal carcinoma in 4 patients. Mucosal swelling in the paranasal sinus was present in 9 patients. One patient had postoperative defects. In two patients both pharyngotympanic tubes did not open although no structural abnormalities could be depicted.

CONCLUSIONS

The opening of the Eustachian tubes during the Valsalva manoeuvre is assessable on MRI. Failure of opening may be due to swelling of the mucosa and may be also associated with tumours. MRI assessment may be helpful in patients with chronic otitis media, where the information about tubal function is important in preoperative planning.

KEY POINTS

•Eustachian tube opening during Valsalva manoeuvre can be visualised with MRI •Lesions hampering tubal opening can be delineated at the same MRI examination •Functional MRI of the Eustachian tubes might determine the cause of dysfunction.

Malignant mucosal melanoma in the nasal cavity: an uncommon cause of epistaxis

Malignant mucosal melanoma of the nasal cavity is extremely rare. It is usually diagnosed in the elderly. We report a 78-year-old man who had symptoms of occasional episodes of epistaxis and blood-tinged sputum for about 1 month. Physical examination showed a dark-colored mass lesion over the left nasal cavity, and biopsy of it revealed malignant melanoma. Wide excision of the tumor was performed via endoscopic surgery, and adjuvant radiotherapy was also arranged. Diagnosis of malignant melanoma mainly depends on histochemistry and immunostain. Up to now, surgery offers the best chance for local tumor control. However, postoperative radiotherapy or chemotherapy is often needed because mucosal melanomas tend to have distant metastasis and local failure. Immunotherapy may play a role in improving outcome, but evidence is lacking.