Malignant melanoma of the anorectum—a rare entity

Objective  

Primary anorectal melanoma is a rare entity with a poor prognosis accounting for approximately 0.1-4.6% of anal tumours and 0.5-1.6% of all melanomas. Almost 60% of patients have already disseminated disease at initial diagnosis.     

Cutaneous melanoma in a multiethnic population: is this a different disease?

HYPOTHESIS: Cutaneous melanoma in nonwhite persons has a manifestation and a prognosis that are different than those of cutaneous melanoma in white persons. DESIGN: Case series. SETTING: Tertiary care university-affiliated community medical center located in a multiethnic state in which white persons are a minority of the population. PATIENTS: Consecutive series of 357 patients with melanoma seen between January 1994 and August 2003. MAIN OUTCOME MEASURES: Ethnicity, age, sex, primary site, tumor thickness, nodal status, stage at diagnosis, and survival. RESULTS: There were 208 men and 149 women who ranged in age from 15 to 93 years (mean, 58 years). Twenty-two patients initially had unknown primary sites. Of these 357 patients, 67 (18.7%) were nonwhite. There was no statistically significant difference in the age (P =.10) or sex (P =.57) distribution of these 2 populations. Nonwhite patients at initial diagnosis had thicker tumors (P =.002), more frequently had ulcerated primary tumors (P<.001), more frequently had positive nodes (P =.004), and were at a more advanced stage (P =.002) than their white counterparts. The anatomic distribution between the 2 populations was significantly different (P<.001), with a high incidence of melanoma on the sole and subungual locations and a substantially less frequent occurrence on the head and neck, trunk, and extremities in the nonwhite population when compared with the white population. The overall survival rate of the nonwhite patients was significantly worse than that of the white patients, but when stratified by stage at initial diagnosis, there was no difference in outcome. CONCLUSIONS: In a multiethnic population, cutaneous melanoma in nonwhite persons is unusual but not rare. Although the diagnoses are distinctly different at initial examinations, suggesting a potential biological component, stage-for-stage outcomes are similar between white and nonwhite persons and suggest a need for early diagnostic interventions with unusual pigmented lesions in nonwhite persons.     

Malignant melanoma and filariasis: a coexistence or an association?

Malignancy has been reported with chronic lymphedema, especially lymphangiosarcoma. The authors report on a patient with lymphedema due to filariasis, presenting with an ulcerated pigmented lesion that was malignant melanoma. A literature search revealed no previous report of such lesions existing together.     

Sentinel node biopsy for malignant melanoma: a staging procedure only?

Sentinel node biopsy (SNB) is an established staging tool for malignant melanoma. It allows identification of patients with metastatic disease at a very early stage and to collect accurate and complete prognostic information for these patients. Having noted that in a relevant percentage of patients the sentinel node is the only site of metastases, some authors have postulated a therapeutic role for SNB. In this paper, the possibility of a therapeutic role of SNB is evaluated. Relevant literature on the topic has been analyzed. Several findings suggest that not all patients with a positive SNB have further lymph node involvement. The prognostic indicators currently available do not significantly correlate with non-sentinel node (NSN) involvement. It seems that more than morphological data of the tumor and of the lymph node metastasis, biologic markers may be investigated to understand tumor behavior and predict NSN involvement. At present, SNB must still be considered a staging procedure only and an appealing field of research to understand the behavior of melanoma. Better understanding of the biology of melanoma and of the host??s immune response towards it may lead to identification of those patients with the sentinel node as the only site of metastases.     

5-Aminolevulinic acid ester–induced protoporphyrin IX in a murine melanoma cell line

The use of 5-aminolevulinic acid (5-ALA) ester derivatives as precursors of endogenous protoporphyrin IX (PpIX) has been proposed as a good strategy for improved drug diffusion across biological membranes. In the present work, the 5-ALA ester derivatives hexyl-ALA (h-ALA), octyl-ALA (o-ALA), and decyl-ALA (d-ALA) were synthesized, and their efficacy to induce endogenous PpIX was explored in a murine melanoma cell line (B-16) as compared with that of 5-ALA. The maximum level of PpIX induced in cells treated with 5-ALA, h-ALA, o-ALA, and d-ALA was reached at optimal concentrations of 0.3, 0.075, 0.1, and 0.075 mM, respectively. The derivatives h-ALA and o-ALA appear as the most efficient PpIX precursors in this cell line, since a higher or similar PpIX production could be achieved with a fourfold and threefold lower dose of these precursors compared with 5-ALA. The phototoxicity effect of h-ALA and o-ALA ester derivatives showed the same phototoxicity behavior detected for 5-ALA but at much lower drug doses. Our study suggests that h-ALA and o-ALA esters improve intracellular PpIX formation in B-16 cells at reduced concentrations. This should enable clinical applications at lower precursor doses with reduced effective costs.     

Is completion lymphadenectomy after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary?

HYPOTHESIS: Completion lymph node dissection (CLND) has usually been recommended after metastatic disease is identified in the sentinel lymph node (SLN) biopsy to eradicate further metastases in nonsentinel nodes. We hypothesized that patients with negative lymph nodes included in the initial SLN specimen have low risk of metastases in the residual draining basin and may not require CLND. DESIGN: Chart review. SETTING: University-affiliated tertiary care referral center. PATIENTS: Between January 1, 1997, and May 31, 2003, 506 consecutive patients underwent SLN biopsy for staging of primary cutaneous melanoma. INTERVENTION: The SLN biopsy identified 87 patients (17.2%) with metastatic melanoma, of whom 80 underwent CLND. RESULTS: In 28 patients, all SLNs were found to contain metastatic melanoma. Seven (25%) of these patients had additional metastases identified in the CLND specimen. In 52 patients, 1 or more SLNs did not contain metastatic melanoma. Five (10%) of these patients had additional metastases in the CLND specimen (P =.02). CONCLUSIONS: Although no evidence of metastatic melanoma was found on CLND in most patients in whom negative nodes had been removed with positive SLNs at the initial biopsy, 10% of these patients did have further metastases. This subgroup of patients (positive SLNs and negative nodes in the SLN biopsy specimen) is at significantly lower risk for further metastasis, but CLND cannot be safely omitted even for these patients.     

Do nodal metastases from cutaneous melanoma of the head and neck follow a clinically predictable pattern?

BACKGROUND: Potential lymphatic drainage patterns from cutaneous melanomas of the head and neck are said to be variable and frequently unpredictable. The aim of this article is to correlate the anatomic distribution of pathologically involved lymph nodes with primary melanoma sites and to compare these findings with clinically predicted patterns of metastatic spread. METHODS: A prospectively documented series of 169 patients with pathologically proven metastatic melanoma was reviewed by analyzing the clinical, operative, and pathologic records. Clinically, it was predicted that melanomas of the anterior scalp, forehead, and face could metastasize to the parotid and neck levels I-III; the coronal scalp, ear, and neck to the parotid and levels I-V; the posterior scalp to occipital nodes and levels II-V; and the lower neck to levels III-V. Minimum follow up was 2 years. RESULTS: There were 141 therapeutic (97 comprehensive, 44 selective) and 28 elective lymphadenectomies (4 comprehensive dissections, 21 selective neck dissections, and 3 cases in which parotidectomy alone was performed). Overall, there were 112 parotidectomies, 44 of which were therapeutic and 68 elective. Pathologically positive nodes involved clinically predicted nodal groups in 156 of 169 cases (92.3%). The incidence of postauricular node involvement was only 1.5% (3 cases). No patient was initially seen with contralateral metastatic disease; however, 5 patients (2.9%) failed in the contralateral neck after therapeutic dissection. In 68% of patients, metastatic disease involved the nearest nodal group, and in 59% only a single node was involved. CONCLUSIONS: Cutaneous malignant melanomas of the head and neck metastasized to clinically predicted nodal groups in 92% of patients in this series. Postauricular and contralateral metastatic node involvement was uncommon.     

Is incisional biopsy of melanoma harmful?

BACKGROUND: In the era of sentinel lymph node (SLN) biopsy, there has been concern that manipulation, injection, and massage of intact primary melanomas (after incisional or shave biopsy) could lead to an artifactual increased rate of SLN micrometastases or an actual increased risk of recurrence. The aim of this study was to evaluate the difference in the incidence of SLN metastasis, locoregional recurrence (LRR), disease-free survival (DFS), distant disease-free survival (DDFS), or overall survival (OS) for patients who undergo excisional versus incisional versus shave biopsy. METHODS: Analysis of database from a multicenter prospective randomized study from centers across the United States and Canada. Eligible patients were 18 to 71 years old, with cutaneous melanoma > or = 1.0 mm Breslow thickness. All patients underwent SLN biopsy using blue dye and radioactive colloid injection. SLNd were evaluated by serial histological sections with S100 immunohistochemistry. Statistical analysis was performed using univariate and multivariate analyses with a significance level of P < .05; survival analysis was performed by the Kaplan-Meier method with the log-rank test. RESULTS: A total of 2,164 patients were evaluated; 382 patients were excluded for lack of biopsy information. Positive SLNs were found in 220 of 1,130 (19.5%), 58 of 281 (20.6%), and 67 of 354 (18.9%) of patients with excisional, incisional, or shave biopsy, respectively (no significant difference). There were significant differences among the 3 biopsy types in ulceration (P = .018, chi2) and regression (P = .022, chi2); there were no differences in age, gender, Breslow thickness, Clark level, lymphovascular invasion, tumor location, or histologic subtype. Biopsy type did not significantly affect LRR, DFS, DDFS, or OS. CONCLUSIONS: The concern that incomplete excision of primary melanomas may result in an increased incidence of SLN micrometastases, artifactual or real, is unfounded. Similarly, there is no evidence that biopsy type adversely affects locoregional or distant recurrence. Although shave biopsy is generally discouraged because it may lead to inaccurate tumor thickness measurements, it does not appear to affect overall patient outcome.     

Sentinel lymph node biopsy in oral malignant melanoma—a possible means of investigating the clinically node-negative neck

Sentinel node biopsy has been used to determine the presence of nodal metastases in cutaneous melanoma and is being investigated as a tool in patients with oral squamous cell carcinomas. Two patients at Canniesburn Plastic Surgery Unit with oral mucosa malignant melanoma underwent sentinel node biopsy, using a combination of preoperative lymphoscintigraphy to identify lymphatic drainage, the preoperative use of blue dye injection (in one case) and localisation of radioactive nodes with a hand-held gamma probe (in both cases). The first patient presented with a well lateralised anterior tongue melanoma and was found to have sentinel nodes on both sides of the neck, all of which were clear of tumour; the second patient had diffuse melanosis of the palate with an invasive component on the left side and was found to have a sentinel node on the right side containing melanin. Our experience suggests that sentinel node biopsy is technically possible for oral melanoma and may be used to investigate the neck of patients with oral melanoma.     

Gastrointestinal bleeding as presentation of small bowel metastases of malignant melanoma: Is surgery a good choice?

INTRODUCTIONMelanoma shows a particular predilection in involving small intestine both in a single site and in multiple localization and acute or chronic gastrointestinal bleedings are often the first sign of tumour.PRESENTATION OF CASEWe report two cases of GI metastases of malignant melanoma, one presented with only a big mass that cause intestinal obstruction and the other with a tumour spread throughout the small intestine that produce enterorrhagia.DISCUSSIONDiagnosis and follow-up are very difficult: CT scan, PET-CT scan and capsule endoscopy should be complementary for the assessment of patients with GI symptoms and melanoma history.CONCLUSIONWhat is the role of surgery? Several studies suggest metastasectomy to achieve both R0 results and palliative resolutions of acute symptoms, such as obstruction, pain, and bleeding.     

Does primary melanoma of the bladder exist?

Primary melanoma of the urinary bladder is a rare neoplasm to which very strict diagnostic criteria apply. Although reports of previous cases exist, these criteria have yet to be met. We report a case of a young lady from whom a malignant melanoma of the bladder was resected. This was presumed to be primary as detailed investigation failed to find any other site from which metastases could have originated. We discuss the diagnostic criteria of this entity and stress the difficulty in conclusively demonstrating that, despite some of these criteria being met, a lesion such as this is primary in origin. This case could be the longest surviving patient with primary melanoma of the bladder, however we will never be able to prove that spontaneous regression of an undiagnosed extravesical primary malignant melanoma did not occur.