|Year : 2006 | Volume
| Issue : 1 | Page : 24-27
Malignant melanoma of the oral cavity: Report of two cases
J Shah1, M Jain2
1 Dept. of Oral Medicine & Radiology, G.D.C.H, Ahmedabad-380016, Gujarat, India
2 Dept. of Oral Medicine & Radiology, Ahmedabad Dental College & Hospital (MOHA), Gujarat, India
4, Bhagirath society, Naranpur, Ahmedabad-380016 Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Primary malignant melanoma of the oral cavity is an uncommon neoplasm and represents less than 2% of all reported melanomas. Malignant melanoma is more common among males and in 5`h to 6`h decades of life. The most frequent site of occurrence are palate and maxillary gingiva followed by mandibular gingiva, buccal mucosa, tongue and floor of mouth. Most melanomas are believed to develop denovo from melanocytes within skin or mucosa. Oral melanoma has poor prognosis.
Two typical cases of malignant melanoma are reported. In case I, the site of involvement was palate and maxillary gingiva while in case II, it was mandibular gingiva. The first case presented with swelling and black discoloration of overlying mucosa with segmental mobility of upper left quadrant and mobility of involved teeth. Radiographically, this case exhibited destruction of palatal bone with floating teeth appearance of involved quadrant. Second case represented with swelling, bleeding, and black discoloration of overlying mucosa. This patient also exhibited black macular lesion in opposite side of buccal mucosa. Histologically, both the cases were confirmed as malignant melanoma.
Keywords: Primary malignant melanoma, Compound nevus, Melanocytes.
|How to cite this article:|
Shah J, Jain M. Malignant melanoma of the oral cavity: Report of two cases. J Oral Maxillofac Pathol 2006;10:24-7
| Introduction|| |
Oral melanomas are uncommon and thought to arise primarily from the melanocytes in the basal layer of squamous mucosa. The first reported case of primary malignant melanoma of oral cavity was described by Weber in 1859 ,. Melanocytic density has a regional variation. In contrast to cutaneous melanomas which are etiologically linked to sun exposure, risk factors for mucosal melanomas are unknown. These melanomas have no apparent relationship to chemical, thermal, and mechanical event to which oral mucosa is constantly exposed . It may arise in a preexisting junctional and compound nevus ,.
The oral cavity is not the exclusive site of occurrence of mucosal melanoma. Other sites affected are eyes, upper respiratory tract, and vagina. The most frequent site for mucosal melanoma is conjunctiva followed by upper respiratory tract and oral cavity. Mucosal melanomas may be primary or metastatic from other location in the body. It is very important to rule out the possibility of the primary malignant melanotic lesion elsewhere in the oral cavity .
Primary malignant melanoma of the oral mucosa can occur at any age group but it is extremely rare below 30 years. The mean age reported is 54 years. The most frequent site of occurrence is palate and maxillary gingiva and other oral sites include mandibular gingiva, buccal mucosa, tongue, and floor of the mouth. As such there are various types of cutaneous melanomas, but for oral melanoma it is very difficult to categorize them because of the anatomic architecture. The lesion appears in the oral cavity as a deeply pigmented area either with ulceration or hemorrhage, which tends to increase progressively in size ,,,. Radiographically bone involvement in oral melanoma appears as irregular radiolucency with invasive border and floating teeth appearance of involved teeth.
Histologically, the lesion is characterized by increased numbers of atypical melanocytes. The intraepithelial component (radial growth phase) is characterized by the presence of large epitheloid melanocytes distributed in a so called 'pagetoid manner'. The vertical growth phase is characterized by proliferation of malignant epitheloid melanocytes in the underlying connective tissue.
| Case reports|| |
A 40-year-old male reported with chief complaint of pain, swelling, and black discoloration in upper left quadrant since one year. Past medical history was non contributory. On examination, extra orally there was diffuse, nontender, firm swelling of 5cm x2cm size, present in left maxillary region which extends from infraorbital margin to corner of mouth and 2 cm laterally from ala of the nose obliterating the nasolabial folds with normal overlying skin [Figure - 1]. Intraorally, a diffuse, non-tender, soft swelling of 3cm x 2cm size was present buccally and palatally, in relation with upper right central incisor to upper left second premolar, with black hyperpigmentation of overlying mucosa with bleeding tendency. Involved teeth in the attached segment were mobile (grade III). Upper left central incisor and first premolar were displaced palatally while upper left canine and second premolar were displaced labially. Spacing was present in the involved teeth [Figure - 2]. Right and left submandibular lymph nodes were enlarged, palpable, non tender and mobile.
A 80-year-old male reported with chief complaint of painless swelling and bleeding in lower right quadrant since 2 months. Past medical and dental history were not significant. A back well defined, oval swelling of 4cm x 2cm size present in right mandibular alveolar ridge extending from lower right canine to right second molar region with obliteration of buccal and lingual vestibules.
Swelling was non-tender, soft, with bleeding tendency [Figure - 3]. Another black macular lesion of 3cm x 2cm size was present in the left (non affected side) buccal mucosa [Figure - 4]. Right and left submandibular lymph nodes were enlarged, palpable, tender, and mobile.
Radiographs of both the patients were taken. In case 1, upper occlusal radiograph showed radiolucent area extending from upper right central incisor to upper left second premolar with invasive border and loss of lamina dura and floating teeth appearance of involved teeth [Figure - 5], while in case 2, OPG showed normal bone.
Incisional biopsy was taken from both affected (right side) and non- affected sides (left side) of the buccal mucosa. Histologically the affected side showed increased number of atypical melanocytes in the epithelium and connective tissue, with spindle shaped cells in the connective tissue thus diagnosed as malignant melanoma, spindle cell type [Figure - 6]. Biopsy from the non affected side showed atrophic stratified squamous epithelium, with melanin containing cells in the basal layer. Brown to black melanin pigments were also seen in lamina propria just below the epithelium and diagnosed as compound nevus [Figure - 7].
| Discussion|| |
Primary malignant melanoma of the oral cavity is rare. Prevalence ranges from 0.4 to 1.4 and 2 to 5 % of all melanomas. Lesions are slightly more common in males than females. Although this tumour occurs between the age of 40 to 70 yrs, it has been discovered as early as 7 and as late as 95 years. The favourable sites are palate and maxillary gingiva. Mandible, buccal mucosa, tongue, floor of mouth, and lip account for only 20 to 30% of cases ,. Both our patients were males, the lesions occurring in the maxillary gingiva in a 40-year-old in the first case, and in the mandibular alveolus in a 80-year-old in the second case.
Unfortunately oral melanomas usually remain asymptomatic with recognition of lesion occurring when there is breakdown of the overlying epithelium or hemorrhage. The ulcerated epithelium lacks both the induration and rolled borders that are features characteristic of squamuous cell carcinoma which makes the clinical detection difficult ,. Rolled borders are absent in melanoma because the atypical melanocytes exhibit pagetoid mode of spread resulting in uniform epithelial thickening .
Out of two cases reported, one case presented with painful swelling and another case presented with painless swelling. Both the cases showed the black coloured swelling without induration and rolled borders. As such there was no history of preexisting melanosis in any case but second case exhibited black macular lesion on the buccal mucosa (unaffected side) and histologically it was diagnosed as compound nevus. Malignant melanoma may precede in a pre- existing pigmented lesion. Hence close follow up of the benign lesion is must.
Radiographically, malignant melanomas show ill-defined radiolucency with invasive border and floating teeth appearance . Out of two cases reported here, the first case presented with diffuse radiolucency and floating teeth appearance of the involved area because of the involvement of underlying bone where as the other case showed no bone involvement radiographically.
Histopathologically oral melanomas showed presence of melanocytes in epithelium and they are distributed in a 'pagetoid manner'. As the disease progresses, malignant epitheloid melanocytes proliferate into underlying connective tissue. Melanocytes are atypical small, ovoid and/ or spindle shaped.
This malignancy has a distinct tendency for both regional and distant metastases to sites such as the lung, liver, breast and bones. Prognosis is much less favourable than in cutaneous melanoma. Metastases occurs via lymphatic or vascular showers of melanoma cells or both . Hence examination of regional and distant lymph nodes as well as other organs is very important. Both our cases presented without any systemic abnormalities and lymph node involvement. Long term and regular follow up is must to rule out metastasis even after proper therapy.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
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|[Pubmed] | [DOI]|