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RECURRENT NASAL MALIGNANT MELANOMA

Haritosh K Velankar, Ka Pradhan
Lecturer in ENT; Hon. HOD ENT Surg, Rajawadi Hospital, Padmashri DY Patil Medical College, Ghatkopar.

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Malignant melanoma, of the nose is extremely rare tumour, about 0.5-2% of all the Malignant Melanomas. After a wide excision of the tumour there is a very high chance of local reccurrance or distant metastases. Treatment of the tumour is basically, wide excision followed by, either radiotherapy or chemotherapy. It is seen that chemotherapy or radiotherapy some times aggravate the reccurance, by reducing the patient’s Immune system. Medical therapy such as, local or intralesional BCG injections, and interferon injections is given to boost the immune system.

It is very necessary to increase the immune status, as low immunity is the basic cause of local reccurance or distant metastases.

INTRODUCTION

Malignant Melanoma of the nasal mucosa is very rare, about 0.5-2% of all the malignant melanomas.[1] Usually they have a pigmented appearance, but Amelanotic tumours are not uncommon and are often diagnosed as anaplastic cacinomata, unless the intracytoplasmic pigment is sought. Local reccurence is high and is also the determinent of the treatment failure. One such case of nasal mucosal malignant melanoma is reported.

CASE REPORT

65 year old male patient came to our OPD with swelling in the right nostril, with duration over 4-5 months.
He had history of right side nostril obstruction,

Right nostril epistaxis (minimal)

Watering of the right eye

Patient gave h/o of prolonged use of snuff for almost 40 years.

Patient gave h/o of treatment taken for the same, in one of Mumbai’s major institutes. He had similar complaints at that time, and was operated for the same. Operative notes revealed, that right inferior turbinectomy was done along with removal of the mass, as it was arising from that turbinate.

Histopathology report indicated, it, to be a malignant melanoma.

There was reccurence of symptoms within 2-3 months after surgery, but now the patient did not follow up with same institution, instead he chose to come to our institution.

On his first OPD visit in our Hospital, he presented with, blackish coloured mass in right nostril, which bleed minimally on touch

- Severe deviation of septum to opposite (left) side.

- Posterior rhinoscopy was clear

- Right eye had severe epiphora

- Neck showed no glands

Investigations

Routine investigations of blood including, LFT and HIV were normal.

X-rays PNS showed haziness in the right nostril, maxillary and ethmoid sinuses.

CT scan revealed, involvement of all the sinuses on right side, without breach in lamina praparacia and pushing the septum on to the opposite side. USG abdomen showed on distant metastasis.

After investigating we did a wide excision of the tumour, with 1 cm safe margin by a sublabial extended Caldwell-Luc or Denkers approach.

The tumour mass along with the inferior and medial wall of maxilla, ethmoids was removed. Haemostasis achieved and incision closed, with nasal pack to prevent bleeding. Histopathology, showed stratified columnar epithelium. Thejunction between stratified columnar epithelium and stroma showed proliferation of melanocytes in epithelium, which confirmed it as a malignant melanoma.

Unfortunately, the patient did not follow up for further treatment.

Fig 1. Pre-operative photograph

Fig 2. CT Scan of the patient

Fig 3. Intra-operative photograph

DISCUSSION

Malignant melanoma is, usually seen in person above the age of 50 years, both sexes equally affected. Grossly it presents as a slaty grey or bluish black polypoidal mass within nasal cavity, most frequently arising from, either anterior part of nasal septum, middle or inferior turbinate or arising from lacrimal sac.[2] Cervical nodal metastasis may be present at the initial examination and distant metastasis are very common. The tumour spreads by lymphatics and blood stream. The treatment of localised tumour is by wide excision. The success of operation and reccurrence depends on patient’s immune response,[3] They respond poorly to radiotherapy; chemotherapy is equally unsuccessful and may aggravate the situation by altering the patient’s immune status. There are reports however of local radiotherapy given which have showed improved local control and the time for recurrence was delayed.[4] Reports of chemotherapy i.e. decarbazine, carmustine and cisplatin are noted but with little benefit.[5]

Medical treatment to increase the immune response was tried like, BCG vaccines injected intradermally or intralesionally. Chemo-hormonal therapy using tamoxifen (TAM), TAM is widely known to be an anti-oestrogenic chemotherapeutic agent in treatment of cancer (breast) and is thought to exert its anti-neoplastic effect in cancer tissues by competing with oestrogen for oestrogen receptors. The mechanism of effect of TAM in malignant melanoma is not clear. Interferon as adjuvant to surgical treatment in patients with melanoma who were free of disease post-operatively but at high risk of systemic recurrence was also tried. 20 million IU/M2 intravenously five times in a week for four weeks, (induction phase), followed by 10 million IU/M2 subcutaneously three times in a week for 48 weeks, (maintenance phase). Despite numerous trials there is little evidence that any form of immune stimulation is of value in the management of malignant melanoma.

REFERENCES

1.Seo W, Ogasawara H, Sakagami M. Chemotherapy formalignant melanomas of nose. SO Rhinology Mar. 1997; 35 (1) : 19-21.

2.Albertson M, Tennvall J, Andesson T, Biorklund A, Elnar A. Melanoma Research Jul. 1992; 2 (2) : 101-4.

3.Hills P. Radiotherapy May-Jun. 1988; 54 (615) : 111-2.

4.Mc Rae RG, Bellino JP, Khasgiwala C. Control of malignant melanomas. Laryngoscope Nov. 1982; 92 (11) : 1247-8.

5.Rossenberg SA, Lotze NT, et al. Combination therapy with Interferon and Interleukins.

6.Conley JJ. Melanomas of the mucous membranes of Head and Neck. Laryngoscope 1999 : 1248-54. 1-4.

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