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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 39-42

Oral mucosal melanoma: A case report


Department of Oral Medicine and Radiology, Sri Venkata Sai Institute of Dental Sciences, Mahabubnagar, Telangana, India

Date of Submission10-Nov-2016
Date of Acceptance13-Jul-2017
Date of Web Publication04-Aug-2017

Correspondence Address:
Uma M Jangili
Department of Oral Medicine and Radiology, Sri Venkata Sai Institute of Dental Sciences, Mahabubnagar, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_140_16

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   Abstract 

Malignant melanoma is most deadly of all primary skin cancers. Over 90% of melanomas occur on the skin. Half of such melanomas occur in the oral cavity, followed by nasal cavity (44%) and sinuses (8%). In the oral cavity, the most frequent sites of occurrence are hard palate and maxillary gingiva. Mucosal melanomas represent a diagnostic challenge than the more common cutaneous melanomas because oral melanomas demonstrate significant heterogeneity in morphological features, developmental process, and biological behaviour. This case report highlights an exophytic, lobulated oral malignant melanoma involving maxillary gingiva and is presented to reemphasize the fact that any pigmented lesion in the oral cavity should be examined with suspicion; proper investigation should be carried out to rule out any untoward experiences later.

Keywords: Gingiva, malignant melanoma, palate


How to cite this article:
Gantala R, Jangili UM, Katne T, Gotoor SG. Oral mucosal melanoma: A case report. J Indian Acad Oral Med Radiol 2017;29:39-42

How to cite this URL:
Gantala R, Jangili UM, Katne T, Gotoor SG. Oral mucosal melanoma: A case report. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 May 31];29:39-42. Available from: http://www.jiaomr.in/text.asp?2017/29/1/39/212081


   Introduction Top


Oral malignant melanoma was first described by Weber in 1859, which was later recognized as a clinical entity by Lucke as “Melanotic sarcoma” in 1869.[1] Malignant melanoma encompasses melanocytes which are derivatives of the neural crest that constitute the melanin pigment in the basal layer of epithelium. It is an aggressive tumor with a high tendency to early metastasis regionally to lymph nodes and distant metastasis to lung and liver being the most common.[2]


   Case Report Top


An 85-year-old female presented with brownish-black painless growth in the upper anterior region since 2 months. Patient gave the history of being edentulous since 30 years and was a denture wearer since 20 years; she stopped using dentures from the last 2 months. The growth was initially small in size and gradually attained the present size, which was associated with difficulty in wearing the denture, eating, speaking, and frequent bleeding on provocation. Personal history revealed no adverse habits.

On examination, solitary bilateral submandibular lymph nodes were palpable with a size approximately 2.5 × 3.5 cm, which were firm, mobile and nontender [Figure 1]. Intraorally, a well-defined solitary exophytic brownish black growth of size approximately 5 × 3.5 cm was noticed on the maxillary anterior alveolar ridge predominantly occupying the left maxillary alveolar ridge and vestibule crossing the midline. Mesiodistally, the lesion was extending from maxillary right canine to left maxillary first molar anatomical tooth regions. Superiorly, the lesion was extending into the depth of the vestibule causing its obliteration and inferiorly 1 cm on to the palatal mucosa [Figure 2]. The surface of the lesion was lobulated and interspersed with areas of erosion. An area of diffuse blackish pigmentation was appreciated on the labial mucosa with size approximately 4 × 3.5 cm, topographically crossing the midline. On palpation, the lesion was tender with firm to hard consistency and tendency to bleed. The denture was ill-fitting since 2 months and devoid of sharp edges. Taking into account, ABCDE criteria after thorough clinical examination, a provisional diagnosis of oral malignant melanoma was made and clinical differential diagnosis of hemangioma was suspected [Figure 3].
Figure 1: Extraoral picture

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Figure 2: Intraoral picture depicting the palatal extent of the lesion with bleeding

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Figure 3: Intraoral picture depicting a well-defined solitary exophytic brownish black growth in the maxillary anterior alveolar ridge

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Patient was subjected to further investigations; orthopantomogram (OPG) revealed completely edentulous maxillary and mandibular arches with irregular, ill-defined, moth eaten like radiolucency in the left anterior maxillary alveolar ridge [Figure 4]. As the clinical features were in favor of malignant melanoma (based on ABCDE criteria), an advanced imaging [computed tomography (CT)] was planned to obtain finer details both in terms of its invasion and aggression. CT revealed a fairly defined expansile osteolytic lesion involving alveolar and palatine process of left maxilla, in the midline showing well-defined margins, narrow zone of transition with areas of cortical breaks in outer aspect with perifocal soft tissue fullness [Figure 5],[Figure 6],[Figure 7]. Based on the radiographic features, a differential diagnosis of squamous cell carcinoma was made. Based on clinical and radiographic presentation, according to AJCC Cancer Staging Manual 7th edition (2010), TNM staging for present case was stage IVA (T4aN1M0) [Table 1].[3]
Table 1: Classification for the mucosal melanoma of the head and neck, AJCC Cancer Staging Manual 7th edition (2010)

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Figure 4: Panoramic radiograph depicting an irregular, ill-defined moth eaten like radiolucency in the left anterior maxillary alveolar ridge

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Figure 5: CT axial section revealed an expansile osteolytic lesion involving alveolar and palatine process of left maxilla, in paramidline region with minimal extension to the contralateral side, with areas of cortical breaks in outer aspect

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Figure 6: CT sagittal section revealed an expansile osteolytic lesion in the anterior region of maxilla

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Figure 7: 3D reconstruction view revealed erosion of bone in the anterior maxilla on left side

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An incisional biopsy was performed under local anesthesia involving the margins of the lesion with local hemostatic measures, and H and E section revealed hyperplastic stratified parakeratinized squamous epithelium infiltrating into the underlying connective tissue stroma. Connective tissue showed atypical melanocytes in the form of nests and sheets with cytological features of malignancy such as pleomorphism, hyperchromatism, and mitotic figures. Dysplastic features such as cellular atypia and anisocytosis were also seen in the connective tissue. The histopathological features were in favour of malignant melanoma [Figure 8] and [Figure 9]. The patient and her family were informed about the diagnosis, therapeutic options and prognosis of the lesion. However, patient failed to turn up for further evaluation and treatment.
Figure 8: Photomicrograph showing invasion of atypical malignant melanocytes arranged in nests and sheets within the fibrous connective tissue stroma

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Figure 9: Photomicrograph showing atypical melanocytes (shown by yellow arrows) exhibiting pleomorphism and hyperchromatism with brown pigmentation invading in to the connective tissue

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   Discussion Top


Melanoma constitutes only 3–5% of all cutaneous malignancies, and accounts for most skin cancer related deaths (77%). Oral melanoma is an aggressive neoplasm which accounts for less than 0.5%.[4] Despite the obscureness of the etiology, most of the oral melanomas are thought to arise de novo or may be due to some suggested risk factors such as cigarette smoking, denture irritation, tobacco and formaldehyde exposures, and alcohol consumption, however, their correlation is still unclear.[5]

It has male predilection (3:1), affecting adults with a peak incidence in the sixth decade of life, which is in contrast to the present case. The most common involved sites are palatal mucosa and the maxillary gingiva. Clinical course is initially asymptomatic holding uniform brown/black pigmentation, hindering the early diagnosis. Variation in color, pain, ulceration, and bleeding may occur in the advancing front of the lesion, which are consistent with the present case.[6] ABCDE criteria which is used in the clinical diagnosis of cutaneous melanoma holds good even for oral malignant melanoma.[7]

Despite the aggressive nature of the lesion, radiologically, only mild erosion of bone is appreciated. Use of CT and magnetic resonance imaging (MRI) helps in delineating the extent and detection of regional lymph node metastasis.[8] Histopathology of the biopsied specimen is the gold standard for the diagnosis, which depicts the existence of the atypical cells and high density of atypical melanocytes in the epithelium and connective tissue junction. Immunohistochemical studies showing MART-1, S-100 protein, and HMB-45 reactivity of the lesional cells are useful in differentiating such melanomas from other malignancies.[9]

Though surgical excision is the gold standard treatment, it may be combined with chemotherapy (interferon a2b and dacarbazine), radiotherapy and immunotherapy. Immunochemotherapy following surgery is a novel approach with low recurrence rate.[8] Breslow’s tumor thickness grading system measures the thickness of the tumor from the epidermal surface to the invasive front of the tumor. Thin melanomas that are less than 0.76 mm in thickness usually have an excellent prognosis. 1 mm is considered the international standard (cut-off point) for thin melanomas beyond which the prognosis is not favorable.[10]


   Conclusion Top


Incidence of mucosal melanoma alongside in a denture wearer has become quiet an interesting finding as documented in the light of literature review. We add up the same as the patient is denture wearer and further research at the molecular level is to be initiated in the arena to rule out or add on in the etiological spectrum.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gupta S, Tandon A, Ram H, Gupta OP. Oral malignant melanoma: Report of 3 cases with literature review. Natl J Maxillofac Surg 2015;6:103-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Manigandan T, Sagar GV, Amudhan A, Hemalatha VT, Babu NA. Oral malignant melanoma: A case report with review of literature. Contemp Clin Dent 2014;5:415-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Coutinho-Camillo CM, Louren SV, Soares FA. Head and neck: Primary oral mucosal melanoma. Atlas Genet Cytogenet Oncol Haematol. In press.  Back to cited text no. 3
    
4.
Rathore RS, Phulari RG, Vasavada DG, Patel DK. A rare and extensive case of oral malignant melanoma involving mandibular gingiva. J Clin Diagn Res 2016;10:ZD11-2.  Back to cited text no. 4
[PUBMED]    
5.
Naik NP, Kiran AR, Samata Y, Kumar AV. Deadliest tumor of oral cavity: A rare case of intra oral malignant melanoma. J Oral Res Rev 2014;6:49-52.  Back to cited text no. 5
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6.
Ali EA, Karrar MA, El-Siddig AA, Zulfu A. Oral malignant melanoma: A rare case with unusual clinical presentation. Pan Afr Med J 2015;22:113.  Back to cited text no. 6
[PUBMED]    
7.
Ardekian L, Rosen DJ, Peled M, Rachmiel A, Machtei EE, El Naaj IA, et al. Primary malignant melanoma. Report of 3 cases. J Periodontol 2000;711:117-20.  Back to cited text no. 7
    
8.
Hashemipour MS. Malignant melanoma of oral cavity: A review of literature. Ind J Dent Res 2008;19:47-5.  Back to cited text no. 8
    
9.
Neville BW, Damn D, Allen C, Bouquot JE. Oral and maxillofacial pathology. 3rd ed. WB Saunders: Philadelphia; 2009. p. 433-9.  Back to cited text no. 9
    
10.
Nambiar S, Vishwanath MN, Bhat S, Farzana F, Khwaja T, Alrani D. Oral malignant melanoma: A brief review. J Clin Exp Pathol 2016;6:1-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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