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| CASE REPORT |
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| Year : 2021 | Volume
: 33
| Issue : 1 | Page : 107-110 |
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Nodular malignant melanoma of maxillary gingivae: A rare presentation and a proposed clinical classification of oral malignant melanoma
Jigna S Shah, Himali A Shah, Yogesh Rathva
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat, India
| Date of Submission | 29-Nov-2020 |
| Date of Decision | 30-Jan-2021 |
| Date of Acceptance | 16-Feb-2021 |
| Date of Web Publication | 26-Mar-2021 |
Correspondence Address:
Dr. Himali A Shah
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaomr.jiaomr_248_20
 Abstract | | |
Malignant melanoma arises from melanocytic cells. Oral mucosal melanoma is a rare malignancy with the tendency to metastasize and locally invade tissues more readily than other malignant tumors of the oral cavity. Here, a very rare entity of the pigmented nodular variety of the oral malignant melanoma of maxillary buccopalatal gingiva with regional lymph node involvement and distant metastasis to the lungs is reported. A new proposed clinical classification of oral malignant melanoma is explained. Early detection is very important for a better prognosis.
Keywords: Maxillary gingiva, metastasis, oral malignant melanoma
How to cite this article:
Shah JS, Shah HA, Rathva Y. Nodular malignant melanoma of maxillary gingivae: A rare presentation and a proposed clinical classification of oral malignant melanoma. J Indian Acad Oral Med Radiol 2021;33:107-10 |
How to cite this URL:
Shah JS, Shah HA, Rathva Y. Nodular malignant melanoma of maxillary gingivae: A rare presentation and a proposed clinical classification of oral malignant melanoma. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Apr 18];33:107-10. Available from: https://www.jiaomr.in/text.asp?2021/33/1/107/312208 |
| Introduction | |  |
Malignant melanoma (MM) arises from melanocytic cells. Melanocytes are neural crest-derived cells that migrate to the skin, mucous membranes, and several other sites.[1] Oral malignant melanoma (OMM) is a rare malignancy with the tendency to metastasize and locally invade tissues more readily than other malignant tumors of the oral cavity. Mucosal melanoma involving the sinonasal cavity, oral cavity, pharynx, larynx, and upper esophagus is extremely rare and accounts for only 0.5% of all oral neoplasms. Nearly 80% of oral melanomas (OMs) arise in the mucosa of the upper arch, with the majority occurring on the keratinizing mucosa of the palate and maxillary alveolar gingivae while other oral sites such as mandibular gingiva, buccal mucosa, tongue, and floor of the mouth may get involved rarely.[1],[2]
A very rare case of mucosal melanoma of the maxillary buccopalatal gingiva exhibiting exophytic (nodular) growth with regional lymph node involvement and distant metastasis to the lungs is presented.
| Patient Information | | |
A 60-year-old female patient reported to the department of Oral Medicine and Radiology department with the chief complaint of asymptomatic dark-colored growth on the upper left posterior region for two months. The patient was hypertensive and taking medication for the past 10 years. No history of trauma or preexisting palatal pigmentation was present. No relevant family history was present.
| Timeline | | |
Before two months, the patient noticed a very small swelling. Then the patient went to some private dental clinic and medications were given. But the patient did not get any relief. The swelling gradually increased in size showed some discoloration. Therefore, the patient again went to an ayurvedic clinic. A topical application was advised to the patient. However, the patient was not satisfied with the treatment and thus came to our hospital.
| Clinical Findings | | |
Intraorally, well-defined, nontender, soft pedunculated with a rough overlying surface, greyish black exophytic growth with bleeding tendency was present in the left maxillary premolar–molar area involving buccal and palatal gingiva. Approximate size of the growth was 1.5 × 1.5 cm [Figure 1]. The teeth in the affected area were vital and no tooth mobility was noted. Submandibular lymph nodes were firm, enlarged, nontender, and nonfixed on both the sides. | Figure 1: Intraorally (left) bluish-black proliferative growth on the buccal and palatal gingiva extending from the left maxillary premolar region to the molar region and orthopantomogram (OPG) (right) showing interdental bone loss in relation to the maxillary left premolar–molar region
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Pigmented exophytic growth with bleeding tendency and short duration were strongly favoring the diagnosis as MM.
| Differential Diagnosis | | |
Hemangioma or other vascular malformations.
| Diagnostic Assessment | | |
We went for routine laboratory and various radioimaging investigations as per the need for the diagnosis, i.e., OPG, CT Scan, USG, MRI, and PET-CT and histological investigation to confirm the diagnosis.
Laboratory investigations showed no abnormality and were within normal limits.
An OPG showed irregular interdental bone loss in the maxillary left premolar-molar region [Figure 1]. CT was advised to check for the bone changes. It showed deviated nasal septum with mild right inferior turbinate hypertrophy and a few small calcified and noncalcified nodules of indeterminate nature scattered through both lung fields as well as enlarged lymph nodes at level Ib and bilateral level II [Figure 2]. The CT findings were not conclusive regarding oral lesions, especially soft tissue component; hence, MRI was advised, which showed ill-defined subtle soft-tissue fullness involving upper left alveolus at the level of second premolar to first molar extending into adjacent palate medially and laterally within the vestibule of the oral cavity [Figure 2]. USG was advised to rule out the metastatic node. USG report showed a 22 × 10 mm hypoechoic node at level-II in the right side of the neck suggestive of a metastatic node. It also showed a 16 × 10 mm oval node with fatty hilum at level-II on the left side, suggestive of reactive node [Figure 2]. PET–CT was done to rule out metastasis and showed hypermetabolic heterogeneously enhancing soft-tissue lesion in the upper left alveolus in the premolar–molar area with multiple hypermetabolic metastatic cervical level-II lymph nodes [Figure 2]. All clinical and radiographical findings were suggestive of MM with regional lymph node involvement and lung metastasis. | Figure 2: CT (upper left-UL): few small calcified and noncalcified nodules of indeterminate nature scattered through both lung fields. MRI (UR): ill-defined subtle soft tissue fullness involving the upper left alveolus at the second premolar to first molar extending into the palate and vestibule. USG (LL): level-II hypoechoic node at the right side of neck and an oval node with fatty hilum at level- II on the left side. PET–CT (LR): hypermetabolic heterogeneously enhancing soft tissue lesion in the upper left alveolus in the premolar–molar area with multiple hypermetabolic metastatic cervical lymph node of level-II
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An incisional biopsy was done to confirm the diagnosis. Histopathologically, large polygonal cells with prominent macronucleoli and abundant cytoplasm with melanin pigmentation were seen. Occasional abnormal mitosis with few bizarre tumor cells with large hyperchromatic nuclei was also seen [Figure 3]. Tumor necrosis with junctional activity was also seen at one focus, thus concluding the diagnosis as mucosal malignant melanoma with lymph node involvement and lung metastasis with poor prognosis (stage-IV- Any T, Any N, and M1b). | Figure 3: Photomicrograph showing large polygonal cells with prominent macronucleoli and abundant cytoplasm with melanin pigmentation
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| Therapeutic Intervention & Follow-Up | | |
Surgical intervention was planned. But the patient denied the treatment and unfortunately died within one year.
| Discussion | | |
OMM can occur at any age, the average being 54 years but is less common in people below 30 years. Mucosal melanoma is more prevalent in males with a male to female ratio of 2:1.[1],[3] Primary OMM is a rare neoplasm of unknown etiology. The possible risk factors can be exposure to sunlight, betel quid chewing, cigarette smoking, alcohol consumption, denture irritation etc.[4] Like their cutaneous counterparts, primary oral melanomas are believed to arise either denovo (30% of cases) or from nevi and preexisting pigmented areas.[1],[3] In our case, except hypertension all other histories were negative. The presented case of OMM arose de novo as the patient has a negative history of naevus.
Considering and reviewing various literature, the varied clinical appearance of OMM can simply be classified into three varieties as shown in [Table 1].[5],[6],[7],[8],[9]
- Clinical type of oral malignant melanoma (OMM) mentioned in the table is based on the type of basic surface lesions as macular, nodular, and ulcerated as it has a typical clinical appearance and their mimicker lesions are different as shown in the table. (Clinical differential diagnosis-D/D)
- Clinical coloration of OMM has a wide range from black-brown to white, grey, purple, or even reddish. Hence, clinically pigmented and non-pigmented (Amelanotic) melanoma should be differentiated as their mimicker lesions are different as shown in the table.
- Melanotic macular oral melanoma may be misdiagnosed as other common pigmented entities such as melanotic macule, smoker's melanosis, amalgam tattoo, racial pigmentations, etc., So to avoid misdiagnosis, the clinical type mentioned in the table is very helpful.
- Amelanotic oral melanoma in nodular form is very difficult to diagnose as it resembles a benign tumor–like growth while ulcerated variety looks like a malignant tumor. So to avoid misdiagnosis, clinical D/D according to type & color is very important.
- Differential diagnosis of OMM is discussed in various literature in general but not according to the clinical appearance or color. Hence, to avoid any delay in diagnosis and better prognosis, this clinical classification will help the clinicians to better arrive at the clinical diagnosis of OMM.
The reported lesion was of a pigmented nodular variety as there was a typical characteristic appearance of greyish black-colored exophytic growth on the maxillary buccopalatal gingivae. A nodular type of MM has a poor prognosis even if they are diagnosed at an early stage, as there is a vertical invasion into the underlying connective tissue.[2]
Radiographically, bone involvement in OM appears as irregular radiolucency with an invasive border and a floating tooth appearance of the involved teeth.[3] Computed tomography demonstrates MM as an expansile, homogeneously enhanced mass. This modality is helpful for assessing the extent of the lesion and exploring regional metastasis to the lymph nodes. The presence of metastasis from MM can be established on the basis of its unique MR characteristics. Melanin has paramagnetic properties that can affect the signal on MR images, giving MM a characteristic intensity pattern. They appear hyperintense on T1 weighted sequences and intermediate to hypointense on T2 weighted sequences.[10] The common sites for metastasis are lungs, bone, brain, and liver with widespread involvement in advanced diseases.[2] Regional lymph node involvement with lung metastasis was reported in the present case.
Histopathologically, the present case showed all the typical features of MM.[1],[3] In OMM, the diagnosis is confirmed by histopathological means but radiographic aids such as USG, CT, MRI, and PET scan shows exact extension and metastasis of the lesion. Its hidden location and rich vascularization make it more aggressive and mortal than cutaneous melanoma.[7] Metastasis to regional lymph nodes and distant spread to bone are encountered in end-stage patients and have a poor prognosis.[10] The reasons for poor prognosis in the present case may be age (60 years), short duration (2 months), the nodular variety of growth with regional lymph involvement (level-II on the right and left sides), and distant metastasis to the lungs.
Surgery can be combined with radiotherapy, chemotherapy, or immunotherapy. Postoperative radiotherapy is generally recommended if there is a poor prognosis. Even though melanoma is regarded as poorly radiosensitive, other irradiation modalities such as intraoral mold, intraoral electron beam, or interstitial brachytherapy have also been used.[2] Unfortunately, in our case, the outcome of the treatment plan could not be assessed.
| Conclusion | | |
A very rare case of nodular mucosal melanoma of the maxillary buccopalatal gingiva with regional lymph node involvement and distant metastasis to the lung is presented. Various parameters like age, short duration, nodular variety, regional lymph node involvement, and distant metastasis are accountable for poor prognosis in our case. Careful clinical examination and early detection by histopathological means of any pigmented growth supported by various radioimaging investigations such as CT, MRI, USG, and PET scan are essential for a better prognosis of this lethal entity.
Declaration of patient consent
Patient consent was obtained to use the relevant clinical details and images for the scientific publication purpose without revealing the identity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 9. | Perera E, Gnaneswaran N, Jennens R, Sinclair R. Malignant melanoma. Healthcare (Basel) 2013;2:1-19. |
| 10. | Devi P, Bhovi T, Jayaram RR, Walia C, Singh S. Malignant melanoma of the oral cavity showing satellitism. J Oral Sci 2011;53:239-44. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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