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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
  Table of Contents    
CASE REPORT  
Year : 2012  |  Volume : 16  |  Issue : 1  |  Page : 88-90
 

Second primary oral melanoma: A rare presentation


Department of Oral and Maxillofacial Pathology, Saraswati Dental College and Hospital, Lucknow, India

Date of Web Publication17-Feb-2012

Correspondence Address:
Meghanand T Nayak
Vyas Dental College and Hospital, KudiHoud, Pali Road, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Melanomas are neoplasms of melanocytic origin. They are aggressive neoplasms with an unpredictable behavior, and can involve virtually any organ of the body. Oral melanomas are very rare and have an extremely poor prognosis. Early diagnosis and prompt treatment is the key to reduce the morbidity and mortality. A second primary tumor is a new primary tumor developing in a person with a history of tumor, in a new site or tissue and subsequent to the initial tumor. Patients with previous history of melanoma are associated with a higher risk of developing second primaries. A case of second primary oral melanoma in a 55-year-old female is reported here. The anachronistic presentation of the primary and the second primary lesions make this case clinically interesting. Noteworthy immunohistochemical findings were recorded, HMB-45 positive and S-100 negative.


Keywords: Buccal mucosa, follow-up, HMB-45, hard palate, oral melanoma, second primary malignancies


How to cite this article:
Nayak MT, Singh A, Mathur R M, Wadhwani P. Second primary oral melanoma: A rare presentation. J Oral Maxillofac Pathol 2012;16:88-90

How to cite this URL:
Nayak MT, Singh A, Mathur R M, Wadhwani P. Second primary oral melanoma: A rare presentation. J Oral Maxillofac Pathol [serial online] 2012 [cited 2019 Oct 18];16:88-90. Available from: http://www.jomfp.in/text.asp?2012/16/1/88/92980



   Introduction Top


Melanoma is a malignant neoplasm of the melanocytes, which are derived from neural crest cells. Although most melanomas arise from the skin, they may also arise from mucosal surfaces or other sites where neural crest cells migrate. [1]

Primary mucosal melanomas are exceptionally rare and accounts for only 0.2-8% of all melanomas. [2] Clinically, metastatic melanoma involving the skin appears as a dermal nodule or plaque-like lesion, often in close proximity to the primary tumor. [3] The development of second primary neoplasms in patients with cutaneous melanomas has been previously reported. Here, we are reporting first case of second primary oral melanoma.


   Case Report Top


A 55-year-old female reported to our institution complaining of a blackish discoloration on the left cheek since 5-6 months. Patient also complained of a feeling of discomfort during normal mastication in the region. The patient revealed that she was previously diagnosed as having melanoma on the anterior part of the hard palate and she had undergone partial maxillectomy followed by radiotherapy 7 years back.

Her previous clinical records revealed that the earlier lesion was blackish macular discoloration on hard palate, palatal to permanent left maxillary central incisor (FDI # 21) anteriorly and extending to the level of permanent maxillary left second premolar (FDI # 25) posteriorly. The mesial margin was encroaching upon the midline, while the distal margin was irregular and about 1-2 cm away from the alveolar ridge. Partial maxillectomy including both halves of maxilla was performed to remove the primary growth and an adequate free margin of 4 cm was included. The patient had uneventful recovery. The surgical defect was covered with an obturator. Her excisional biopsy confirmed the diagnosis of malignant melanoma (Clark's Level II). The patient was later treated with chemotherapy and radiotherapy. Postoperative radiotherapy records revealed that radiation was given by Cobalt-60-4400 cGy on 22 Fc. to whole neck for 20 days. A total dose of 6000 cGy in two phases was advised; however, the treatment was withdrawn after 22 Fc. as the patient had symptoms of radiation mucositis.

Physical examination of the present lesion revealed a solitary, exophytic, nodular growth measuring about 3 × 2 × 0.5 cm on left posterior buccal mucosa in relation to permanent mandibular left III molar (FDI # 38). The lesion extended from buccal aspect of mandibular III molar anteriorly to 0.5 cm posteriorly over retromolar region. The lesion was well defined and elevated, with nodular surface. The color of the lesion was variegated [Figure 1]. No other lesions were found elsewhere in the body and no lymph nodes were palpable. The lesion was excised completely and was subjected to biopsy [Figure 2]. The sections of excisional biopsy revealed fibrous connective tissue stroma infiltrated by islands of tumor mass. The tumor was composed of proliferating ovoid or polygonal cells, which were disposed diffusely. The cells exhibited hyperchromatic round nuclei and showed moderate anisocytosis [Figure 3]. Melanin pigmentation was seen in most part of the tumor. A diagnosis of "Nodular melanoma with Clark's level IV involvement" was made. A combined radiotherapy and immunotherapy was implemented to the patient and she has now successfully survived for over 10 years from the initial onset of the disease. Patient underwent radiotherapy and immunotherapy and has survived for 10 years.
Figure 1: Intraoral photograph showing the nodular and variegated appearance of the tumor

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Figure 2: Tumor bed after complete excision of the tumor mass

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Figure 3: Histopathology reveals tumor mass composed of proliferating ovoid or polygonal cells with hyperchromatic nuclei and melanin pigmentation (H and E, stain ×40)

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   Discussion Top


Oral melanoma is a rare entity occurring at a frequency of less than 2% of the all the head and neck cancers. [4] Men are affected about 3.5 times more commonly than the women. The ethnic groups most commonly affected by oral melanomas are Japanese, black Africans, American Indians, and Hispanics. [5] This malignancy is more frequently seen on the hard palate and maxillary gingiva. [6] Other oral sites are mandible, tongue, buccal mucosa, and upper and lower lip.

When the melanocytes or their precursor cells turn neoplastic, they possibly lead to malignancies which usually metastasize to adjacent tissues. The rich vascular supply present in the oral cavity contributes to the dissemination of the melanomas. [7]

A thorough clinical examination of any pigmented lesion that may exhibit growth potential must be done and biopsied to rule out melanomas. Melanomas metastasize first to the regional lymph nodes and then to secondary sites, most commonly skin, subcutaneous soft tissue, lung, and brain. In primary melanomas (stage I and II) recurrences are local-regional, while in patients with stage III disease recurrences are usually systemic. In our case, the lymph nodes were not palpable and the aspirations were negative; we could not find any metastatic deposits.

A second primary melanoma is a new or de novo primary melanoma that arises at the periphery of a previously excised melanoma, in the context of a field defect. It is important to differentiate an additional melanoma from a metastatic melanoma, because the prognosis of an independent primary lesion is likely to be much better than that of a metastasis. [8]

Increased incidence of germ-line mutations has been noted in CDKN2A locus in patients with multiple primary melanomas. [9],[10] In this case, the first primary lesion; occurred on the hard palate was superficial and indolent, while the second primary lesion which occurred after a gap of 7 years was present on the buccal mucosa and was nodular in nature with variegated surface. Probably this change in presentation was in response to the stepwise accumulation of genetic abnormalities. Nodular melanomas are vertical growth phase melanomas and comprise 15% to 30% of all melanomas. [11] They usually appear as a darkly pigmented, pedunculated, or polypoid nodule. Our case had a similar presentation.

The antibody HMB-45 and S-100 reacts with a 10-kDa cytoplasmic glycoprotein that is part of the premelanosome complex. [12],[13] A positive HMB-45 immunostaining and a focal or absent S-100 staining was noted in our case [Figure 4] and [Figure 5]. It has been previously reported that in a small subset of melanomas S-100 protein is either not expressed or is expressed at a level below that which can be detected by routine immunohistochemistry. [14] Nevertheless, a positive HMB-45 reactivity provides a strong evidence of melanocytic histiogenesis.
Figure 4: Immunohistochemical analysis of HMB-45 showing strong positivity, hence revealing melanocytic origin (×40)

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Figure 5: Immunohistochemical analysis of S-100 showing focal positivity or negative staining (×40)

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For individuals with a history of a prior cutaneous melanoma, the risk of a second primary is very high. [14] Although the risk is highest in the first year after initial diagnosis, the risk of developing a second melanoma have ranged from 2-11% at 5 years. [15],[16]

The most important elements in the follow-up of oral melanoma patients are medical history and physical examination, paying particular attention to recurrences. To the best of our knowledge this report documents the first case of second primary oral melanoma occurring in a previously treated patient, who has survived over 10 years.

 
   References Top

1.Femiano F, Lanza A, Buonaiuto C, Gombos F, Di Spirito F, Cirillo N. Oral malignant melanoma: A review of the literature. J Oral Pathol Med 2008;37:383-8.  Back to cited text no. 1
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2.Pliskin ME. Malignant melanoma of the oral cavity. In: Clark Jr. WH Goldman L, Mastrangelo MJ, editors. Human Malignant Melanoma. New York: Grame and Stratton; 1979. p. 125-37.  Back to cited text no. 2
    
3.Elder DE. Metastatic melanoma. In: Elder DE, editor. Pathobiology of Malignant Melanoma. Basel, Switzerland: S Karger AG; 1987. p. 182.  Back to cited text no. 3
    
4.Mendenhall WM, Amdur RJ, Hinerman RW, Werning JW, Villaret DB, Mendenhall NP. Head and neck mucosal melanoma. Am J Clin Oncol 2005;28:626-30.  Back to cited text no. 4
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5.Meleti M, Leemans CR, Mooi WJ, Vescovi P, van der Waal I. Oral malignant melanoma: A review of the literature. Oral Oncol 2007;43:116-21.  Back to cited text no. 5
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6.Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 4 th ed. Philadelphia, Pennsylvania: WB Saunders; 1983. p. 133-4.  Back to cited text no. 6
    
7.Eisen D, Voorhees JJ. Oral melanoma and other pigmented lesions of the oral cavity. J Am Acad Dermatol 1991;24:527-37.  Back to cited text no. 7
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8.Elder DE, Murphy GF, Xu X. Benign pigmented lesions and malignant melanoma. In: Elder DE, Elenitsas R, Johnson BL Jr, Murphy GF, editors. Lever's Histopathology of the skin. 9 th ed. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins; 2005. p. 774.  Back to cited text no. 8
    
9.Blackwood MA, Holmes R, Synnestvedt M, Young M, George C, Yang H, et al. Multiple primary melanoma revisited. Cancer 2002;94:2248-55.  Back to cited text no. 9
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10.Monzon J, Liu L, Brill H, Goldstein AM, Tucker MA, From L, et al. CDKN2A mutations in multiple primary melanomas. N Engl J Med 1998;338:879-87.  Back to cited text no. 10
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11.Clark WH Jr, Elder DE, Van Horn M. The biologic forms of malignant melanoma. Hum Pathol 1986;17:443-50.  Back to cited text no. 11
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12.Blessing K, Sanders DS, Grant JJ. Comparison of immunohistochemical staining of the novel antibody melan-Awith S100 protein and HMB-45 in malignant melanoma and melanoma variants. Histopathology 1998;32:139-46.  Back to cited text no. 12
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13.Donato R. Functional roles of S100 proteins, calcium-binding proteins of the EF-hand type. Biochim Biophys Acta 1999;1450:191-231.  Back to cited text no. 13
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14.Magro CM, Crowson AN, Mihm MC. Unusual variants of malignant melanoma. Mod Pathol 2006;19(Suppl 2):S41-70.  Back to cited text no. 14
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15.Greene MH. The genetics of hereditary melanoma and nevi. 1998 update. Cancer 1999;86(11 Suppl):2464-77.  Back to cited text no. 15
    
16.Goggins WB, Tsao H. A population-based analysis of risk factors for a second primary cutaneous melanoma among melanoma survivors. Cancer 2003;97:639-43.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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