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Gingival and pharyngeal metastasis from a malignant melanoma
Gingival and pharyngeal metastasisfrom a malignant melanoma Report
of a case
Edward L. Mosby, D.D.S.,* William E. Sugg, Jr., D.D.S.,** and W. R. Hiatt, D.D.S.,*+* San Diego, Calif. NAVAL
HOSPITAL,
SAN
DIEGO,
CALIF.
Malignant melanoma is a rare disease, comprising 1 to 3 per cent of all malignant tumors. Fewer than 2 per cent of all malignant melanomas occur in the oral cavity. Since m&static malignant melanoma to the gingiva has not been hitherto reported, the case presented here is of interest.
M
alignant melanoma is an enigmatic disease, as it is almost always fatal. Baldridge and Waldron’ state that the five-year survival rate for patients with negative nodes, both clinically and microscopically, is about 30 per cent. The prospect for survival of a patient with clinically and/or microscopically positive nodes is lessened considerably. Primary malignant melanoma of the oral cavity is an extremely rare tumor. In 1958 Chaudhry, Hampel, and Gorlin2 reviewed the literature and found that 105 cases had been reported in the preceding 100 years. They report that the treatment of choice forprimary oral malignant melanoma is radical surgery. Thirty-two patients were treated surgically with approximately a 10 per cent five-year survival rate and thirteen patients received radiation treatment, one having a three-year survival, Metastatic malignant melanoma to the mouth and, in particular, the gingiva is not mentioned in the literature. However, it has been stated that several reported primary oral malignant melanomas have not completely satisfied the criteria The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy. *Commander, DC, USN; Chief Resident in oral Surgery. **Commander, DC, USN; St& Oral Surgeon. ***Captain, DC, USN; Chief of Dental Service and Head of Training Program of Oral Surgery. 6
Metastasis from malignant
Volume 36 Number 1
mehwma
7
Rig. 1. Prebiopsy view from an anterior aspect showing a 15 mm. metastatic melanoma to the gingiva. Note: The lesion did not appear clinically as a malignant melanoma.
Fig. 8. One week following of bone resorbed by the lesion.
biopsy
the periodontal
pack was removed,
revealing
the area
considered adequate to establish such an origin .3 It is possible, therefore, that the occurrence of metastatic malignant melanomas is higher than we would think from reading the literature. The spread of this lesion has been postulated to be via both lymphatic and vascular channels, with the hematogenous route prevailing. Das Gupta and Brasfield* further reported that in the series of patients they analyzed only 1.6 per cent showed metastasis to the nasopharynx. They reported no metastasis in the oropharynx or gingiva. The treatment of malignant melanoma has included radical surgery, medical therapy, and x-ray therapy. Some of the chemotherapeutic agents used to combat this disease have included Cosmegan, Alkeran, Cytoxan, Oncovin, Mustargen, Hydrea, and thio-TEPA. The single or combined use of these modalities of treatment has, on occasion, increased the time to the development of recurrent
8
Mosby, Sugg, and Hi&t
Oral Surg. July, 1973
or metastatic disease.5 Recently intra-arterial therapy with dimethpl triazeno imidazole carboxamide (DTIC, NSC 45388) has proved to be of some benefit in the treatment of a localized tumor6 The case presented here is not one of a primary lesion; therefore, the treatment rendered was of only a palliative nature. However, had this been a primary lesion, early detection with early radical surgical treatment could possibly have increased the survival time. CASE REPORT A 29.year-old Caucasian man, a captain in the United States Marine Corps, was in his usual state of good health until approximately April 20, 19’70, at which time he noted a small nodule at the left nxilla. The nodule was nontender and could not be associated with :I previous history of infection or trauma. When spontaneous healing did not occur over a An excisional biopsy was performed on May 26. The 4week period, he sought treatment. biopsy specimen showed changes compatible with malignant melanomn. Radiographs and metnstatic work-up were normal and showed no evidence of metastasis. On June 2 wide excision of a nevus adjacent to t,he twelfth thoraeic and first, lumbar vertebrae and a left axillary node dissection mere performed. The pathologist’s report indicated that the nevus contained the primary site. There was one node positive for malignant melanoma in the cw%srd axillnrp specimen. The postoperative course was uneventful. The tumor board recommended re-evaluation at Y-month intervals, to include liver- and kidney-function tests and metnstatic scans. The patient was followed at Y-month intervals until September, 1971. During this 15month period the results of all studies were within normal limits. On Sept. 13, 1971, the patient presented for admission at the Naval Hospital in San Diego with the following complaints : dysphagia and anorexia during the previous 2 weeks, a 10 pound weight loss over the preceding 4 weeks, and a posterior neck mass. A 0.5 by 0.5 cm. subcutaneous hard nodule was discovered in the right posterior cervical area. A 1 by 1 cm. pedunculated polypoid lesion was present on the posterior wall of the right oral pharynx. A small 2 to 3 mm. nodule was present on the right upper gingiva between the cuspid and premolar teeth. (Over a 4-week period this lesion subsequently grew to 13 to 15 mm.) (Fig. 1). The liver was palpable but not otherwise grossly abnormal. Small shotty inguinal lymph nodes were present. Significant laboratory findings on admission were as follows: Twenty-four-hour urine was positive for melanin on two occasions. Liver scan was abnornml and suggested the presence of metastatir tumor in the liver. Done scan was interpreted as showing arcas suspicious for metastntic involvement in the lower dorsal spine and in the region of the right sacroiliac joint. Excisional biopsies of the lesions revealed the presence of malignant melanoma (Fig. 3). The gingivxl lesion did CRUSC bony destructions (Fig. 2). Because of the obvious presence of disseminating melanoma, it was decided after careful deliberation to treat the patient chemothera.peutically, using hydroxy-urea in an attempt to halt the progression of the disease. The patient’s clinical course was slowly downhill. Except for :I progressing rise in alkaiine phosphatase and LDH, the patient’s various laboratory and x-ray determinations remained stable until late January, 1972. Repeat general physical examination then revealed him to be extremely pallid and cadaveric in appearance, with moderate dyspnen at rest. He remained mentally alert and well oriented. Since no therapy other than symptomatic was available, he was transferred to a Veterans’ Administration Hospital nearer his home. Four days after arrival at that facility, he died of disseminated melanoma.
SUMMARY
This patient had malignant melanoma, arising in the area of the left scapula, metastatic to the left axillary node group at the time of initial treatment. Despite apparently curative surgery in *June, 1970, he developed evidence of
Metastasis from
malignant
melanoma
9
Fig. 3. A, Low-power magnification showing the neoplasm to be entirely covered with squamous epithelium. The lesion shows a monotonous mass of large neoplastic cells with large! pleomorphic nuclei. (Magnification, x10.) B, The cells are uniform with hyperchromatic nucler and prominent nucleoli. Cells are noted to be in an alveolar pattern.
disseminated melanoma, with metastasis including the oropharynx and gingiva, in September, 1971. From that time onward, his clinical course was progressively downhill, leading to his death in February, 1972. The authors wish to acknowledge the Medical Photography Laboratory, Naval Hospital, San Diego, for their assistance with the photographs. The authors also wish to thank Commander R. V. Curio, United States Naval Dental School, N.N.M.C., Bethesda, Maryland, for his assistance with the photomicrographs. REFERENCES
Melanomas of the Mouth, ORAL SURG. 1. Baldridge, 0. L., and Waldron, C. A.: Malignant 7: 1108-1115, 1954. Malignant Melanoma of the 2. Chaudhry, A. P., Hampel, A., and Gorlin, R. J.: Primary Oral Cavity: A Review of 105 Cases, Cancer 11: 923-928, 1958. 3. Greene, G. W., Haynes, J. W., Dozier, M., Blumberg, J. M., and Bernier, J. L.: Primary Malignant Melanoma of the Oral Mucosa, ORAL SURG.6: 1435-1443, 1953. 4. Das Gupta, T., and Brasfield, R.: Metastatic Melanoma: A Clinicopathological Study, Cancer 17: 1323-1339, 1964.
10
Mosby, Sugg, and Hi&t
Oral Surg. July, 1973
5. Nathanson, L., Hall, T. C., Jawter, G. F., and Farber, S.: Melanoma as a Medical Problem, Arch. Intern. Med. 119: 479-492, 1967. 6. Savlov, E. I?., Hall, T. C., and Oberfield, R. A.: Intra-arterial Therapy of Melanoma With Dimethyl Tnazeno Imidazole Carboxamide (NSC-45388), Cancer 28: 1161-1164, 1971. Reqwest reprints to: Commander Edward L. Mosby U. 8. Naval Hospital San Diego, Calif. 92134
of a case
Edward L. Mosby, D.D.S.,* William E. Sugg, Jr., D.D.S.,** and W. R. Hiatt, D.D.S.,*+* San Diego, Calif. NAVAL
HOSPITAL,
SAN
DIEGO,
CALIF.
Malignant melanoma is a rare disease, comprising 1 to 3 per cent of all malignant tumors. Fewer than 2 per cent of all malignant melanomas occur in the oral cavity. Since m&static malignant melanoma to the gingiva has not been hitherto reported, the case presented here is of interest.
M
alignant melanoma is an enigmatic disease, as it is almost always fatal. Baldridge and Waldron’ state that the five-year survival rate for patients with negative nodes, both clinically and microscopically, is about 30 per cent. The prospect for survival of a patient with clinically and/or microscopically positive nodes is lessened considerably. Primary malignant melanoma of the oral cavity is an extremely rare tumor. In 1958 Chaudhry, Hampel, and Gorlin2 reviewed the literature and found that 105 cases had been reported in the preceding 100 years. They report that the treatment of choice forprimary oral malignant melanoma is radical surgery. Thirty-two patients were treated surgically with approximately a 10 per cent five-year survival rate and thirteen patients received radiation treatment, one having a three-year survival, Metastatic malignant melanoma to the mouth and, in particular, the gingiva is not mentioned in the literature. However, it has been stated that several reported primary oral malignant melanomas have not completely satisfied the criteria The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy. *Commander, DC, USN; Chief Resident in oral Surgery. **Commander, DC, USN; St& Oral Surgeon. ***Captain, DC, USN; Chief of Dental Service and Head of Training Program of Oral Surgery. 6
Metastasis from malignant
Volume 36 Number 1
mehwma
7
Rig. 1. Prebiopsy view from an anterior aspect showing a 15 mm. metastatic melanoma to the gingiva. Note: The lesion did not appear clinically as a malignant melanoma.
Fig. 8. One week following of bone resorbed by the lesion.
biopsy
the periodontal
pack was removed,
revealing
the area
considered adequate to establish such an origin .3 It is possible, therefore, that the occurrence of metastatic malignant melanomas is higher than we would think from reading the literature. The spread of this lesion has been postulated to be via both lymphatic and vascular channels, with the hematogenous route prevailing. Das Gupta and Brasfield* further reported that in the series of patients they analyzed only 1.6 per cent showed metastasis to the nasopharynx. They reported no metastasis in the oropharynx or gingiva. The treatment of malignant melanoma has included radical surgery, medical therapy, and x-ray therapy. Some of the chemotherapeutic agents used to combat this disease have included Cosmegan, Alkeran, Cytoxan, Oncovin, Mustargen, Hydrea, and thio-TEPA. The single or combined use of these modalities of treatment has, on occasion, increased the time to the development of recurrent
8
Mosby, Sugg, and Hi&t
Oral Surg. July, 1973
or metastatic disease.5 Recently intra-arterial therapy with dimethpl triazeno imidazole carboxamide (DTIC, NSC 45388) has proved to be of some benefit in the treatment of a localized tumor6 The case presented here is not one of a primary lesion; therefore, the treatment rendered was of only a palliative nature. However, had this been a primary lesion, early detection with early radical surgical treatment could possibly have increased the survival time. CASE REPORT A 29.year-old Caucasian man, a captain in the United States Marine Corps, was in his usual state of good health until approximately April 20, 19’70, at which time he noted a small nodule at the left nxilla. The nodule was nontender and could not be associated with :I previous history of infection or trauma. When spontaneous healing did not occur over a An excisional biopsy was performed on May 26. The 4week period, he sought treatment. biopsy specimen showed changes compatible with malignant melanomn. Radiographs and metnstatic work-up were normal and showed no evidence of metastasis. On June 2 wide excision of a nevus adjacent to t,he twelfth thoraeic and first, lumbar vertebrae and a left axillary node dissection mere performed. The pathologist’s report indicated that the nevus contained the primary site. There was one node positive for malignant melanoma in the cw%srd axillnrp specimen. The postoperative course was uneventful. The tumor board recommended re-evaluation at Y-month intervals, to include liver- and kidney-function tests and metnstatic scans. The patient was followed at Y-month intervals until September, 1971. During this 15month period the results of all studies were within normal limits. On Sept. 13, 1971, the patient presented for admission at the Naval Hospital in San Diego with the following complaints : dysphagia and anorexia during the previous 2 weeks, a 10 pound weight loss over the preceding 4 weeks, and a posterior neck mass. A 0.5 by 0.5 cm. subcutaneous hard nodule was discovered in the right posterior cervical area. A 1 by 1 cm. pedunculated polypoid lesion was present on the posterior wall of the right oral pharynx. A small 2 to 3 mm. nodule was present on the right upper gingiva between the cuspid and premolar teeth. (Over a 4-week period this lesion subsequently grew to 13 to 15 mm.) (Fig. 1). The liver was palpable but not otherwise grossly abnormal. Small shotty inguinal lymph nodes were present. Significant laboratory findings on admission were as follows: Twenty-four-hour urine was positive for melanin on two occasions. Liver scan was abnornml and suggested the presence of metastatir tumor in the liver. Done scan was interpreted as showing arcas suspicious for metastntic involvement in the lower dorsal spine and in the region of the right sacroiliac joint. Excisional biopsies of the lesions revealed the presence of malignant melanoma (Fig. 3). The gingivxl lesion did CRUSC bony destructions (Fig. 2). Because of the obvious presence of disseminating melanoma, it was decided after careful deliberation to treat the patient chemothera.peutically, using hydroxy-urea in an attempt to halt the progression of the disease. The patient’s clinical course was slowly downhill. Except for :I progressing rise in alkaiine phosphatase and LDH, the patient’s various laboratory and x-ray determinations remained stable until late January, 1972. Repeat general physical examination then revealed him to be extremely pallid and cadaveric in appearance, with moderate dyspnen at rest. He remained mentally alert and well oriented. Since no therapy other than symptomatic was available, he was transferred to a Veterans’ Administration Hospital nearer his home. Four days after arrival at that facility, he died of disseminated melanoma.
SUMMARY
This patient had malignant melanoma, arising in the area of the left scapula, metastatic to the left axillary node group at the time of initial treatment. Despite apparently curative surgery in *June, 1970, he developed evidence of
Metastasis from
malignant
melanoma
9
Fig. 3. A, Low-power magnification showing the neoplasm to be entirely covered with squamous epithelium. The lesion shows a monotonous mass of large neoplastic cells with large! pleomorphic nuclei. (Magnification, x10.) B, The cells are uniform with hyperchromatic nucler and prominent nucleoli. Cells are noted to be in an alveolar pattern.
disseminated melanoma, with metastasis including the oropharynx and gingiva, in September, 1971. From that time onward, his clinical course was progressively downhill, leading to his death in February, 1972. The authors wish to acknowledge the Medical Photography Laboratory, Naval Hospital, San Diego, for their assistance with the photographs. The authors also wish to thank Commander R. V. Curio, United States Naval Dental School, N.N.M.C., Bethesda, Maryland, for his assistance with the photomicrographs. REFERENCES
Melanomas of the Mouth, ORAL SURG. 1. Baldridge, 0. L., and Waldron, C. A.: Malignant 7: 1108-1115, 1954. Malignant Melanoma of the 2. Chaudhry, A. P., Hampel, A., and Gorlin, R. J.: Primary Oral Cavity: A Review of 105 Cases, Cancer 11: 923-928, 1958. 3. Greene, G. W., Haynes, J. W., Dozier, M., Blumberg, J. M., and Bernier, J. L.: Primary Malignant Melanoma of the Oral Mucosa, ORAL SURG.6: 1435-1443, 1953. 4. Das Gupta, T., and Brasfield, R.: Metastatic Melanoma: A Clinicopathological Study, Cancer 17: 1323-1339, 1964.
10
Mosby, Sugg, and Hi&t
Oral Surg. July, 1973
5. Nathanson, L., Hall, T. C., Jawter, G. F., and Farber, S.: Melanoma as a Medical Problem, Arch. Intern. Med. 119: 479-492, 1967. 6. Savlov, E. I?., Hall, T. C., and Oberfield, R. A.: Intra-arterial Therapy of Melanoma With Dimethyl Tnazeno Imidazole Carboxamide (NSC-45388), Cancer 28: 1161-1164, 1971. Reqwest reprints to: Commander Edward L. Mosby U. 8. Naval Hospital San Diego, Calif. 92134