|Year : 2018 | Volume
| Issue : 2 | Page : 158-160
Oral malignant melanoma
YC Chaitanya1, P Vinil Chaitanya1, M Venkat Reddy1, B Bhavya2
1 Department of Oral Medicine and Radiology, Malla Reddy Institute of Dental Sciences, Afzalgunj, Hyderabad, Telangana, India
2 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Afzalgunj, Hyderabad, Telangana, India
|Date of Submission||28-Jun-2016|
|Date of Acceptance||04-Mar-2018|
|Date of Web Publication||16-Jul-2018|
Dr. B Bhavya
H. No. 108, Block No. 8A, APIIC Colony, Opposite Radhika Theatre, ECIL, Hyderabad, - 500 062, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Primary malignant melanoma of the oral cavity is a rare neoplasm. In this article, we report the case of a 55-year-old woman with primary malignant melanoma of the maxillary gingiva. Based on the clinical and histopathological examination, a final diagnosis of malignant melanoma was given. Despite its rarity, melanoma is the most important pigmented lesion of oral cavity because of its deadly nature. Early detection and treatment are essential for better prognosis in mucosal malignant melanoma.
Keywords: Gingiva, maxilla, oral malignant melanoma
|How to cite this article:|
Chaitanya Y C, Chaitanya P V, Reddy M V, Bhavya B. Oral malignant melanoma. J Indian Acad Oral Med Radiol 2018;30:158-60
| Introduction|| |
Primary malignant melanoma of the oral cavity is a rare neoplasm. Primary lesions arising from oral mucosa occur most frequently on the maxillary gingiva, and palate, with the lips following as the third most common in frequency. The incidence of melanoma has been steadily increasing in the past several decades with an annual increase of 3–8% worldwide. Oral malignant melanoma (OMM) accounts for 5% of all oral malignancies. OMM has been reported as having a higher incidence in Japan, India, and Africa than that in the western countries. Mucosal melanomas tend to present at an advanced stage, are more aggressive, and present in a vertical (nodular) growth phase of the disease.
| Case History|| |
A 55-year-old female patient presented with the chief complaint of a painless swelling in the anterior maxillary region which had begun 3 months ago. There was no history of trauma, systemic illness, or being associated with bleeding or pain. Intraoral examination revealed a nontender mass on the labial gingiva of the maxillary anterior of approximately 3 × 3 cm in size. The mass was pedunculated, had a smooth surface, and well-defined margins. The color of the overlying mucosa was dark blue to black in some areas. Similar melanosis was evident on the palatal gingiva of maxillary anterior and buccal gingiva up to the region of maxillary second premolars on either side [Figure 1] Clinical photograph showing a pedunculated dark blue to black mass of about 3 × 3cms on the labial gingiva of the maxillary anteriors and melanosis on buccal gingiva up to the region of maxillary second premolars on either side].
|Figure 1: Clinical photograph showing a pedunculated dark blue to black mass of about 3x3cms on the labial gingiva of the maxillary anteriors and melanosis on buccal gingiva up to the region of maxillary second premolars on either side|
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Based on the above findings, a provisional diagnosis of malignant melanoma was given. Differential diagnosis includes hemangioma, melanoacanthoma, and oral melanotic macule.
An incisional biopsy was done under local anesthesia, which showed sheets of polygonal cells with hyperchromatic nuclei with prominent nucleoli with mast cells showing brown-black melanin pigment. Areas of necrosis, hemorrhage, inflammatory cells infiltrate, and nuclear debris were also seen, giving the impression of malignant melanoma [Figure 2].
|Figure 2: Low power view (×10) shows sheets of polygonal cells with hyperchromatic nuclei, prominent nucleoli and with mast cells showing brown-black melanin pigment. And areas of necrosis, hemorrhage, inflammatory cells infiltrate and nuclear debris.|
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Patient was subjected to orthopantomography (OPG) and advanced imaging modalities such as computed tomography (CT), which showed no evident changes in the underlying bone [Figure 3] and [Figure 4]. Clinical, radiographic, and ultrasonographic examination revealed no distant metastasis. Surgery was performed and 1-year follow-up did not show any recurrence.
|Figure 4: Computed tomography shows no evident changes in maxilla and in mandible|
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| Discussion|| |
Oral melanoma is a neoplasm of melanocytes in the basal layer of mucosa. OMM may present itself in two patterns, (1) there is rapid appearance and enlargement of pigmented lesion and (2) it is preceded by pigmentation for a variable period of time. Oral pigmentations precede melanoma (for several months or years) in 30% of the cases.
While cutaneous melanomas are divided into clinically and pathologically well-established varieties, definitive classification of oral mucosal melanoma is not available. The workshop on OMM that convened at the annual meeting of the Western Society of Teachers of Oral Pathology in 1995 established that oral lesions should be classified separately from cutaneous forms, and the terms in-situ OMM, invasive OMM, and atypical melanocytic proliferation (for an equivocal lesion) were considered appropriate to refer to oral lesions.
Because of its hidden location and rich vascularization, mucosal melanoma usually presents at a more advanced stage and is therefore associated with a higher mortality rate than cutaneous melanoma. It seems certain that mucosal melanoma originates from melanocytes present in mucosa, however, exposure to sunlight is not an etiologic factor. Although irritants and carcinogenic compounds in the air, such as tobacco smoke and formaldehyde, have been implicated, the potential role of these compounds is not clear.
According to Tanaka et al., oral melanomas could be classified into five types, based on their clinical appearance –pigmented nodular, non-pigmented nodular, pigmented macular, pigmented mixed, and nonpigmented mixed. This neoplasm may occur with or without a radial growth phase. The clinical coloration of oral melanomas has a wide range, which can appear as black, gray, purple, and even red. While some lesions are uniform in color, others exhibit marked variations. They are asymmetric, irregular in outline, and occasionally multiple. Their surface architecture ranges from macular to ulcerated and nodular.
Despite the rarity of the disease, melanoma is the most important pigmented lesion in the oral cavity because of its deadly nature and most, if not all, oral biopsies of pigmented lesions are aimed at excluding malignant melanoma. If diagnosed early, the malignant cells are limited to the epithelium or invasion is minimal, melanoma is either 100% curable by excision (for in situ lesion) or is associated with a 5-year survival rate of 95%. According to “Westop Banff Workshop Proceedings, 1995,” surgery is considered to be the primary treatment for malignant melanoma, and because oral melanomas have a grave prognosis, radiotherapy and chemotherapy serve as adjuvant.
Microscopically, the dominant form of oral melanoma is similar to cutaneous acral lentiginous melanoma and consists of quite a monomorphic population of spindled or dendritic melanocytes. The tumor cells often have a contact with epithelium, but pagetoid spreading is not typical. Other forms of oral melanomas are similar to nodular melanoma without pre-existent radial phase. The tumor cells can be spindled, epithelioid, or mixed. Immunohistochemistry is indispensable for the diagnosis, especially if the lesion is amelanotic or poorly pigmented. S-100 protein is positive in 97%, HMB-45 in 71%, and melan-A in 74% of cases of mucosal melanomas.
The clinical differential diagnosis includes tattoos, melanotic macules, Laugier's disease, melanocytic nevus, drug intake, some vascular lesions, and oral pigmented lesions associated with endocrine disorders or different syndromes.
The exuberant growth of malignant melanoma in the present case indicates that superficial spreading malignant melanoma in the form of a tan or a brown or black admixed lesion might have existed in the maxillary anterior palate which was mistaken for pigmentation. For this reason, it has been suggested that the appearance of melanin pigmentation in the mouth and its increase in size and in depth of color should be viewed seriously.
| Conclusion|| |
Early detection and treatment is essential for better prognosis in malignant melanoma and hence the need for clinicians to meticulously examine the oral cavity and biopsy of all pigmented lesions can be emphasized more. More efforts should be made to create public awareness so that early detection of such lesion can be made possible.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]