Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 4622  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  Article in PDF (14 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  Acknowledgment
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed14547    
    Printed164    
    Emailed11    
    PDF Downloaded132    
    Comments [Add]    
    Cited by others 4    

Recommend this journal


 


 
CASE REPORTS
Year : 1994  |  Volume : 40  |  Issue : 1  |  Page : 31-3

Malignant melanoma of nasopharynx extending to the nose with metastasis in the neck.


Dept. of Oto-Rhino-Laryngology, BYL Nair Charitable Hospital, Bombay, Maharashtra.

Correspondence Address:
D S Grewal
Dept. of Oto-Rhino-Laryngology, BYL Nair Charitable Hospital, Bombay, Maharashtra.

Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 0008568712

Rights and PermissionsRights and Permissions


 :: Abstract 

Malignant melanoma is a rare tumor in otorhinolaryngology. In this paper, we have reported the first case of melanoma of nasopharynx which we came across in 20 years of ENT practice. A 55 year old male patient with complaints of swelling of nose and left side of neck, nasal blockage and epistaxis was diagnosed as melanoma of nose with metastasis in the neck based on clinical and radiological examination. The tumour was excised by lateral rhinotomy with supraomohyoid block dissection on the left side. The tumour was found to originate from lateral wall of nasopharynx and middle turbinate. The surgery was followed by radiotherapy. Diagnosis of melanoma was confirmed on histopathology. During 30 months follow-up, no recurrence was noticed.


Keywords: Case Report, Combined Modality Therapy, Follow-Up Studies, Head and Neck Neoplasms, pathology,secondary,therapy,Human, Male, Melanoma, pathology,secondary,therapy,Middle Age, Nasopharyngeal Neoplasms, pathology,therapy,Prognosis,


How to cite this article:
Grewal D S, Lele S Y, Mallya S V, Baser B, Bahal N K, Rege J D. Malignant melanoma of nasopharynx extending to the nose with metastasis in the neck. J Postgrad Med 1994;40:31

How to cite this URL:
Grewal D S, Lele S Y, Mallya S V, Baser B, Bahal N K, Rege J D. Malignant melanoma of nasopharynx extending to the nose with metastasis in the neck. J Postgrad Med [serial online] 1994 [cited 2019 Nov 11];40:31. Available from: http://www.jpgmonline.com/text.asp?1994/40/1/31/575





  ::   Introduction Top


Malignant melanomas of the nasopharynx and nasal cavity occur rarely in India; in 1965, Kully and Shreedharan[1] reported the first case. Ravid and Esteeves[2] reported that Lucke in 1869 operated on a 52 year old man suffering from melanotic sarcoma of the nasal mucosa. The first case in the American literature was reported by Lincoln in 1885[3]. Melanomas are tumors arising from melanocytes which are neuroectodermally derived cells located in the basal layers of skin, skin adnexas and some of the mucosal membrane. Common sites for melanomas are head, neck and the lower extremities as they are exposed to sunlight, which is one of the predisposing factor. Less commonly they occur in the oral and genital mucosa, nail beds, conjunctiva, orbit, esophagus, nasal mucosa or nasopharynx, vagina and leptomeninges. In this paper we have described a case of malignant melanoma of the nasopharynx extending to the nose with metastasis in the neck.


  ::   Case report Top


A 55-year-old male patient came to us with the complaints of swelling of the nose, nasal blockage and epistaxis for two months. He noticed a small swelling one cm in diameter, on the left side of the nose 2 months back. The symptoms increased rapidly. Two weeks after this the patient noticed a swelling on the left side of neck which increased rapidly in size. On clinical examination, a huge swelling was noticed on the left side of the nose measuring 5 x 4 cm. There was a fleshy, bluish red, friable, non-tender mass in the left nostril, which was completely blocking the nasal passage and bled slightly on touch. The left ala was stretched and dilated blood vessels were seen over it. The septum was markedly deviated to the right by the mass [Figure - 1].

On posterior rhinoscopy the mass was found to be occupying the nasopharynx. Examination of the throat, ears and larynx were normal.

There were two soft, mobile, enlarged, non-tender, non-matted lymph nodes on the left side together measuring 4 x 4 x 3 cm in the jugulodigastric region [Figure - 2].

The routine hematological and biochemical investigations revealed that haemoglobin was 10.6 gm%, total W.B.C count was 7200/mm[3] with polymorphs - 70%, lymphocytes - 28% and eosinophils - 2%. Fasting blood sugar was 105 mg%, and blood urea nitrogen was 14.2 mg%. Urine and stool examinations were normal. X -Ray of paranasal sinus (Water's view) showed a soft tissue shadow over the nasal region extending to the left maxillary sinus, frontal sinuses and right maxillary sinus [Figure - 3] X-ray chest was normal; CT scan was not done.

A provisional diagnosis of melanoma of nose with metastasis in the left neck was made. The patient was operated and tumour was excised by lateral rhinotomy with supraomohyoid block dissection on the left side. On operation it was found that the middle and inferior turbinates on the left side were lacerated and there was a septal perforation measuring 2 x 1 cm. The septal perforation was probably caused by pressure necrosis. The melanoma was polypoidal and capsulated which ruputured during removal and hence it was removed in pieces. The final attachment was broad based and was found on the lateral wall of nasopharynx, anterior to the  Eustachian tube More Details orifice, extending to the posterior end of the middle turbinate. The left maxillary antrum was inspected by Caldwell-Luc approach and was normal. Anterior and posterior nasal packing was done. Supraomohyoid block dissection was done on the left side and it was found that the lymph nodes were transformed into a mass, which was blue in colour and filled with thick bluish fluid. Radiotherapy, was given following complete wound healing. The patient was followed for a period of 2 years and there has been no recurrence.

After removal of tumour, the gross examination revealed multiple bits of size 2.5 x 2 x 1 cms, totally aggregating to form 7 x 5 cm mass. It was firm and dark blue to black in colour. The lymph nodes were two in number, together measuring 4 x 3.5 x 1.5 cm and had thick capsule with dark areas of extensive necrosis.

On microscopic examination, tumour showed extensive areas of necrosis and nests of tumour cells. Individual tumour cells had moderate to abundant eosinophilic cytoplasm, enlarged pleomorphic nuclei with prominent nucleoli, cytoplasm and nucleus was covered with large amount of melanin pigment [Figure - 4] and [Figure - 5].

Lymph nodes showed destruction of normal architecture and replacement by sheets and nests of tumour cells with scattered areas of necrosis. Individual tumour cells showed moderate to abundant eosinophilic cytoplasm, small amounts of melanin pigment and pleomorphic, hyperchromatic nuclei showing increased mitotic activity. Few cell nests showed central areas of necrosis [Figure - 6].

Presence of melanin was confirmed by histochemical method (Masson Fontana and melanin bleach) and immunohistochemical study to demonstrate Vimentine, S100 protein was done.


  ::   Discussion Top


The incidence of melanomas of the head and neck and nasal cavities varies from 0.4 to 4%[4]. The tumour occurs between 50-70 years of age[3] and is slightly more common in males than females, although age and sex do not affect the prognosis[5],[6].

This is the first case of melanoma we have seen in 20 years of ENT practice. In the upper respiratory tract the commonest sites are the nose and paranasal sinuses with decreasing incidence as the respiratory tract is descended. The site most frequently involved is the nasal septum in our case the tumour originated from the lateral wall of the nasopharynx and the middle turbinate, which is one of the less common sites. Malignant melanomas of the nasal cavities and sinuses are characterized by early and repeated recurrences. Regional metastasis to lymph nodes is uncommon in Negroes whereas it is very frequent in the white races. In this case as the tumororiginated from the nasopharynx, a very early metastasis was seen and it was rapidly progressive.

According to Batsakis, et al[5], of the mucosal melanomas in head and neck, 56% occur in upper respiratory tract and only 0.6% cases occur in the nasopharynx. In a survey of 158 cases of melanomas of upper respiratory tract, Batsakis found only one such case, which was reported by Conley and Pack[7]. Besides this, they also recorded two cases of melanoma of eustachian tube orifice with metastasis to the middle ear. The interesting fact about our case was that the meianoma was polypoidal with a broad based origin in the lateral wall of nasopharynx anterior to the eustachian tube opening, extending to the middle turbinate and because of the involvement of the nasopharynx, a very early metastasis was observed (within two weeks).

Various methods of therapy, including surgery, irradiation alone, irradiation with surgery and chemotherapy have been used in treating malignant melanoma of the nose. Surgical exclusion is the best treatment, as malignant melanoma are considered to be radioresistant. Different chemotherapeutic regimens have been tried which include - vinca alkaloids, alkylating agents, antimetabolites, levamisole, DTIC (dimethyl - trizeno - imidazolecarboxamide) and dactinomycin but all with unsatisfactory results[4].

The prognosis for these tumours is very poor. Ravid and Esteeves[2] described 5 patients with melanoma of the nose, who survived for 5 years but died of the same in the sixth year. The 5 year survival rate varies between 6 and 17%[8].


  ::   Acknowledgment Top


We are grateful to our Dean Dr (Mrs) KD Nihalani for allowing us to publish this paper.

 
 :: References Top

1. Kutty MK, Shreedharan T. Malignant melanoma of the nasal septum. J Laryngol A65; 79:249-252.  Back to cited text no. 1    
2.Ravid JM, Esteeves JA. Malignant melanoma of the nose and paranasal sinuses and juvenile melanoma of the nose. Arch Otolaryngol 1960; 72:431-444.  Back to cited text no. 2    
3.Pantazopoulos PE. Primary malignant melanoma of the nasal fossa. Ann Otol Rhinol Laryngol 1965; 74:604-610.  Back to cited text no. 3    
4.Berthelsen A, Anderson AP, Jensen TS, Hansen HS. Melanomas of the mucosa in the oral cavity and the upper respiratory passages. Cancer 1984; 54:907-912.  Back to cited text no. 4    
5.Batsakis JG, Regezi JA, Soloman AR, Rice DH. The pathology of head and neck tumors; mucosal melanomas, Part B. In: Head and Neck Surgery 1982; 4:404-418.  Back to cited text no. 5    
6.Snow GB, van der Waal I. Mucosal melanomas of the head and neck. Otolaryngol Clin North Am 1988; 19:549-564.  Back to cited text no. 6    
7.Conley J, Pack GT. Melanoma of the mucous membrane of the head and neck. Arch Otolatyngol 1974; 99:315-319.  Back to cited text no. 7    
8.Holdcraft J, Gallagher X. (1969) Malignant melanomas of the nasal and paranasal sinus mucosa, Ann Otol Rhinol Laryngol 1969; 78:1-20.   Back to cited text no. 8    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

This article has been cited by
1 Extracutaneous malignant melanomas
Hussein MR
CANCER INVESTIGATION. 2008; 26(5): 516-534
[Pubmed]
2 A rare tumor of the rhinopharynx
Mekni, A., Bouraoui, S., Amdouni, N., Haifa, T.-G., Kchir, N., Zitouna, M., Haouet, S.
Annales de Pathologie. 2004; 24(4): 375-376
[Pubmed]
3 Mucosal malignant melanoma in upper aerodigestive tract: Report of two cases
Oktay, M.F., Askar, I., Kilinc, N., Topcu, I.
Acta Chirurgiae Plasticae. 2004; 46(1): 16-18
[Pubmed]
4 Nasopharynx: Clinical, pathologic, and radiologic assessment
Weber, A.L., Al Arayedh, S., Rashid, A.
Neuroimaging Clinics of North America. 2003; 13(3): 465-483
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow