Comparison of primary and metastatic malignant melanoma of the esophagus: clinicopathologic review of 10 cases

Comparative Epigenetic Profiling Reveals Distinct Features of Mucosal Melanomas Associated with Immune Cell Infiltration and Their Clinical Implications

Mucosal melanoma exhibits limited responsiveness to anti-PD-1 therapy. However, a subgroup of mucosal melanomas, particularly those situated at specific anatomic sites like primary malignant melanoma of the esophagus (PMME), display remarkable sensitivity to anti-PD-1 treatment. The underlying mechanisms driving this superior response and the DNA methylation patterns in mucosal melanoma have not been thoroughly investigated. We collected tumor samples from 50 patients with mucosal melanoma, including 31 PMME and 19 non-esophageal mucosal melanoma (NEMM). Targeted bisulfite sequencing was conducted to characterize the DNA methylation landscape of mucosal melanoma and explore the epigenetic profiling differences between PMME and NEMM. Bulk RNA sequencing and multiplex immunofluorescence staining were performed to confirm the impact of methylation on gene expression and immune microenvironment. Our analysis revealed distinct epigenetic signatures that distinguish mucosal melanomas of different origins. Notably, PMME exhibited distinct epigenetic profiling characterized by a global hypermethylation alteration compared with NEMM. The prognostic model based on the methylation scores of a 7-DMR panel could effectively predict the overall survival of patients with PMME and potentially serve as a prognostic factor. PMME displayed a substantial enrichment of immune-activating cells in contrast to NEMM. Furthermore, we observed hypermethylation of the TERT promoter in PMME, which correlated with heightened CD8+ T-cell infiltration, and patients with hypermethylated TERT were likely to have improved responses to immunotherapy. Our results indicated that PMME shows a distinct methylation landscape compared with NEMM, and the epigenetic status of TERT might be used to estimate prognosis and direct anti-PD-1 treatment for mucosal melanoma.

SIGNIFICANCE

This study investigated the intricate epigenetic factor of mucosal melanomas contributed to the differential immune checkpoint inhibitor response, and found that PMME exhibited a global hypermethylation pattern and lower gene expression in comparison to NEMM. TERT hypermethylation may contribute to the favorable responses observed in patients with mucosal melanoma undergoing immunotherapy.

Rare malignant neoplasm of the esophagus: current status and future perspectives

Esophageal cancer is common worldwide, including in Japan, and its major histological subtype is squamous cell carcinoma. However, there are some rare esophageal cancers, including neuroendocrine neoplasm, gastrointestinal stromal tumor, carcinosarcoma and malignant melanoma. The biological and clinical features of these cancers differ from those of esophageal squamous cell carcinoma. Therefore, different treatment strategies are needed for these cancers but are based on limited evidence. Neuroendocrine neoplasm is mainly divided into neuroendocrine tumor and neuroendocrine carcinoma by differentiation and the Ki-67 proliferation index or mitotic index. Epidemiologically, the majority of esophageal neuroendocrine neoplasms are neuroendocrine carcinoma. The treatment of neuroendocrine carcinoma is similar to that of small cell lung cancer, which has similar morphological and biological features. Gastrointestinal stromal tumor is known to be associated with alterations in the c-KIT and platelet-derived growth factor receptor genes and, if resectable, is treated in accordance with the modified Fletcher classification. Carcinosarcoma is generally resistant to both chemotherapy and radiotherapy and requires multimodal treatments such as surgery plus chemotherapy to achieve cure. Primary malignant melanoma is resistant to cytotoxic chemotherapy, but immune checkpoint inhibitors have recently demonstrated efficacy for malignant melanoma of the esophagus. This review focuses on the current status and future perspectives for rare cancer of the esophagus.

Esophageal tumors: The keys to diagnosis by pneumo-computed tomography

OBJECTIVE

To review and describe the most characteristic radiological findings of the most frequent esophageal tumor lesions, with emphasis on the esophago-gastric distention technique pneumo-computed tomography performed in our institution. To know the main advantage of this distension technique.

CONCLUSION

Malignant tumor lesions (predominantly squamous cell carcinoma in the mid esophagus and adenocarcinoma in the distal esophagus) present as asymmetric wall thickening, mucosal irregularity, or mass extending into adjacent organs with lymph node involvement. Benign tumors (mainly leiomyoma being the most frequent and others such as lipoma) present as endoluminal growth, with defined borders and homogeneous attenuation. Post-contrast enhancement is scarce or moderate. The technique of computed tomography pneumotomography technique achieves an additional distension of the esophageal lumen in all cases. It allows delimiting the superior and inferior borders of the lesions, helping the surgeon to define the therapeutic strategy.

Primary malignant melanoma of the esophagus combined with squamous cell carcinoma: A case report

BACKGROUND

Primary malignant melanoma of the esophagus is a rare malignant tumor of the esophagus, and its combination with squamous cell carcinoma is also rare. Here, we report the diagnosis and treatment of a case of primary esophageal malignant melanoma combined with squamous cell carcinoma.

CASE SUMMARY

A middle-aged man underwent gastroscopy for dysphagia. Gastroscopy revealed multiple bulging esophageal lesions, and after pathologic and immunohistochemical analyses, the patient was finally diagnosed with "malignant melanoma with squamous cell carcinoma". This patient received comprehensive treatment. After one year of follow-up, the patient was in good condition, and the esophageal lesions seen on gastroscopy were controlled, but unfortunately, liver metastasis occurred.

CONCLUSION

When multiple esophageal lesions are present, the possibility of multiple pathological sources should be considered. This patient was diagnosed with primary esophageal malignant melanoma combined with squamous cell carcinoma.

Primary colonic melanoma: a rare entity

Gastrointestinal melanoma is usually metastatic in origin, and primary melanoma within the gastrointestinal tract is rarely reported. Colon is considered to be an extremely uncommon site for primary melanomas. Herein, we report the first case of a large primary melanoma within the transverse colon with gastric involvement. CT scan found a mass within the colon, which seemed to connect to the gastric antrum. Esophagogastroscopy showed an ulcerated lesion in the greater curvature of the stomach. Subsequent colonoscopy identified a large ulcerated lesion rendering significant stenosis of the transverse colon. Biopsy following colonoscopy indicated a diagnosis of colonic melanoma based on pathological findings, which identified submucosal malignant melanoma cells with epithelioid and spindle features. Immunohistochemical stains were positive for S-100, HMB-45, Vimentin, and Melan-A. A series of clinical and imaging examinations revealed no suspicious primary cutaneous or ocular lesions. The diagnosis of primary colonic melanoma was considered. A radical transverse colectomy with subtotal gastrectomy were conducted subsequently. Definite diagnosis of primary colonic melanoma can be established after ruling out the possibility of being a metastasis from other more common primary sites. Primary colonic melanomas are a challenge to diagnose and often need a multidisciplinary treatment approach, including surgery, BRAF-targeted therapy, and immunotherapy.

The Thousand Faces of Malignant Melanoma: A Systematic Review of the Primary Malignant Melanoma of the Esophagus

Primary Malignant Melanoma of the Esophagus (PMME) is an extremely rare cancer of the esophagus, accounting for 0.1−0.8% of all oro-esophageal cancers and <0.05% of all melanoma subtypes, with an estimated incidence of 0.0036 cases per million/year. We conduct a careful analysis of the literature starting from 1906 to the beginning of 2022, searching the PubMed, Science.gov, Scopus and Web of Science (WoS) databases. A total of 457 records were initially identified in the literature search, of which 17 were duplicates. After screening for eligibility and inclusion criteria, 303 publications were ultimately included, related to 347 patients with PMME. PMME represents a very rare entity whose very existence has been the subject of debate for a long time. Over time, an increasing number of cases have been reported in the literature, leading to an increase in knowledge and laying the foundations for a discussion on the treatment of this pathology, which still remains largely represented by surgery. In recent times, the possibility of discovering greater mutations in gene hotspots has made it possible to develop new therapeutic strategies of which nivolumab is an example. Future studies with large case series, with clinicopathological and molecular data, will be necessary to improve the outcome of patients with PMME.

Immunotherapy against esophageal primary amelanotic malignant melanoma relapse

Melanoma is a malignant tumor derived from melanocytes. Esophageal melanomas occur infrequently, especially primary amelanotic malignant melanoma of the esophagus (PAMME), which is extremely rare. Here, we report the case of a 74-year-old man with an esophageal amelanotic melanoma on the esophagogastric junction (EGJ) found on esophagogastroduodenoscopy. Radical surgery for the tumor at the EGJ was performed with total gastrectomy and D2 lymph node dissection. Diagnosis of PAMME was confirmed postoperatively by immunohistochemical staining. Four months after the surgery, abdominal computed tomography revealed multiple liver metastases. The patient received seven cycles of nivolumab monotherapy and two subsequent cycles of nivolumab and ipilimumab, and these metastases diminished. Recently, new therapeutic agents including immunotherapy have been developed for malignant melanoma and these agents have the potential of improving the prognosis of PAMME. Here, we present new insights into the diagnosis and therapeutic methods that can be used against primary esophageal melanoma.

Characteristics and prognosis of primary malignant melanoma of the esophagus

Primary malignant melanoma of esophagus (PMME) is a rare malignant tumor of esophagus. This study aimed to investigate the clinic pathologic characteristics and analyze the factors that might affect the prognosis of PMME patients.A total of 20 PMME patients who underwent surgical treatment in our hospital from 1975 to 2017 were analyzed. The clinical data, surgical and pathologic features of all patients were collected.For 20 PMME patients, the average age was 57.3 ± 10.7 years, and the male patients account for 75%. Most of the tumors (95%) were located in the middle and lower of the esophagus. There were 7 patients with primary tumor invasion beyond the muscular layer (T3 + T4) and 10 patients with lymph node metastasis (LNM). The median survival time of 20 patients was 12 months, and the 1-year and 5-year survival rates were 50% and 16.9%, respectively. The probability of LNM in tumors confined to submucosa (T1) and myometrium (T2) was lower than that in tumors with deeper invasion (T3, T4) (P = .035). Multivariate analysis showed that tumor node metastasis (TNM) staging was the independent prognostic factor for survival of PMME patients (hazard ratio [95% confidence interval], 4.15 [1.36-12.67]; P = .012).For PMME patients, tumors with deeper invasion were more likely to have LNM, and TNM staging was an independent predictor of prognosis for survival. Early detection of the disease and radical resection of the tumor are critical for better survival of the PMME patients.

Clinical, Imaging, and Pathologic Features of Conditions with Combined Esophageal and Cutaneous Manifestations

A variety of clinically significant conditions can affect both the esophagus and the skin. Esophageal and cutaneous manifestations may directly reflect the underlying disease process, as in infections such as herpes simplex virus, bullous diseases such as epidermolysis bullosa and mucous membrane pemphigoid, connective tissue diseases such as systemic sclerosis, and inflammatory diseases such as lichen planus. Alternatively, esophageal and cutaneous findings may result from conditions that are closely associated with and potentially pathognomonic for but distinct from the underlying disease process, as in genetic diseases such as Cowden syndrome or paraneoplastic syndromes such as acrokeratosis paraneoplastica. Other diseases such as Crohn disease may have cutaneous manifestations that directly reflect the same underlying inflammatory process that affects the gastrointestinal tract or cutaneous manifestations that represent reactive or associated conditions distinct from the underlying inflammatory process. The cutaneous manifestations of disease may precede, coincide with, or follow the esophageal manifestations of disease. The authors present the characteristic clinical features and imaging findings associated with common and uncommon conditions that have esophageal and cutaneous manifestations. Each condition is presented with a brief overview, discussion of salient clinical and cutaneous manifestations, and description of the typical esophageal imaging findings, with particular attention to implications for diagnosis, prognosis, and treatment. Recognition of potential associations between cutaneous lesions and esophageal imaging findings is important for establishing a specific diagnosis or generating a meaningful differential diagnosis.

Clinicopathological presentations and surgical outcomes of esophageal melanoma

Background

Primary malignant melanoma of the esophagus is a rare tumor with a poor prognosis; the optimal treatment strategy has yet to be established. This study aimed to clarify clinical features, courses, and outcomes of patients undergoing surgical resection of primary malignant melanoma of the esophagus.

Methods

Six patients with primary malignant melanoma of the esophagus, in whom the absence of other primary melanomas had been confirmed, were selected from the medical database maintained in Toranomon Hospital. Their clinicopathological characteristics and long-term outcomes were retrospectively reviewed and analyzed.

Results

All 6 patients (five males and one female) underwent radical esophagectomy with three-field regional lymphadenectomy, and none received neoadjuvant therapy. Tumor invasion was classified into T1 in 5 (83%) cases and T3 in one (17%). Four (67%) patients had nodal metastases (one N1, one N2 and two N3). No distant metastatic lesions were detected preoperatively in any of our cases. Postoperative surveillance revealed recurrence in all 6 patients, and 5 (83%) died of the disease. The median overall survival was 24 months. One patient with a T3N3M0 tumor was treated after surgery with a dacarbazine-nimustine-vincristine regimen followed by irradiation for bone recurrence and survived for 87 months postoperatively. Another patient with a T1N3M0 tumor who survived for 27 months after liver and bone recurrence was treated with nivolumab, ipilimumab, and dacarbazine.

Conclusion

Although the courses of patients with primary malignant melanoma of the esophagus were consistently unfavorable, surgical resection with multidisciplinary therapeutic modalities may prolong survival in some cases.

Primary malignant melanoma of esophagus: clinicopathologic characterization of 20 cases including molecular genetic profiling of 15 tumors

Primary malignant melanoma of esophagus is very rare, and its clinicopathologic and genetic features have not been extensively investigated. In this study, 20 tumors from 14 male and 6 female patients (40-79 years old) were evaluated. Dysphagia, chest pain, and weight loss were frequent symptoms. Thirteen melanomas, including two with multiple lesions, involved the distal third of esophagus. The median tumor diameter was 6 cm. Epithelioid morphology, moderate atypia, and pigmentation were typical findings. None of the patients had melanoma elsewhere, and all tumors exhibited a junctional peri-epithelial component consistent with a primary lesion. The median mitotic activity was 11 per 10 high-power fields (range, 0-31). Nine patients died of tumor within 4-22 months, however, two showed long-term (96 and 104 months) survival. In 15 cases, tissue for further immunohistochemical and molecular studies were available. BRAF, KIT, and NRAS mutation status was assessed by Sanger sequencing in all 15 tumors. The next-generation sequencing of 50 or 409 genes was performed in five and three cases, respectively. IGF1R expression indicating activation of the IGF axis was seen in 82% (9/11) of tumors. However, no BRAF mutations were identified. In 33% (5/15) of tumors, NRAS mutations were detected. KIT expression was seen in 50% (7/14) of melanomas including single KIT mutant. Two of three tumors evaluated with 409 genes panel revealed multiple driver mutations indicating sub-clonal expansion, whereas a single mutation (TSC1 p.H371Q) was the sole change in the third case. SF3B1 p.K666T and p.R625C mutations were detected in two cases. However, no co-occurrence of SF3B1 and GNAQ or GNA11 mutations, seen in uveal melanoma, was detected. FBXW7 p.R465C and p.R479G mutations, linked to cancer progression, were found in two of eight tumors. In summary, esophageal melanoma mutation profile indicates complexity of molecular mechanisms underlying its pathogenesis.

Malignant melanoma of the esophagus complicated with poorly differentiated mucinous adenocarcinoma of the stomach: A case report

RATIONALE

Primary malignant melanoma of the esophagus (PMME) is a rare malignancy that only accounts for <2% of all primary esophageal tumors. Here, we report the even rarer occurrence of PMME in combination with poorly differentiated mucinous adenocarcinoma of the stomach.

PATIENT CONCERNS

A 64-year-old man was presented to the hospital with >1 month of eating dysphagia. Enhanced computed tomography (CT) scan only found a space-occupying lesion in the lower esophagus with moderate enhancement. However, gastroscope showed not only esophageal masses, but also gastric mucosa changes.

DIAGNOSES

Poorly differentiated mucinous adenocarcinoma and PMME were diagnosed based on pathological biopsy and immunohistochemical methods.

INTERVENTIONS

The patient underwent laparoscopic gastric cancer radical surgery, esophageal resection, and colonic replacement of the esophagus.

OUTCOMES

Abdominal CT and esophagography performed 1 week after surgery showed that it was consistent with postoperative changes without other abnormalities. However, the patient died 3 months after discharge without receiving any other treatment.

LESSONS

This case suggests more attention should be drawn to the diagnosis of multiple primary malignant neoplasms in elder patients, and also highlights the need to fulfill comprehensive examinations before surgery in case of misdiagnosis. Besides, it is challenging to finding a reasonable treatment for such rare condition.

Immunohistochemistry: sole tool in diagnosing a rare case of primary vaginal amelanotic melanoma

We report a rare case of vaginal amelanotic melanoma. Malignant melanomas are cutaneous and extracutaneous tumors that arise from embryological remnants of neural crest cells/melanocytes. Amelanotic melanomas at such rare locations can be misdiagnosed both clinically and radiologically. Therefore, histopathological examination and immunohistochemistry are mandatory for the diagnosis of these tumors. We diagnosed this case using histopathology and confirmed the diagnosis based on the presence of immunohistochemical markers human melanoma black 45 (HMB45) and S-100.

Intraepithelial Melanoma in the Stomach After Treatment With Immune Checkpoint Blockade Therapy

Melanoma is the most common tumor to metastasize to the gastrointestinal tract, commonly affecting the small intestine, colon, and anorectum. Primary mucosal melanoma can arise in any gastrointestinal site, most frequently affecting anorectal mucosa. Melanoma involving the gastric mucosa, specifically, is exceedingly rare and carries a poor prognosis with a median survival of 5 months. The presence of atypical melanocytes exclusively within gastric epithelium has not been previously described. We report a case of a 52-year-old man with widespread BRAFV600E mutant metastatic melanoma who was referred to our institution for immune checkpoint antibody-blockade therapy. The patient had previously been treated with BRAF inhibitors, and despite initial response to therapy, developed resistance leading to disease progression and multiorgan involvement including the liver, spleen, and axial skeleton. Immune checkpoint antibody blockade with ipilimumab and pembrolizumab has been shown to induce significant tumor regression in patients with melanoma by upregulating T-cell activity and removing the natural check on the host immune response. After his first dose of combination therapy, the patient underwent an upper gastrointestinal tract endoscopy for severe nausea and was found to have 2 pigmented lesions within the gastric body, one of which was biopsied. The biopsy showed gastric body-fundic type mucosa with melanophages and scattered atypical intraepithelial melanocytes within the lamina propria, which were strongly positive for S100, HMB45, SOX10, and MITF. A Fontana-Masson silver stain was performed for confirmation. The finding of predominantly atypical intraepithelial melanocytes associated with melanin pigment was interpreted as metastatic melanoma to the stomach with some regression in response to immune checkpoint blockade therapy.

Clinicopathological characteristics, staging classification, and survival outcomes of primary malignant melanoma of the esophagus

BACKGROUND

Primary malignant melanoma of esophagus (PMME) is a remarkably rare and highly aggressive tumor. Studies related with clinicopathological findings, staging classification, and clinical outcomes are lacking.

METHODS

We reviewed 21 cases of PMME at the Tianjin Medical University Cancer Institute and Hospital from January 2002 to February 2017.

RESULTS

Nineteen patients (90.48%) presented a history of dysphagia for months, and two (9.52%) experienced retrosternal pain. Histologically, tumors were composed of atypical melanocytes with melanocytosis surrounding the tumor. The overall survival was 1-40 months, with the median time of 10 months. The mucosal staging classification for upper aerodigestive tract showed better distribution of overall survival with different stages than that of the American Joint Commission on Cancer staging classification for esophagus, but without statistical difference. Both the clinical and pathological characteristics were not highly consistent with overall survival.

CONCLUSIONS

PMME is a considerably aggressive tumor with poor prognosis. The staging classification of mucosal melanoma of the upper aerodigestive tract may be a good option for PMME patients.

A long-term survivor with esophageal melanoma and pulmonary metastasis after single-stage esophagectomy and lobectomy: Case report and literature review

RATIONALE

The optimal therapeutic regimen for primary malignant melanoma of the esophagus (PMME) need to be further elucidated. Besides, the efficacy of surgery for PMME with remote metastasis is uncertain for its rarity.

PATIENT CONCERNS

Herein a previously healthy patient was admitted for dysphagia and fatigue, without significant weight loss.

DIAGNOSES

The pathological and molecular tests revealed his diagnosis of BRAF-mutant, advanced PMME with localized pulmonary metastasis.

INTERVENTIONS

Single-stage Ivor-Lewis esophagectomy and lobectomy were performed successfully, followed by 4 cycles of conventional chemotherapy, and concurrent high-dose interferon lasting for 1 year.

OUTCOMES

The patient survived without logo-regional recurrence or remote metastasis during the follow up of two and a half years up to now.

LESSONS

Timely resection of localized primary and metastatic lesions might deliver a chance to obtain better prognosis for selected PMME patients; however, high-quality trials with longer follow-up are needed.

A Rare Disease of the Digestive Tract: Esophageal Melanosis

Esophageal melanosis which is characterized by melanocytic proliferation in the squamous epithelium of the esophagus and melanin accumulatin of esophageal mucosa (EM) is a rare disease of the digestive system. Although esophageal melanosis is considered to be a benign disease, its etiology is not cleared and has been reported to be the precursor lesion of esophageal primary melanomas. In this report, we aimed to note esophageal melanosis in a 55-year-old female case who applied to our clinic with difficulty in swallowing, burning behind the breastbone in the stomach, heartburn, indigestion, and pain in the upper abdomen after endoscopic and pathologic evaluation. Complaints dropped with anti-acid therapy and case was followed by intermittent endoscopic procedures because of precursor melanocytic lesions.

Primary Malignant Melanoma of the Esophagus With Unusual Endoscopic Findings: A Case Report and Literature Review

Primary malignant melanoma of the esophagus (PMME) is a rare disease with an extremely poor prognosis. We experienced a 79-year-old man with PMME who had unusual endoscopic findings. On endoscopy, an elongated lump was detected on 1 side of the vertical axis of the esophagus. The mass extended progressively for 15 cm along the esophageal longitudinal axis and invaded half of the esophageal circumference. These endoscopic findings were not characteristic of PMME, and the condition was confirmed with biopsy and immunohistochemical staining. Here, we present this rare case and review the recent relevant literature regarding PMME. Doctors should be aware that PMME might present with unusual endoscopic findings.

Primary Spindle Cell Malignant Melanoma of Esophagus: An Unusual Finding

Malignant melanoma of esophagus is usually a metastatic tumour rather than a primary tumour. Primary malignant melanoma accounts for less than 0.2% of all esophageal neoplasm. We report a case of primary spindle cell malignant melanoma of esophagus in a 69-year-old male who presented with history of dysphagia since 1 month. Radiological examinations revealed polypoidal growth at lateral aspect of esophagus. Biopsy was reported as grade III squamous cell carcinoma. Video assisted thoracoscopic esophagectomy was performed. Histopathological examination along with immunohistochemistry gave confirmed diagnosis of primary spindle cell malignant melanoma of esophagus. Though a rare entity, due to its aggressive nature and poor prognosis primary malignant melanoma should be one of the differential diagnoses in a patient with polypoidal esophageal mass lesion. Despite radical surgical treatment prognosis is extremely poor.

Primary esophageal melanoma: report of a case

INTRODUCTION

Primary malignant melanoma of the esophagus is a rare tumor representing only 0.1-0.2% of esophageal malignancies. The goal of the study was to report on the management of a new case diagnosed and treated in our site.

CASE REPORT

A 67-year-old patient presented with dysphagia to solids with no other remarkable history or associated skin lesions. He underwent gastroscopy, which revealed a polypoid mass suggestive of neoplasm in the distal third of the esophagus. Biopsy indicated melanoma with positive immunohistochemical markers S100 and HMB45, and negative cytokeratins and CEA. Computerized tomography (CT) and positron-emission tomography (PET) scans showed no local infiltration or distant metastases. An Ivor-Lewis esophagectomy procedure was performed with regional lymphadenectomy. Postoperative stay lasted for three weeks, and no remarkable postsurgical complications arose. The pathological study of the specimen confirmed the diagnosis of primary esophageal melanoma.

DISCUSSION

Primary malignant melanoma of the esophagus has an unfortunate prognosis as it is an aggressive tumor usually diagnosed at an advanced stage, with local invasion and metastatic disease. Currently, surgery is the treatment of choice, with the remaining adjuvant therapies obtaining limited results.

Rapid and clinically significant response to masitinib in the treatment of mucosal primary esophageal melanoma with somatic KIT exon 11 mutation involving brain metastases: A case report

BACKGROUND

Malignant melanoma in the gastrointestinal tract may be primary or metastatic. Mucosal melanoma is a quite rare and aggressive disease, growing hidden and diagnosed with a certain delay which makes treatment difficult.

CASE REPORT

The authors present the first patient with c-kit exon 11 mutated primary esophageal melanoma treated with oral tyrosine kinase inhibitor masitinib. A 55-year-old-man presented with esophageal melanoma metastising into visceral organs and to the brain. The patient showed objective and clinical significant therapeutic response to masitinib. After initiation of masitinib, dysphagia and odynophagia disappeared within 1 week. Following 1 month of treatment, computed tomography showed a regression in the number and size of brain metastatic lesions and regression in visceral lesions. This therapeutic response, despite the aggressive disease on treatment initiation, effectively enabled the patient to have 6 months of quality life.

CONCLUSION

This report corroborates the plausibility of treating advanced melanoma carrying a mutation of KIT with masitinib. It also raises the question of masitinib treatment beyond progression. Additionally, the observed masitinib treatment effect on the brain suggests accumulation of therapeutically relevant concentration of masitinib in the central nervous system. This observation has possible ramifications for treatment of intracranial neoplasms.

Primary Malignant Melanoma of the Esophagus: A Case Report and Review of the Literature

BACKGROUND Primary malignant melanoma of the esophagus (PMME) is a rare cancer with a poor prognosis. It is often difficult to differentiate from non-epithelial malignant tumors, and immunohistochemical staining may be needed to diagnose the condition. The mainstay of treatment is usually surgical with curative or palliative intent, since radio- and chemotherapy do not really improve the outcome. The average survival rate after surgery is 34.5 months. At the time of diagnosis, 40-80% of cases have local regional lymph node metastases. CASE REPORT The case of a 67-year-old male patient with PMME is reported. He presented with progressive dysphagia. A computerized tomography was performed in which a polypoid mass was observed in the distal esophagus. It was originally suspected to be an adenocarcinoma, but was subsequently correctly diagnosed by immunohistochemical staining with HMB-45 antibody and by the presence of S-100 protein. A subtotal esophagectomy was performed. CONCLUSIONS Very few cases of PMME have been reported in the literature and there is only limited clinical experience with this disease. Therefore, it is very difficult to establish clear criteria for clinical recognition of this type of melanoma. Early histopathological confirmation of the character is essential for further treatment in case of confirmation of malignancy.

Primary malignant melanoma of the esophagus: A case report and review of the literature

Primary malignant melanoma of the esophagus (PMME) is a rare malignancy and the prognosis is typically poor. There is currently a lack of appropriate treatment strategies and clear guidance. The current study presents the case of a 65-year-old female with a two-month history of progressive dysphagia, the investigations of which resulted in a diagnosis of PMME. The patient was treated with a radical transhiatal esophagectomy with subcarinal lymphadenectomy followed by combined chemoimmunotherapy. The patient remains alive with no evidence of tumor progression at the 12-month follow-up. The purpose of the present study was to report a new case and to review the recent relevant literature regarding the treatment of PMME.

Rare presentations of primary melanoma and special populations: a systematic review

A subset of patients with melanoma present in rare and unique clinical circumstances requiring specific considerations with respect to diagnostic and therapeutic interventions. Herein, we present our review of patients with: (1) primary mucosal melanoma of the head and neck, gastrointestinal, and genitourinary tracts; (2) primary melanoma of the eye; (3) desmoplastic melanoma; (4) subungual melanoma; (5) melanoma in special populations: children, nonwhites, as well as a discussion of familial melanoma.

[Metastatic malignant melanoma of the oesophagus: case report]

We report a case of metastatic malignant melanoma in the oesophagus. 13 years after the wide excision of primary skin melanoma, we found a polypoid tumor in the upper third of the oesophagus. Biopsy result was melanoma malignum. After negative staging we performed transhiatal oesophagectomy with gastric conduit and cervical anastomosis. Metastatic nature of the oesophageal tumor was proven by histology. After uneventful postoperative course, the patient received adjuvant dacarbazine treatment. The patient was is in good condition, and disease free on the 18 month follow-up.

Endoscopic and pathologic findings associated with clinical outcomes of melanoma in the upper gastrointestinal tract

BACKGROUND

Melanoma that involves the upper gastrointestinal (GI) tract is rare and studies relating to endoscopic and pathologic findings with clinical outcomes are lacking. We reviewed the gross and microscopic patterns of the upper GI tract in primary and metastatic melanoma, and examined their association with clinical outcomes.

METHODS

Twenty-nine cases of primary esophageal (n = 19) and metastatic gastric and/or duodenal melanoma (n = 10) that were detected during upper GI endoscopy between 1995 and 2011 were retrospectively analyzed.

RESULTS

Three types of gross patterns were recognized-nodular pattern in 7 cases, mass-forming pattern in 18 cases, and flat pigmented pattern in 4 cases. In primary esophageal melanoma, 13 patients (68.4 %) underwent surgery and 9 received palliative therapy. Of all cases, 22 patients (75.9 %) died of disease progression; the median overall survival period was 12 months (interquartile range [IQR] 4.5-24.5 months), and from recognition of upper GI tract melanoma the median overall survival period was 9 months (IQR 3.5-17.0 months). In primary esophageal cases, skin melanoma stage better discriminated the patients with good prognosis than the esophageal cancer stage. The flat pigmented gross pattern proved to be a good prognostic factor in primary and metastatic GI tract melanomas (p = 0.016 and p = 0.046, respectively).

CONCLUSIONS

Melanoma of the GI tract is a highly aggressive disease with a poor prognosis, both in primary and metastatic cases. However, in primary esophageal melanoma, careful inspection of the mucosa during endoscopic examination followed by surgical resection may result in extended survival.

Metastatic melanoma in an esophagus demonstrating Barrett esophagus with high grade dysplasia

Background

Metastatic melanoma involving the esophagus is rare; the occurrence of metastatic melanoma in a background of Barrett esophagus is rarer still. We report a case of an 80 year-old male who presented to our institution for workup of Barrett esophagus with high-grade dysplasia and who proved to have metastatic melanoma occurring in the background of Barrett esophagus, the first report of this kind, to our knowledge, in the English literature.

Case presentation

An 80 year-old Caucasian male was diagnosed at an outside institution with Barrett’s esophagus with high grade dysplasia and presented to our institution for therapy. The patient underwent endoscopic mucosal resection using a band ligation technique of an area of nodularity within the Barrett esophagus. Microscopic examination demonstrated extensive Barrett esophagus with high-grade dysplasia as well as a second tumor which was morphologically different from the surrounding high-grade dysplasia and which was positive for S-100, HMB 45 and Melan-A on immunohistochemistry, consistent with melanoma. Further workup of the patient demonstrated multiple radiologic lesions consistent with metastases. Molecular studies demonstrated that the melanoma was positive for the 1799T>A (V600E) mutation in the BRAF gene. The overall features of the tumor were most consistent with metastatic melanoma occurring in a background of Barrett esophagus with high-grade dysplasia.

Conclusion

This case demonstrates a unique intersection between a premalignant condition (Barrett esophagus with high grade dysplasia) and a separate malignancy (melanoma). This report also shows the utility of molecular testing to support the hypothesis of primary versus metastatic disease in melanoma.

Primary malignant melanoma of the esophagus: a rare and aggressive disease

Primary malignant melanoma of the esophagus is an uncommon tumor, with approximately 300 cases having been reported thus far. The purpose of this study was to describe a case of a 60 year-old man with a 10 month history of progressive dysphagia and thoracic pain, the investigations of which led to a diagnosis of primary malignant melanoma of the esophagus. The patient underwent a transhiatal esophagectomy with subcarinal lymphadenectomy, and isoperistaltic gastric tube replacement of the esophagus. Nine months after surgery, he developed ischemic colitis, and metastasis in the mesentery was diagnosed. His disease progressed and he died one year after the esophagectomy. A review of the literature was performed.

Primary malignant melanoma of the esophagus

Primary malignant melanoma of the esophagus (PMME) comprises only 0.1–0.2% of all malignant esophageal tumors. PMME tumors are highly aggressive and metastasize early via hematogenic and lymphatic pathways. Treatment outcome is poor because the cancer has often advanced at the time of diagnosis. Inoperability, unsuccessful treatment with radiotherapy and chemotherapy in advanced tumors and metastases have contributed to its poor prognosis. Here, we present the endoscopic features, endoscopic ultrasonography findings and management of a PMME case.

Plasmacytoid melanoma of the urinary bladder and lymph nodes with immunohistochemical expression of plasma cell markers revealing primary esophageal melanoma

Plasmacytoid variant of melanoma is reported in only rare cases. We present the case of a 54-years-old man admitted for enlarged lymph nodes in the lumbar region. Initial diagnosis of plasmablastic lymphoma/plasma cell myeloma was considered. At our institute, a bladder polyp was removed. Microscopic exam demonstrated dense plasmacytoid cells infiltration with pigment deposits. Immunohistochemical study showed strong expression of HMB45, Melan A, and vimentin. There was focal positivity with S100 protein and CD138/syndecan-1. The diagnosis of metastatic plasmacytoid melanoma was finally established. Clinical exam revealed an esophageal melanoma with melanosis supporting its primary location. Although rarely, melanoma especially plasmacytoid variant may express plasma cell markers which may lead to erroneous diagnosis of plasma cell proliferation. Careful morphological examination for melanin pigment and the use of panel of melanocytic markers are helpful for diagnosis.

Signet-ring cell melanoma of the gastroesophageal junction: a case report and literature review

We report the first case, to our knowledge, of a possible primary, signet-ring cell melanoma of the gastroesophageal junction. The mass was initially diagnosed as an invasive, poorly differentiated carcinoma; however, on further review and immunohistochemical workup, the diagnosis of signet-ring cell melanoma was made. The lesion consisted of oval to round epithelioid cells undermining the gastric mucosa and infiltrating the muscularis mucosae. Tumor cells demonstrated abundant cytoplasm and eccentrically located nuclei, many with signet-ring cell morphology. The tumor cells were negative for mucin and pancytokeratin, strongly positive for S100 protein and Melan-A, and focally but strongly positive for human melanoma black-45. Diagnostic imaging failed to prove another site of melanoma, and no history of melanoma or cutaneous lesion was reported by the patient. Therefore, it was determined this was likely a primary lesion. We review the literature and previously reported cases of this rare histologic variant of melanoma.

Current status of primary malignant melanoma of the esophagus: clinical features, pathology, management and prognosis

Primary malignant melanoma of the esophagus (PMME) is a rare disease with an extremely poor prognosis. Up to 2011, approximately 300 cases had been reported worldwide. The average age of onset is 60.5 years old, with a prevalence of males (2:1). A typical finding of PMME is a lobular or polyploid, well-circumscribed and pigmented tumor, partly covered with normal mucosa. PMME represents various colors depending on its melanin quantity and commonly coexists with intramural metastases, melanocytosis or melanoma in situ. The tumor is located from the middle to lower thoracic esophagus. The accuracy of diagnosis from biopsy is approximately 80%, because many cases are misdiagnosed as a poorly differentiated carcinoma because of the absence of melanin granules. A definite diagnosis was made by immunohistochemical examination with positive results of S100 protein, HMB45 and neuron-specific enolase. PMME has a highly metastatic potential, and the incidence of distant metastasis at the initial diagnosis is around 40-80%. A metastatic tumor from cutaneous malignant melanoma is another pigmented esophageal tumor to be considered when making the differential diagnosis for PMME. Junctional activity with melanotic cells in the adjacent epithelium and the presence of in situ melanoma and/or a satellite tumor without a previous history of cutaneous melanoma are definitive. Most of the reported patients were treated with radical esophagectomy, which is believed to be an effective approach for localized PMME. Five-year survival rates have been achieved in 37% recently, while adjuvant therapy has not been proven to increase overall survival but plays a palliative role.

Simultaneous resection of metastatic melanoma in the esophagus and primary cutaneous melanoma showing partial regression: report of a case

We herein describe a case of melanoma that metastasized to the esophagus from a primary melanoma of the abdominal skin in a 40-year-old female. Esophagography and endoscopy demonstrated a 30-mm protruding mass in the proximal third of the esophagus, and this was diagnosed as malignant melanoma by mucosal biopsy. The patient also had a pigmented lesion on her abdominal skin, which was diagnosed immunohistochemically as a primary malignant melanoma from the resected specimen. The esophageal tumor was resected by transthoracic esophagectomy. Histopathologically, the radial growth phase of the tumor cells was not present in the esophageal lesion, which was diagnosed as melanoma metastatic to the esophagus. Postoperatively, the patient received 5 courses of DAV-Feron chemotherapy. Eight months after the chemotherapy, multiple metastases developed, including to the subcutis, bronchus, liver, adrenal gland and mediastinum. Chemotherapy was not effective at this stage. The patient died of multiple organ failure 21 months after initial esophagectomy.

Anorectal malignant melanomas: experience of Uludag University

Anorectal melanomas represent a group of mucosal melanomas with unknown etiology and poor prognosis. The lesions can be misdiagnosed as hemorrhoids during clinical examination. We reviewed the morphological and clinical features of 14 anorectal melanomas, and discuss the treatment modalities of this entity. Fourteen patients who were diagnosed with anorectal malignant melanoma between 1997 and 2004 were evaluated with regard to age, sex, size, morphology, lymph node or distant metastasis, treatment modality and survival. Eight patients were female and six were male, and their mean age was 58 years. The size of melanoma ranged from 3 cm to 8 cm. Pathological evaluation revealed epithelioid and spindle cell type tumor in seven and two patients, respectively, whereas, in the remaining seven patients, the tumor was composed of both types. Pigmentation was apparent in all tumors. There was lymph node metastasis in 11 patients and distant metastasis in all patients. Eleven patients underwent abdominoperineal resection and three were treated by local excision. Mean survival was 8.7 months. Prognosis of anorectal melanoma remains poor. Awareness of the diverse clinicopathological features of these lesions, both on the part of the clinicians and pathologists, is crucial for their early detection and proper treatment.

Genetic aberrations in primary esophageal melanomas: molecular analysis of c-KIT, PDGFR, KRAS, NRAS and BRAF in a series of 10 cases

We present a series of 10 primary esophageal melanomas of Caucasian patients characterized clinicopathologically and on the molecular level. Mutation analysis for c-Kit (exons 9, 11, 13 and 17), PDGFR (exons 12, 14 and 18), NRAS and KRAS were determined using PCR and direct sequencing. Analysis of the V600E mutation of BRAF was performed using mutation-specific PCR. Expression of c-Kit and PDGFR-A was additionally determined using immunohistochemistry. One tumor harbored a missense mutation in the c-Kit (p.F504L) and in the KRAS gene (p.G12S). A different c-Kit mutation (c.1507_1508 ins TTGCCT) was detected in another case. A third case had a V600E BRAF mutation. Using immunohistochemistry, c-Kit expression could be detected in all cases. The two cases with c-Kit mutations showed high c-Kit expression. None of the tumors showed a PDGFR mutation or expression or a NRAS mutation. We conclude that molecular analysis can identify targets for a specific therapy such as tyrosin kinase inhibitors as additional treatment option in these highly malignant tumors.

Multimethod imaging, staging, and spectrum of manifestations of metastatic melanoma

The incidence of melanoma has been steadily increasing. Imaging plays an important role in tumour assessment as metastatic melanoma can involve multiple organs. Computed tomography (CT) is currently the most widely used technique for tumour staging, surveillance and assessment of therapeutic response, but ultrasound, magnetic resonance imaging (MRI) and positron-emission tomography (PET)-CT also play important roles in the imaging of this tumour. In this article, we review the pathways of spread, staging according to the recently updated TNM classification, pathology, typical and atypical imaging features at common and uncommon sites, and treatment of metastatic melanoma.

Recent advances in the use of stents for esophageal disease

The use of self-expanding metal esophageal stents has evolved dramatically over the last 20 years. Stents themselves have morphed from simple open-mesh wire devices to a variety of partially and fully covered metal and plastic protheses designed to resist in-growth and migration. Indications include grown considerably from simply palliating malignant dysphagia to the treatment of benign conditions such as refractory strictures, perforations, and fistulas, bridging tumors through neoadjuvant therapy and even serving as support for mucosal healing after ablative therapies. This article describes the current experience with esophageal stenting for malignant and benign conditions and examines new innovations in stent design and applications.

Nevus-like appearance of primary malignant melanoma of the esophagus

The primary malignant melanoma of the esophagus (PMME) is a rare malignant disease, accounting for only 0.1–0.2% of all esophageal neoplasms, and the majority of the patients are diagnosed at advanced stages with poor prognosis. We present here a case of 56-year-old woman with epigastric pain and her endoscopic finding revealed several flat and black pigmented mucosal lesions within the distal portion of the esophagus which looked like flat nevus. The histopathology and immunohistochemical profile of the tissue specimens were diagnostic of malignant melanoma.

Amelanotic malignant melanoma of the esophagus: Report of two cases with immunohistochemical and molecular genetic study of KIT and PDGFRA

The author reports herein two cases of amelanotic malignant melanoma of the esophagus. Case 1 is an 87-year-old woman who was admitted to our hospital because of nausea and vomiting. Endoscopic examination revealed an ulcerated tumor of the distal esophagus, and a biopsy was taken. The biopsy showed malignant polygonal and spindle cells. No melanin pigment was recognized. Immunohistochemically, the tumor cells were positive for melanosome (HMB45), S100 protein, KIT and Platelet derived growth factor receptor-α (PDGFRA). The patient was treated by chemotherapy and radiation, but died of systemic metastasis 12 mo after the presentation. Case 2 is a 56-year-old man presenting with dysphagia. Endoscopic examination revealed a polypoid tumor in the middle esophagus, and a biopsy was obtained. The biopsy showed malignant spindle cells without melanin pigment. Immunohistochemically, the tumor cells were positively labeled for melanosome, S100 protein, KIT and PDGFRA. The patient refused operation, and was treated by palliative chemotherapy and radiation. He died of metastasis 7 mo after the admission. In both cases, molecular genetic analyses of KIT gene (exons 9, 11, 13 and 17) and PDGFRA gene (exons 12 and 18) were performed by the PCR direct sequencing method, which showed no mutations of KIT and PDGFRA genes. This is the first report of esophageal malignant melanoma with an examination of the expression of KIT and PDGFRA and the mutational status of KIT and PDGFRA genes.

Esophageal Cancers: A Clinicopathologic and Immunohistochemical Study of 223 Cases

The author reviewed 950 cases of consecutive esophageal biopsies in the last 15 years in out pathology laboratory of our hospital. There were 223 malignant lesions (23.5%). The number and frequency (percentages) were as follows: 54 mild dysplasia (5.7%), 30 moderate dyplasia (3.2%), 32 severe dysplasia (3.4%), 13 carcinoma in situ (1.4%), 71 squamous cell carcinoma (7.5%), 7 primary adenocarcinoma (0.7%), 1 primary signet ring cell carcinoma (0.1%), 4 primary small cell carcinoma (0.4%), 2 primary amelanotic malignant melanoma (0.2%), 1 primary undifferentiated sarcoma (0.1%), 7 gastric cancer invasion (0.7%), and 1 primary adenoid cystic carcinoma (0.1%). In this article, the clinical, histopathologic and immunohistochemical features of these esophageal cancers were described.