Malignant Mucosal Melanoma of Nasal Cavity (melanic variant)

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1 International Journal of Advances in Health Sciences (IJHS) ISSN Vol2, Issue2, 2015, pp Research Article Malignant Mucosal Melanoma of Nasal Cavity (melanic variant) Laxmi Narayan Garg 1, Nasib chand 2, Bhavna Gulati 2, Palak Mahajan 2, Hinna Bansal 2 and Subash Goel 3 1 Department of ENT, 2 Department of Pathology, 3 Department of Surgery MMIMS and R Mullana, Ambala (HR), India Corresponding Author; nasib_chand2004@yahoo.com [Received-16/03/2015, Accepted-24/03/2015] ABSTRACT Malignant melanoma of nasal mucosa and paranasal sinuses is a very rare tumor, which can be melanin producing or non melanin producing ie amelanotic variant. Rhinosinusal mucosal melanoma constitutes less than 1% of all melanic tumors and 2-8% of overall cancers developing in nasal fossae and paranasal sinuses. Patient gets medical attention very late in the course of disease due to ignorance of early mild/nonspecific symptoms in the way of high degree of local and distant invasion by the disease, and this finally leads to poor prognosis. Studies show average 5 year survival as 20-30% for cutaneous and 10-15% for mucosal melanomas. Here, we present a case of 60 yrs old male presenting with right nasal mass associated with off and on nasal bleeding. On suspicion of malignancy he was investigated, confirmed by Biomarkers study and operated after final diagnosis, Later, patient was referred to Radiation oncology for appropriate treatment. Key words; malignant melanoma, Rhinosinusal, mucosal, Immunohistochemistry. INTRODUCTION Mucosal malignant melanoma of nose is extremely rare and unpredictable presentation in Otorhinolaryngeal practice. First case of nasal melanoma was reported in1869 by Lucke and since then, less than 1% of melanic tumors has been reported and only 2-8% of all neoplasms developed in the nasal fossae and sinuses. 1 Nasal/paranasal melanoma is a rare tumor and has a poor prognosis. 2 Primary melanoma of head and neck comprises 25-30% of all melanomas. 3 Aerodigestive mucosal melanoma (0.4-4%) mostly occur in the nasal cavity or paranasal sinuses (maxillary >ethmoid sinuses). 4,5 Peak incidence is between 5 th and 8 th decade of life. Males are more commonly involved than females. Age and sex in particular, do not affect prognosis. 6,7 Tumor shows aggressive behavior and average five year survival is only 20-30% in case of cutaneous and 10-15% for mucosal melanomas.

2 CLINICAL HISTORY A 60 years old patient presented with six month history of unilateral right sided nasal reddish brown mass ( Figure 1) causing right nasal obstruction and recurrent off and on bleeding, with H/o smoking. On anterior Rhinoscopy, a mass was visualized in the right nasal cavity, excised surgically and sent for Histopathological examination (HPE). DISCUSSION Melanomas are malignant tumors, that arise from melanocytic proliferation, which in turn derive from neuroectodermal cells, located in the basal layer of skin and mucosa. 80% of melanomas arise from skin and remaining 20% in the head & neck region and other sun exposed areas of the body respectively. Smoking is also thought to be activating factor for melanocytic changes like melanogenic metaplasia 6. Mucosal melanoma of nasal cavity is rarely encountered lesion and constitutes 1.3% of all malignant melanomas 8. The tumor carries very poor prognosis, because of local recurrence and early distant metastasis via both lymphatic (5-15%) and other pathways. Commonest site of metastasis is submandibular lymph nodes. Although, there is no accepted staging system (TNM) for nasal/sinusal melanomas, but clinically, we have three stage classification as; Stage1 primary tumor without metastases; Stage2 primary tumor with loco-regional node metastasis; Stage3 primary tumor with distant metastases. 9 American armed forces institute of pathology, proposed a staging system for nasosinusal and nasopharyngeal melanoma in 2003, stated as; T1; primary tumor at one anatomical site. T2; primary tumor at two or more sites. N1; any lymph node metastasis and M1- any distant metastasis 10. Overall prognosis depends on time at which, patient presents, is also important. It also depends on size and location of tumor, as in our case, patient mainly presented with off and on epistaxis and difficulty in breathing due to progressive nasal obstruction. Unfortunately, the tumor is usually well advanced at time of presentation and also shows recurrences, lymph node involvement and distant metastases respectively. As far as differential diagnosis is concerned, tumor must be differentiated from round cell tumors (benign, intermediate or malignant), Benign tumors like( nasal polyps, osteoma, chondroma, schwannoma, neurofibroma and cementoma 11 ), Intermediate tumors including, inverted papilloma, meningioma, hemangioma, and hemangiopericytomas 11,12. The malignant tumors include Squamous cell carcinoma (most common), followed by adenoid cystic carcinoma, adenocarcinoma, neuroblastoma, rotund-cell sarcoma, lymphoma, and undifferentiated small cell carcinoma. HPE is the final tool for correct and definitive diagnosis. Diagnosis of malignant melanoma is challenging particularly, when the tumor shows melanin (high or low) positivity ie (melanic/ amelanic variants). After H&E section examination, the diagnosis is made and further confirmed by Immunohistochemical markers study like S-100 specifically, HMB-45 monoclonal antibody derived (cytoplasmic positivity in 65 95% of cases), particularly for primary and metastatic melanomas including amelanotic M, spindle cell M, and acral lentigenous M. It can also be seen in signet ring cell M, myxoid M, small cell M, balloon cell M, and other different anatomical sites melanomas such as Gall bladder, Urinary bladder, anorectal, vulva, sinusal region, uterine cervix and other than mucosal sites melanomas such as, bones 14 and Pulmonary blastomas 16 respectively. Other tumor markers are Melan- A Nasib chand, et al. 176

3 (very specific for differentiation from sarcoma, plasmacytoma and carcinosarcomas), Vimentin (mesenchymal), Cyclin-D (nuclear), tyrosine and CD 44 (membranous) positivity for tumor cells. In our case also, the excised mass was processed and examined by light microscopy. HPE shows ulcerated surface epithelium, having underlying tumor composed of sheets and clumps of large polygonal cells with abundant cytoplasm, showing little melanin and large hyperchromatic vesicular nuclei along with many macronuclei are seen.fare number of mitotic figures seen(figure- 3) Atypical and typical pseudoglandular pattern was also evident at places. Masson Fontana stain shows red colored nuclei and brownish black cytoplasmic melanin granules (Figure-4). Immunohistochemistry (S-100) shows cytoplasmic pigment (Figure-5) CONCLUSION While dealing with a tumor mass arising from nasal mucosa especially, when it is associated with nasal bleeding/or obstruction, is very distressing to patient. A point of suspicion arises regarding diagnosis, treatment and it s future outcome in terms of prognosis. Clinical diagnosis is sometime evident and is also supported by Endoscopic examination as well as C T Scan. The final diagnosis is based on Histopathological examination (gold standard), which is further confirmed by Immunohistochemical techniques(ihc) including study of Biomarkers of high specificity for malignant melanoma such as S-100,HMB-45 and Melan-A respectively. So early diagnosis and wide Surgical excision followed by postoperative Radiotherapy can only improve survival, Inspite of local recurrence, nodal and distant organ metastasis. Other poor prognostic factors include advanced age, obstructive symptoms of nasopharynx and paranasal sinuses, vascular invasion into liver and skeletal muscles, cellular pleomorphism and high mitotic index respectively. REFERENCES; 1 Kung S,Deschenes GR,Keane W, Cunnane M, Jacob Amouero MP, Rosen M, Paranasal sinus melanoma masquerading as chronic sinusitis and nasal polyposis, Ear Nose Throat J,2007,86(9): Huang SF, Liao CT, Kan CR, Chen IH, Primary mucosal melanoma of the nasal cavity and paranasal sinuses: 12 years of experience, J Otolaryngol, 2007, 36(2): Goldsmith HS, Melanoma: an overview, CA Cancer J Clin,1979, 29(4): McKinnon JG, Kokal WA, Neifeld JP, Kay S, Natural history and treatment of mucosal melanoma, J Surg Oncol, 1989,41(4): Stern SJ, Guillamondegui OM, Mucosal melanoma of the head and neck, Head Neck, 1991, 13(1): Batsakis JG, Suarez P, El-Naggar AK, Mucosal melanomas of the head and neck, Ann Otol Rhinol Laryngol, 1998,107(7): Snow GB, van der Waal I, Mucosal melanomas of the head and neck, Otolaryngol Clin North Am, 1986, 19(3): Chang AE, Karnell LH, Menck HR, The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society, Cancer,1998, 83(8): Rinaldo A, Shaha AR, Patel SG, Ferlito A, Primary mucosal melanoma of the nasal cavity and paranasal sinuses, Acta Otolaryngol, 2001, 121(8): Batsakis JG, Pathology of tumors of the nasal cavity and paranasal sinuses and neck cancer, W.B. Saunders Co.,Philadelphia, 1999, Nasib chand, et al. 177

4 11 Conley JJ, Melanomas of the mucous membrane of the head and neck, Laryngoscope, 1989, 99(12): Weymüller EA Jr, Neoplasms. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE (eds), Otolaryngology: head and neck surgery,3rd edition, Mosby Year-Book, St. Louis, Ciolofan S,Ionita E, Mogoanta CA,Popescu FC, Anghelina F, Chiutu L and Stanciu G. Malignant melanoma of nasal cavity, Rom J Morphol Embryol 2011,52(2): Leong ASY, Cooper K, Leong FJWM, HMB-45 (melanoma marker). In: Leong ASY, Cooper K, Leong FJWM, Manual of diagnostic antibodies for immunohistology, Greenwich Medical Media, 1999, Ordóñez NG, Sneige N, Hickey RC, Brooks TE, Use of monoclonal antibody HMB-45 in the cytologic diagnosis of melanoma, Acta Cytol, 1988, 32(5): Figures: Figure; 1- Clinical photograph showing brownish mass in the Right nasal fossa. Figure; 2- H&E stained section showing mucosa & sheets of malignant melanocytes having macronuclei (10X). Nasib chand, et al. 178

5 Figure; 3- Section showing sheets of malignant melanocytes(40x). Figure; 4- section showing red nuclei and cytoplasmic brown black pigment (Masson fontana stain. (40X)) Figure; 5- Immunohistochemical stain(s- 100) showing cytoplasmic positivity. (40X). Nasib chand, et al. 179