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Malignant melanoma of the external auditory meatus
Clinical Oncology (1993) 5:255-256 © 1993 The Royal College of Radiologists
Clinical Oncology
Case Report Malignant Melanoma of the External Auditory Meatus A. R. Banerjee a, D. Meikle 1, P. J. D. K. D a w e s 2 a n d J. A. J. D e a n s a l E N T D e p a r t m e n t , F r e e m a n H o s p i t a l a n d 2Regional R a d i o t h e r a p y C e n t r e , Newcastle G e n e r a l Hospital, Newcastle upon Tyne, Tyne and Wear, UK
Abstract. We report a case of malignant melanoma occurring within the external auditory meatus, in a site not exposed to sunlight; only one such case has previously been reported [1].
Keywords: Malignant melanoma; External auditory meatus
INTRODUCTION Cutaneous malignant melanoma of the head and neck is widely thought to be a consequence of sunlight exposure, and, of this group 13% occur on the ear [2]. In the UK, cutaneous malignant melanoma of the ear is a rare condition. A recent Scottish study found only 13 of 2020 melanomas registered with the Scottish Melanoma Group over a 7-year period to be situated on the ear. Subsite location on the ear was not mentioned, but the paper suggested that the melanomas occurred on the external portion which is exposed to sunlight [3]. Although malignant melanomas of the external auditory meatus have been previously described, they have occurred at the entrance to the canal [4]. The occurrence of a primary cutaneous malignant melanoma of the deep external acoustic meatus has previously been described on only one occasion [1].
CASE REPORT A 76-year-old male retired school teacher presented to the outpatient clinic complaining of a constant clear discharge from his left ear, with intermittent bleeding. He gave a 3-month history of pain in the left side of his face, which, at presentation, was localized to the left ear. His hearing was also reduced in the left ear. On examination, the left external auditory meatus was found to be filled with a
Correspondence and offprint requests to: Mr A. R. Banerjee, Registrar, ENT Department, Pilgrim Hospital, Boston, Lincolnshire, UK.
friable keratinous lesion which bled on contact. No local lymphadenopathy or parotid mass was found and the facial nerve was intact. Pure tone audiometry showed a left-sided conductive hearing loss. An examination under anaesthetic revealed the polypoid mass to be arising from the bony cartilaginous junction of the canal floor. The tumour was debulked and sent for histological examination. The remaining keratin was removed to reveal a healthy intact tympanic membrane. Histological analysis revealed a partly necrotic malignant melanoma. A C T scan was performed and did not show any sign of local spread. In view of this, the lack of metastatic spread on examination, and the patient's age, it was decided to proceed to a wide local excision without elective cervical lymph node dissection. At operation a wide margin of conchal cartilage and all the canal cartilage were included in the resection margins. An area of parotid gland and parotid lymph nodes was included in the resected specimen. The bony canal proximal to the lesion was drilled out to leave a thin bony floor to the canal. A sternocleidomastoid flap was lifted to close the defect. Following the operation the patient made good progress and the wound healed without problems. Regular review in the outpatient clinic was performed. Sixteen months after the operation the patient complained of persistent pain in the wound scar, which was uncontrolled by analgesics, and an examination under anaesthetic was therefore performed. Moderate canal stenosis was noted and a pale fleshy mass in the upper end of the scar was biopsied. Histological analysis revealed a recurrence of malignant melanoma. A radiotherapy opinion was sought and the patient subsequently underwent treatment to the left ear and temporal bone using 236 kV X-rays via a single lateral field measuring 7 × 5 cm. A total of 24 Gy was given in four equal fractions over 22 days. Although the initial response to radiotherapy was encouraging, with a marked diminution in pain, the patient subsequently developed a T8 vertebral crush fracture and lung collapse, presumably due to metastatic spread. Owing to his deterioration in health he was unfit to undergo further investigations to give a definitive diagnosis. The patient eventually died, 2 years after his initial presentation to clinic.
HISTOLOGY The initial debulked specimen was reported as showing partly necrotic, undifferentiated and cytologically pleomorphic malignant tumour. Small amounts of melanin were identified and the lesion classified as a malignant melanoma. The patient then underwent a wide local excision of the tumour. The specimen was reported as containing an ulcerated pigmented malignant melanoma with a depth of approximately 6 ram. It was impossible to comment on excision margins as the specimen was friable and therefore removed piecemeal. No tumour tissue was identified in the parotid specimen nor in the intraparotid lymph nodes examined. The biopsy taken from the wound site 16 months after the wide excision revealed an undifferentiated unpigmented pleomorphic malignant melanoma.
DISCUSSION The association of malignant melanoma with sunlight exposure is well recognized [2] and the increased risk of outdoor workers to ear melanoma is based on this premise [5]. However, the development of primary cutaneous malignant melanoma in sites not exposed to ultraviolet light is also well documented, and appears to have its greatest incidence in dark skinned races. In a study of Asian Indians, 42 of 78 cutaneous lesions were found to occur on the sole of the foot [6]. Males appear to have a higher incidence of ear melanoma [3,5] and show a higher incidence of mortality than females with the same lesion [7]. The poor prognosis of ear melanoma in both sexes is due to the high proportion of nodular melanomas occurring at this site [8]. Cutaneous malignant melanoma of the ear canal is extremely rare. In a series of 995 cases of head and neck malignant melanomas Conley found none in the external auditory meatus [9]. The only previously recorded case was by Friedmann and Radcliffe [1], who described the lesion occurring in a 68-year-old woman also suffering from otosclerosis. The tumour occurred on the posterior meatal wall adjacent to an intact tympanic membrane. The patient's
256 presenting symptoms were aural discharge and discomfort. Sylven et al., in a series of 36 cases of malignant melanoma of the external ear treated between 1928 and 1944, described four cases occurring in the 'central auricular' area and included the ear canal in this category [4]. Photographs accompanying the text show the l~sions to be arising from the concha and canal entrance, which are areas exposed to sunlight. The tumour we have described arose from an area of the external auditory meatus not exposed to sunlight.
A. R. Banerjee et al. is true of all races, irrespective of latitude of residence, or skin colour [10]. A primary cutaneous malignant melan o m a of the deep external acoustic meatus is reported. The fact that a malignant melanoma occurred in this site and could be treated with good palliation confirms the previously stated need to submit all aural polyps for histopathological examination; the correct treatment of the rare malignant melanoma and the commoner canal lesions is dependent on a clear histopathological diagnosis [11].
4.
5. 6. 7.
8.
References 9.
CONCLUSION Malignant melanoma is a lesion which, although commonly associated with ultraviolet light exposure, can occur in anatomical areas not under such exposure. This
1. Friedmann I, Radcliffe A. Otosclerosis associated with malignant melanoma of the ear. J Laryngol Otol (1954);68:114-9. 2. Stal S, Loeb T, Spira M. Melanoma of the head and neck: Update and perspective. Otolaryngol Clin North Am (1986);19:549-64. 3. Cox NH, Jones SK, Mackie RM. Malignant melanoma of the head and neck in Scotland: An eight-year analysis of trends in preva-
10.
11.
lence, distribution and prognosis. Q J Med 1987;64:661-70. Sylven B, Hamburger CA. Malignant melanoma of the external ear: Report of 36 cases treated between 1928 and 1944. Ann Otol Rhinol Laryngol 1950;59:631-47. Byers RM, Smith JL, Russell N, et al. Malignant melanoma of the external ear: Review of 102 cases. Am J Surg 1980;140:518-21. Sampat MB, Sirsat MV. Malignant melanoma of the skin and mucous membranes in Indians. Indian J Cancer 1966;3:228. Lee JA, Yongshaiyudha S. Incidence of and mortality from malignant melanoma by anatomical site. J Natl Cancer Inst 1971;47:25363. Gusseck GS, Reintgen D, Cox E, et al. Cutaneous Melanoma of the head and neck. Arch Otolaryngol 1983;109:803-8. Conley J. Melanoma of the head and neck. Stuttgart: Georg Thieme Verlag, 1990. McGovern VJ. Aetiology of melanoma: Racial factors. In: Milton GW, editor. Malignant melanoma of the skin and mucous membranes. London: Churchill Livingstone, 1977:2-3. Friedmann I. Pathological lesions of the external auditory meatus: A review. J R Soc Med 1990;83:34-7.
Received for publication November 1992 Accepted following revision February 1993
Clinical Oncology
Case Report Malignant Melanoma of the External Auditory Meatus A. R. Banerjee a, D. Meikle 1, P. J. D. K. D a w e s 2 a n d J. A. J. D e a n s a l E N T D e p a r t m e n t , F r e e m a n H o s p i t a l a n d 2Regional R a d i o t h e r a p y C e n t r e , Newcastle G e n e r a l Hospital, Newcastle upon Tyne, Tyne and Wear, UK
Abstract. We report a case of malignant melanoma occurring within the external auditory meatus, in a site not exposed to sunlight; only one such case has previously been reported [1].
Keywords: Malignant melanoma; External auditory meatus
INTRODUCTION Cutaneous malignant melanoma of the head and neck is widely thought to be a consequence of sunlight exposure, and, of this group 13% occur on the ear [2]. In the UK, cutaneous malignant melanoma of the ear is a rare condition. A recent Scottish study found only 13 of 2020 melanomas registered with the Scottish Melanoma Group over a 7-year period to be situated on the ear. Subsite location on the ear was not mentioned, but the paper suggested that the melanomas occurred on the external portion which is exposed to sunlight [3]. Although malignant melanomas of the external auditory meatus have been previously described, they have occurred at the entrance to the canal [4]. The occurrence of a primary cutaneous malignant melanoma of the deep external acoustic meatus has previously been described on only one occasion [1].
CASE REPORT A 76-year-old male retired school teacher presented to the outpatient clinic complaining of a constant clear discharge from his left ear, with intermittent bleeding. He gave a 3-month history of pain in the left side of his face, which, at presentation, was localized to the left ear. His hearing was also reduced in the left ear. On examination, the left external auditory meatus was found to be filled with a
Correspondence and offprint requests to: Mr A. R. Banerjee, Registrar, ENT Department, Pilgrim Hospital, Boston, Lincolnshire, UK.
friable keratinous lesion which bled on contact. No local lymphadenopathy or parotid mass was found and the facial nerve was intact. Pure tone audiometry showed a left-sided conductive hearing loss. An examination under anaesthetic revealed the polypoid mass to be arising from the bony cartilaginous junction of the canal floor. The tumour was debulked and sent for histological examination. The remaining keratin was removed to reveal a healthy intact tympanic membrane. Histological analysis revealed a partly necrotic malignant melanoma. A C T scan was performed and did not show any sign of local spread. In view of this, the lack of metastatic spread on examination, and the patient's age, it was decided to proceed to a wide local excision without elective cervical lymph node dissection. At operation a wide margin of conchal cartilage and all the canal cartilage were included in the resection margins. An area of parotid gland and parotid lymph nodes was included in the resected specimen. The bony canal proximal to the lesion was drilled out to leave a thin bony floor to the canal. A sternocleidomastoid flap was lifted to close the defect. Following the operation the patient made good progress and the wound healed without problems. Regular review in the outpatient clinic was performed. Sixteen months after the operation the patient complained of persistent pain in the wound scar, which was uncontrolled by analgesics, and an examination under anaesthetic was therefore performed. Moderate canal stenosis was noted and a pale fleshy mass in the upper end of the scar was biopsied. Histological analysis revealed a recurrence of malignant melanoma. A radiotherapy opinion was sought and the patient subsequently underwent treatment to the left ear and temporal bone using 236 kV X-rays via a single lateral field measuring 7 × 5 cm. A total of 24 Gy was given in four equal fractions over 22 days. Although the initial response to radiotherapy was encouraging, with a marked diminution in pain, the patient subsequently developed a T8 vertebral crush fracture and lung collapse, presumably due to metastatic spread. Owing to his deterioration in health he was unfit to undergo further investigations to give a definitive diagnosis. The patient eventually died, 2 years after his initial presentation to clinic.
HISTOLOGY The initial debulked specimen was reported as showing partly necrotic, undifferentiated and cytologically pleomorphic malignant tumour. Small amounts of melanin were identified and the lesion classified as a malignant melanoma. The patient then underwent a wide local excision of the tumour. The specimen was reported as containing an ulcerated pigmented malignant melanoma with a depth of approximately 6 ram. It was impossible to comment on excision margins as the specimen was friable and therefore removed piecemeal. No tumour tissue was identified in the parotid specimen nor in the intraparotid lymph nodes examined. The biopsy taken from the wound site 16 months after the wide excision revealed an undifferentiated unpigmented pleomorphic malignant melanoma.
DISCUSSION The association of malignant melanoma with sunlight exposure is well recognized [2] and the increased risk of outdoor workers to ear melanoma is based on this premise [5]. However, the development of primary cutaneous malignant melanoma in sites not exposed to ultraviolet light is also well documented, and appears to have its greatest incidence in dark skinned races. In a study of Asian Indians, 42 of 78 cutaneous lesions were found to occur on the sole of the foot [6]. Males appear to have a higher incidence of ear melanoma [3,5] and show a higher incidence of mortality than females with the same lesion [7]. The poor prognosis of ear melanoma in both sexes is due to the high proportion of nodular melanomas occurring at this site [8]. Cutaneous malignant melanoma of the ear canal is extremely rare. In a series of 995 cases of head and neck malignant melanomas Conley found none in the external auditory meatus [9]. The only previously recorded case was by Friedmann and Radcliffe [1], who described the lesion occurring in a 68-year-old woman also suffering from otosclerosis. The tumour occurred on the posterior meatal wall adjacent to an intact tympanic membrane. The patient's
256 presenting symptoms were aural discharge and discomfort. Sylven et al., in a series of 36 cases of malignant melanoma of the external ear treated between 1928 and 1944, described four cases occurring in the 'central auricular' area and included the ear canal in this category [4]. Photographs accompanying the text show the l~sions to be arising from the concha and canal entrance, which are areas exposed to sunlight. The tumour we have described arose from an area of the external auditory meatus not exposed to sunlight.
A. R. Banerjee et al. is true of all races, irrespective of latitude of residence, or skin colour [10]. A primary cutaneous malignant melan o m a of the deep external acoustic meatus is reported. The fact that a malignant melanoma occurred in this site and could be treated with good palliation confirms the previously stated need to submit all aural polyps for histopathological examination; the correct treatment of the rare malignant melanoma and the commoner canal lesions is dependent on a clear histopathological diagnosis [11].
4.
5. 6. 7.
8.
References 9.
CONCLUSION Malignant melanoma is a lesion which, although commonly associated with ultraviolet light exposure, can occur in anatomical areas not under such exposure. This
1. Friedmann I, Radcliffe A. Otosclerosis associated with malignant melanoma of the ear. J Laryngol Otol (1954);68:114-9. 2. Stal S, Loeb T, Spira M. Melanoma of the head and neck: Update and perspective. Otolaryngol Clin North Am (1986);19:549-64. 3. Cox NH, Jones SK, Mackie RM. Malignant melanoma of the head and neck in Scotland: An eight-year analysis of trends in preva-
10.
11.
lence, distribution and prognosis. Q J Med 1987;64:661-70. Sylven B, Hamburger CA. Malignant melanoma of the external ear: Report of 36 cases treated between 1928 and 1944. Ann Otol Rhinol Laryngol 1950;59:631-47. Byers RM, Smith JL, Russell N, et al. Malignant melanoma of the external ear: Review of 102 cases. Am J Surg 1980;140:518-21. Sampat MB, Sirsat MV. Malignant melanoma of the skin and mucous membranes in Indians. Indian J Cancer 1966;3:228. Lee JA, Yongshaiyudha S. Incidence of and mortality from malignant melanoma by anatomical site. J Natl Cancer Inst 1971;47:25363. Gusseck GS, Reintgen D, Cox E, et al. Cutaneous Melanoma of the head and neck. Arch Otolaryngol 1983;109:803-8. Conley J. Melanoma of the head and neck. Stuttgart: Georg Thieme Verlag, 1990. McGovern VJ. Aetiology of melanoma: Racial factors. In: Milton GW, editor. Malignant melanoma of the skin and mucous membranes. London: Churchill Livingstone, 1977:2-3. Friedmann I. Pathological lesions of the external auditory meatus: A review. J R Soc Med 1990;83:34-7.
Received for publication November 1992 Accepted following revision February 1993