Oral malignant melanoma detected after resection of amelanotic pulmonary metastasis

INTRODUCTIONSolitary pulmonary metastasis from oral malignant melanoma is very rare.PRESENTATION OF CASEWe demonstrated a 84-year-old patient with a lung nodule that was diagnosed as malignant melanoma by video-assisted thoracoscopic resection. Because primary pulmonary malignant melanoma was extremely rare, the tumor was thought to be a metastasized from an occult primary lesion. A detailed physical examination revealed a black tumor in the oral cavity, and this was suspected to have been the primary. Resection of the hard palate tumor and dissection of the cervical lymph nodes were performed. The patient was simply followed up without further therapy at his request, and he died one year after surgery due to bleeding from a pleural metastasis of malignant melanoma.DISCUSSIONPrimary melanoma of the oral cavity is rare, accounts for 0.5% of all oral cancers, and 0.8–1.8% of all melanomas. Because of absence of symptoms in the early stage of the disease and the presence of the tumor in relatively obscure areas of the oral cavity, the diagnosis is unfortunately often delayed. In view of the rarity of primary lung melanoma, when lung tumor was diagnosed as malignant melanoma, detailed physical examination of the entire skin and mucosa including the oral cavity was necessary.CONCLUSIONOral malignant melanoma was very rare, but oral cavity should be examined when the pulmonary nodule was diagnosed as malignant melanoma.     

A first reported case of metastatic anorectal amelanotic melanoma with a marked response to anti-PD-1 antibody nivolumab: A case report

IntroductionAnorectal amelanotic melanoma (AAMM) is a rare disease with poor prognosis. A standard treatment strategy for AAMM has not been established.Presentation of caseWe report a case of successful treatment of AAMM with nivolumab. A 67-year-old man was referred for colonoscopy which revealed type I tumor in the rectum. AAMM was diagnosed with immunostaining histopathological biopsy findings. Enhanced computed tomography (ECT) revealed the rectal tumor without distant organ metastasis. We performed laparoscopy-assisted abdominoperineal resection. ECT at three months after surgery revealed liver metastases and right ischial bone metastasis. Although we had started dacarbazine monotherapy, black spots that were suspicious of skin metastases had appeared on systemic skin. Therefore, we started nivolumab therapy. ECT at 3 months after initiation of nivolumab showed shrinkage of liver metastasis. We have continued strict follow-up every 2 months and checked no oncologic progression at 17 months after initiation of nivolumab.DiscussionThe anti-PD-1 antibody have improved prognosis of malignant melanoma. However, there are no reports of nivolumab for treatment of AAMM.ConclusionsOur patient is the first reported case of AAMM treated with nivolumab. We consider that nivolumab will be effective for non-cutaneous malignant melanoma.     

Rare nodular malignant melanoma of the heel in the Caribbean: A case report

IntroductionMalignant melanoma of the heel is a rare melanoma subtype with incidence rates that reflect the complex relationship between sun exposure at certain geographic locations, individual melanin levels and overall melanoma risk. It is oftentimes characterized by poor prognosis because of delays in presentation resulting in longitudinal tumor invasion, lymph node involvement and metastasis.Presentation of caseA 59-year-old woman was admitted to the Eric Williams Medical Sciences Complex, Trinidad and Tobago with a 5 mm pruritic lesion on her left heel. At presentation, the lesion was asymmetric with border irregularities, color heterogeneity, with dynamics in elevation and overall size. She was subsequently diagnosed with malignant melanoma with left inguinal lymphadenopathy. A single stage wide local excision (WLE) of the left heel lesion with a split-thickness skin graft (STSG) and a left inguinal lymphadenectomy were performed. Dacarbazine (Bayer) was administered post operatively.DiscussionGlobally, the incidence of malignant melanoma is rapidly increasing, particularly, in countries like Trinidad and Tobago with a significant population of non-fair skinned individuals. There is need for strategic initiatives to increase patient adherence in these populations.ConclusionThe rarity of malignant heel melanomas heightens the need for increased patient awareness and greater clinical surveillance to ensure early diagnosis and treatment.     

A case report of anorectal malignant melanoma with mucosal skipped lesion

IntroductionWe report our experience involving a case of relatively rare anorectal malignant melanoma with skipped lesion.Presentation of caseThe patient was a 72-year-old man who had visited a local clinic complaining of a mass in the anal region, whereupon he was referred to our hospital on suspicion of a malignant melanoma. Close examination revealed a 25-mm black type 1 tumor one-third the size of the circumference of the anal canal and located externally to it. We performed transanal resection of the tumor and confirmed a diagnosis of malignant melanoma. Notably, multiple macular black lesions spaced away from the main lesion were observed during surgery in half of the circumference of the anal canal, from the tumor to the pectinate line. A biopsy of the area also revealed malignant melanoma; therefore, we performed abdominoperineal resection. Pathological diagnosis indicated a submucosal depth; the patient was thus diagnosed with T4 N2c M0 stage IIIb malignant melanoma and was followed on an outpatient basis.DiscussionPatients with anorectal malignant melanoma have very poor prognoses owing to early lymph node metastasis and hematogenous metastasis. Our case illustrates that small anorectal malignant melanoma lesions can spread from the main lesion and invade the mucosa; examinations may sometimes miss such skipped lesions.ConclusionSkipped lesions can occur in anorectal melanomas; thus, careful scrutiny of such lesions is required. Moreover, lesion resection is critical for anorectal malignant melanomas.     

Primary malignant melanoma of the esophagogastric junction: Report of a case

INTRODUCTIONPrimary malignant melanoma of the gastrointestinal tract is very rare, especially in the stomach. We report an extremely rare case of primary malignant melanoma of the esophagogastric junction mainly situated in the stomach.PRESENTATION OF CASEThe patient was a 72-year-old woman who complained of shortness of breath due to severe anemia. Upper endoscopy revealed a soft easy-bleeding polypoid tumor just adjacent to the esophagogastric junction in the stomach. Biopsy of the tumor did not indicate a definite result, except malignant tumor. We performed total gastrectomy with splenectomy, and histological and immunohistological examination revealed malignant melanoma of the esophagogastric junction. She had no remote metastasis or lymphnodal metastasis at the point of surgery; however, she died of multiple metastases 11 months after the operation.DISCUSSIONA definite preoperative diagnosis of primary malignant melanoma was very difficult to make from the preoperative biopsy specimen. This present case was first misinterpreted as undifferentiated carcinoma, or malignant lymphoma. Following the diagnosis of malignant melanoma, the question arose as to whether this was primary or metastatic (as malignant melanoma from other sites is known to metastasize to the stomach). Finally this tumor was diagnosed as a primary one due to the pathologic characteristics such as the existence of junctional activities.CONCLUSIONWe report an extremely rare case of primary malignant melanoma of the esophagogastric junction present in the stomach.     

A case of solitary pulmonary metastasis of choroidal melanoma with an exceptionally long disease-free period

INTRODUCTIONChoroidal melanoma is the most common primary malignant intraocular tumor in adults. And its metastatic spread has been considered to be hematogenous with the liver being the most common site, and a solitary pulmonary metastasis without hepatic involvement is quite rare.PRESENTATION OF CASEWe report the case of a 61-year-old woman with a solitary pulmonary metastasis from choroidal melanoma, which had been originally treated with enucleation 13 years ago. Video-assisted thoracoscopic surgery (VATS) right upper lobectomy was performed for the right upper lobe tumor, which was histopathologically confirmed to be metastatic choroidal melanoma.DISCUSSIONOur case is quite unusual in 2 points; firstly, a solitary pulmonary metastasis without hepatic involvement is rare. Secondly, this mode of metastasis with an exceptionally long disease-free period (13 years) is also rare.CONCLUSIONA pulmonary metastasis from choroidal melanoma is described with reference to relevant literature.     

Metastatic Melanoma in the Gallbladder: Report of a Case

Both primary and secondary gallbladder melanomas are rare and, when a solitary melanoma is found in the gallbladder, it is difficult to determine if it is primary or metastatic disease. We report the case of a young woman found to have a single metastatic gallbladder melanoma. Surgical removal of a solitary metastatic focus remains the treatment of choice for isolated metastasis of a malignant melanoma; however, the effectiveness of complementary chemotherapy and immunotherapy is still being examined. Received: October 15, 2001 / Accepted: July 2, 2002 Reprint requests to: D. Mantas     

Multiple Metastatic Malignant Melanoma Presenting Intraluminal Gallbladder Bleeding

We report a case of malignant melanoma of unknown primary origin presenting metastasis in various organs as well as intraluminal gallbladder bleeding due to gallbladder metastasis. A 58-year-old woman was diagnosed with stage IV metastatic malignant melanoma. Because she exhibited acute cholecystitis and hemobilia due to malignant melanoma of the gallbladder, laparoscopic cholecystectomy was performed to relieve the symptoms. The resected gallbladder specimen showed a pedunculated black mass indicating malignant melanoma. Pathologic examination and immunohistochemical analysis revealed malignant melanoma of the gallbladder. Only a few cases of gallbladder malignant melanoma presenting hemobilia have been reported; here we present our case, including the experience of multidisciplinary treatment.Key words: Gallbladder malignant melanoma, Hemobilia, Laparoscopic cholecystectomyMalignant melanoma can metastasize to various organs. Metastasis often occurs in the lungs, liver, brain, and gastrointestinal tract; however, reported cases of metastatic melanoma of the gallbladder are rare. Though gallbladder melanoma is usually asymptomatic, acute cholecystitis is the most common presentation among symptomatic cases. Other symptoms, such as obstructive jaundice, external biliary fistula, and hemobilia, are rare and found in very few reports. Here, we report a case of multiple metastases of malignant melanoma of unknown primary origin, for which we performed laparoscopic cholecystectomy to treat continuous bleeding from the gallbladder. We conclude that cholecystectomy is indicated for symptomatic stage IV gallbladder of melanoma cases, because the patient who underwent cholecystectomy not only experiences resolved symptoms but also maintained a survival benefit with improved quality of life.     

Malignant Melanoma of the Gallbladder: A Report of Two Cases and Review of the Literature

Melanoma metastatic to the gallbladder is rare. When present, it is often part of a widespread complex of metastases. Primary gallbladder melanomas are also extremely rare and can sometimes be difficult to distinguish from metastatic lesions. The optimal treatment for malignant melanoma of the gallbladder remains unclear, and prognosis is generally poor. We present here two cases of patients with metastatic lesions to the gallbladder. One patient presented with symptomatic cholelithiasis and was found incidentally to have a metastasis. Another patient had known a metastasis, but underwent curative resection of the only site of disease. We review the published literature for gallbladder melanoma, both primary and metastatic to determine the role of surgery in this disease.     

Multiple primary melanomas: Implications for screening and follow-up programs for melanoma

Background: Once individuals are diagnosed with malignant melanoma, they are at an increased risk of developing another melanoma when compared with the normal population. Methods: To determine the impact of an intensive follow-up protocol on the stage of disease at diagnosis of subsequent primary melanomas, a retrospective query was performed of an electronic medical record database of 2,600 consecutively registered melanoma patients. Results: Sixty-seven patients (2.6%) had another melanoma diagnosed at the time of presentation to the clinic or within 2 months (synchronous) and another 44 patients (1.7%) developed a second primary melanoma during the follow-up period (metachronous). For the 44 patients diagnosed with metachronous lesions, the Breslow mean tumor thickness for the first invasive melanoma was 2.27 mm compared with 0.90 mm for the second melanoma. The first melanomas diagnosed are thicker by an average of 3.8 mm (p=0.008). The mean Clark level for the initial melanoma was greater than the mean level for subsequently diagnosed melanomas (p=0.002). Twenty-three percent of the initial melanomas were ulcerated, whereas only one of the second primary lesions showed this adverse prognostic factor (p=0.002). Conclusions: Once individuals are diagnosed with melanoma, they are in a high-risk population for having other primary site melanomas diagnosed and should be placed in an intensive follow-up protocol consisting of a complete skin examination. Presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Primary mucosal desmoplastic melanoma of the head and neck

BACKGROUND: Desmoplastic variants of melanoma rarely affect the mucosa. METHOD: The clinicopathologic features and p53 status of seven primary mucosal desmoplastic melanomas of the oral and nasal cavity were studied. RESULTS: The patients included six men and one woman (median age, 61 years; range, 23-74 years). Desmoplastic melanoma involved the lip in two, alveolus in three, buccal mucosa in one, and nasal vestibule in one patient. Four tumors infiltrated up to lamina propria, and three infiltrated bone and/or cartilage. All were amelanotic spindle cell tumors, five were neurotropic, and two were vasoinvasive. Aberrant p53 expression was seen in six tumors. All tumors recurred locally, and distant metastasis developed in three. Six patients died with disease (survival, 1-41 years; median, 8 years), and one patient was free of disease (survival 20 years). CONCLUSIONS: Primary mucosal desmoplastic melanomas are clinically characterized by local recurrence and may lead to distant metastasis and death even after several years. Alterations in p53 expression are frequently associated with desmoplastic melanoma.     

Acral melanoma with satellitosis,disguised as a longstanding diabetic ulcer: a great mimicry

Acral lentiginous melanoma affects the palms, soles, and nail apparatus. Around 3–15% of all cutaneous melanomas are located on the foot and have a poorer prognosis than melanoma elsewhere. Possible reasons for this prognostic difference may be omitting this area during routine skin check by both the patient and the physicians, in addition to misdiagnosis of melanoma as other benign skin lesions. We describe here an elderly female patient treated for a non‐healing foot ulcer interpreted as a diabetic ulcer, which after 2 years was diagnosed as acral melanoma with satellitosis. Histopathological examination of the amputated distal phalanx revealed an advanced stage melanoma with 1·2 cm Breslow thickness and of Clark level 5. Dermoscopy of the bluish papulonodules scattered on the dorsal foot showed characteristic findings described for metastasis of skin melanoma. This case underlines the importance of considering skin malignancies in case of chronic, non‐healing ulcers in diabetic patients. Furthermore, we point out the critical significance of skin examination as a whole, and dermoscopy being an important tool in the diagnosis of melanoma and/or cutaneous melanoma metastasis.     

The role of FDG-PET-CT is limited in initial staging of nodal metastasis for thin cutaneous melanoma

IntroductionPositron emission tomography computed tomography (PET-CT) is often used to stage nodal metastases in thin cutaneous melanoma, with limited evidence.MethodsA retrospective review of patients with cutaneous malignant melanoma treated at our institution was performed from 2005 to 2015, identifying those who received a PET-CT prior to lymphadenectomy. Biopsy features, lymph node status, and PET-CT results were collected. We calculated the overall sensitivity, specificity, accuracy, likelihood ratios, and positive predictive value of PET-CT in identifying nodal metastases. Results were stratified by initial biopsy tumor depth.ResultsWe identified 367 cases; 95 obtained a PET-CT prior to lymphadenectomy. Overall, sensitivity and specificity of PET-CT was 34.6% and 95.4%, respectively. The positive likelihood ratio and negative likelihood ratio were 7.62 and 0.68, respectively. The accuracy was 78.2%. The positive predictive value for T3 and T4 melanomas were 100% and 81.4%, respectively. For thin melanomas, specificity and accuracy was 88.2% and 88.2%, respectively.ConclusionsPET-CT has low specificity and its use alone is not recommended for initial staging of nodal metastases in thin cutaneous malignant melanoma.     

Metastatic malignant melanoma of unknown primary site to the brain: A case report

Introduction and importanceThe natural history of metastatic melanoma in the absence of a known primary site has been poorly defined. The disease usually presents a significant cause of morbidity and mortality. Around 90% of melanomas have cutaneous origin, but still there are melanomas that could be found in visceral organs or lymph nodes with unknown primary site. Spontaneous regression of the primary site could be an explanation. The disease is frequently diagnosed after treatment for known extracranial metastases and has a poor outcome despite various local and systemic therapeutic approaches.Case presentationHerein, we present a case of a 43-year old female presented with history of headaches and enlarged a left inguinal lymph node. Notably, no cutaneous lesions could be identified by history or on physical examination. CT-scan of the brain revealed a space occupying lesion and the inguinal lymph node biopsy confirmed the diagnosis of metastatic malignant melanoma. The patient succumbed shortly after establishment of diagnosis.Clinical discussionMost patients with brain metastases from malignant melanoma are diagnosed after treatment for known extracranial metastases and have a poor outcome despite various local and systemic therapeutic approaches.ConclusionMetastatic melanomas of brain with unknown primary present a significant morbidity and mortality and confer a poor prognosis. Delay in diagnosis and treatment is of serious concern when it comes to improve the prognosis of patients with this disease. The optimal treatment depends on the objective situation, often surgery, radiosurgery, whole brain radiotherapy and chemotherapy can be used in combination to obtain longer remissions and optimal symptom relieve.     

Acute acalculous cholecystitis caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer: A case report

Introduction and importanceAcute acalculous cholecystitis (AAC) is associated with a high mortality rate. AAC caused by metastasis to the gallbladder is rare. We report a case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer.Case presentationAn 84-year-old male visited our hospital because of epigastric pain. Ultrasonography and computed tomography revealed swelling and thickening of the gallbladder wall, but stones were not observed in the gallbladder. We performed emergency surgery with a diagnosis of acute cholecystitis. Laparoscopy revealed the presence of many nodules around the abdominal cavity including the hepatoduodenal ligament. Inflammation of Calot’s triangle was severe, so we performed subtotal cholecystectomy. We also resected one of the peritoneal nodules. Macroscopically, there were no stones in the gallbladder and histopathological examination revealed acute cholecystitis and existence of adenocarcinoma involving the subserosa of the gallbladder wall and the resected peritoneal nodule. After surgery, esophagogastroduodenoscopy revealed Borrmann type II lesions at the antrum and gastric biopsy showed adenocarcinoma. He was diagnosed with advanced gastric cancer with peritoneal dissemination. His postoperative course was good.Clinical discussionThe cases of AAC caused by gallbladder metastasis have been little reported in the literature. This case is advanced gastric cancer with peritoneal dissemination and AAC was thought to be caused by peritoneal dissemination from operative and histopathological findings. We successfully treated this rare case of AAC with laparoscopic surgery.ConclusionAlthough metastasis to the gallbladder is rare, it is necessary to be aware of this possibility when treating AAC.     

Anorectal Melanoma Misdiagnosed as Hemorrhoids: A Case Report and Review of the Literature

Anorectal melanoma is a rare and aggressive malignant neoplasm with an indolent course, manifesting with nonspecific symptoms and a poor prognosis. We present a case of anorectal melanoma that was initially treated as hemorrhoids and correctly diagnosed after lower gastrointestinal endoscopy. We also present the latest findings in the literature about anorectal melanomas and discuss updates about treatment options and management.     

Primary small bowel melanoma. A case report and a review of the literature

Primary malignant melanoma originating from the small intestine is extremely rare. Only a limited number of cases are described in the literature. Most commonly small intestine is affected by metastatic tumors from other primary lesions. We present a case of a 68-years old male diagnosed with primary malignant melanoma as an ulcerated and bleeding mass in the jejunum - located 40 cm away from the Treitz band. In our case the diagnosis was confirmed at laparotomy and enterectomy. Histology revealed a neoplastic infiltration involving the entire intestinal mucosa, with atypia of neoplastic cells and immunoreactivity to HMB45(+), Melan A(+) and S100(+), confirming the diagnosis of melanoma. There was not revealed a primary lesion in the skin, eye, anus, rectum or in other location by the post-operative investigation. An eleven-month close follow-up has not revealed any metastasis. Therefore a definitive diagnosis of primary malignant melanoma was set.     

Metastatic malignant melanoma to the foot and ankle: A review of the literature and case report

The lower extremity is a frequent site for malignant melanomas. However, skeletal metastases involving the foot and ankle are a rarity. Nearly all documented cases of secondary pedal bone metastasis have originated from a primary subungual melanoma. The following case study illustrates an unusual skeletal metastasis to the foot and ankle arising from a primary malignant melanoma of the torso.     

Anorectal amelanotic melanoma

Objective  Anorectal melanoma is a rare, highly malignant tumour with a poor 5 year survival of 10%. Most anorectal melanomas have gross and/or histologic pigmentation, however about 30% of anorectal melanomas are amelanotic.
Method  We report three cases of amelanotic anorectal melanomas and integrate our data with six case reports of amelanotic malignant melanoma from the literature. Further we compare clinicopathological data and clinical outcome with large series of anorectal melanomas (both, amelanotic and pigmentated).
Results  There were seven females and two males, of median age 62 years (range: 45–75 years). Rectal bleeding was the leading symptom in all cases with a mean duration of 4 months before diagnosis. Eight of nine patients developed distant metastases. Median survival was 14 months (range: 3–60 months). A tumour thickness of < 4 mm was correlated with long-term disease-free survival, whereas tumour thickness of 4 mm or more was correlated with systemic recurrence.
Conclusion  Early diagnosis is key for efficient treatment and improved survival rate for patients with this unusual variant of melanoma. There is no difference in terms of age, time of diagnosis, stage and survival between pigmented and amelanotic anorectal melanoma.     

Primary malignant melanoma of the female urethra: Report of a rare neoplasm of the urinary tract

IntroductionMelanoma is a malignant tumor that can affect any area of the anatomical economy. Its occurance in the female urethra is extremely rare. We report a case of primary malignant urethral melanoma developed in an elderly female patient.Presentation of caseA 70 years old female presented with dysuria, poor stream, gross haematuria, intermittent blood spots, and a painful mass. On physical examination, there were no suspicious lesions on the skin. On external genital examination, a lesion at the level of the urethral meatus was observed. The mass was removed by wide local excision under spinal anaesthesia. The pathological diagnosis was malignant melanoma of the urethra.DiscussionThe common presentations include bleeding and/or discharge per urethra, voiding dysfunction and the presence of tumor mass. Survival depends on the stage, location and size of the neoplasm at the time of diagnosis. Despite major surgery, radiotherapy or immunotherapy; malignant melanoma usually has a poor prognosis.ConclusionMelanoma of the female urethra is an extremely uncommon pathology leading to paucity of literature and any definite recommendations regarding management. The histological and immunohistochemical findings can be helpful in making an early and accurate diagnosis of malignant melanoma in the urogenital region.