DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.

DIAGNOSTIC DILEMMAS LEADING TO FATALITY IN

MUCOSAL MALIGNANT MELANOMA OF HARD PALATE:
A RARE CLINICAL PRESENTATION
*Mohammad Shakeel, **Gaurav kumar, ***Iram khan, ****Ritu Sharma
ABSTRACT

INTRODUCTION
There are several subtypes of melanoma, but

melanoma with progressively enlarging swelling on the

mucosal malignant melanoma, also referred to as oral

right side of the upper neck in 60 year old female for

malignant melanoma, primarily affects the oral cavity and

which she had taken treatment from many local

is an extremely rare phenomenon. Oral malignant

practitioners. Detailed history of the patient was taken.

melanoma (OMM) was first described by Weber in

Investigations carried out are Computed tomography of

1859 . OMM has an estimated incidence of 1.2 cases per

maxillary region and neck, Fine Needle Aspiration

10 million persons per year . Primary oral malignant

Cytology of right cervical lymphnode and incisional

melanoma is rare disease represent only 0.28% of all

biopsy of the tissue from hard palate sent for

melanomas . Mucosal malignant melanoma, arising from

histopathology then final diagnosis of mucosal

the uncontrolled growth of melanocytes is a potentially

malignant melanoma was arrived. Thus to emphasize

aggressive tumor of melanocytic origin present as a black

that early diagnosis and to maintain high index of

macule, later it may develop as a nodule or ulceration,

suspicion for those pigmented lesions occurring in the

with

oral cavity could have improve the prognosis of patient.

melanoma is more frequent among Japanese people and

Key words: Mucosal malignant melanoma,

Cervical lymph node, Computed tomography, Hard
palate, Metastasis.

can occur in hard palate, maxillary gingival, labial and

Address for correspondence:

increase of 3-8% worldwide5. It occurs slightly more

Vol.-9, Issue-I, Jan-June - 2015

We report a case of hard palate mucosal malignant

Dr. Gaurav Kumar

asymmetry

and

irregular

borders.

Mucosal

buccal mucosa of oral cavity .

The incidence of melanoma has been steadily

increasing in the past several decades with an annual
often in males

6,14

, 2.8:1 male to female ratio and the

H/No. 1404, HIG , SECTOR-I,

age range is from. 20-83 years worth an average age of

LDA COLONY KANPUR ROAD,

LUCKNOW, U.P, INDIA.

56 years . Oral malignant melanoma frequently

Email: kumargaurav.1014@gmail.com,
Ph. : 9559815295

of metastasis and has poor prognosis . Surgery, either

exhibits an extremely aggressive behavior, high index

7

alone or in association with radiotherapy, is the

preferred treatment modality. Prognosis is poor with a
3

5-year survival rate varying from 0 to 55% .

54

*Associate Professor, Deptt. of ENT, ELMC, Lucknow, India, **Junior Resident, Deptt. of ENT, ELMC, Lucknow, India, ***Associate Professor, Deptt. of Forensic MED. & Toxicology, HIMS,
Lucknow, India, **** Junior Resident, Deptt. of Pathology, MGMCH, Jaipur, India

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

CASE REPORT:

revealed solitary right upper cervical lymph node

A 60 year old female reported to Department of

Otolaryngology, Eras Lucknow Medical College,
Lucknow with a complaint of a painless, pigmented
patch on right side of anterior hard palate from last one
year which was progressively increasing and bleeds on
touch.

She

took

treatment

from

many

local

practitioners but was not relieved. Later on she

developed progressively enlarging swelling on the right

palpable about 3.0 2.0 cm in size, which was freely

mobile, firm and non-tender [Figure1(a)]. Computed
tomography (CT) of maxillary region and neck revealed
irregular lobulated lesion of soft tissue density arising
from hard palate opposite right maxillary incisor to first
pre molar teeth and not crossing the midline, measuring
approximately 30 10 22 mm size and no bony
erosion[Figure 2 (a, b)]. There is also evidence of a large
necrotic

right

level

cervical

lymphadenopathy

side of the upper neck to the present state of about

measuring 32 21 mm [Fig.2 (c)]. An incisional biopsy of

lemon size [Fig.1(a)]. She gave no other history of any

the lesion was performed and histopathological section

systemic illness or trauma to the head and neck region.

[Fig. 3] shows parakeratinized stratified squamous

Her general physical examination was insignificant and

epithelium with atypical melanocytes along with melanin

her vital signs were under normal limits. Intra oral

pigmentation throughout the stroma proving the diagnosis

examination showed non tender non ulcerated nodular

of mucosal malignant melanoma. Fine Needle Aspiration

soft tissue swelling of bluish-black pigmentation

Cytology of right cervical lymphnode [Fig. 4] shows

measuring 3.0 2.5 cm in dimension. It extended from

dispersed population of melanin containing highly

right maxillary incisor to first premolar teeth not

pleomorphic cells having high N/C ratio, anisokaryosis

crossing the midline and on palpation borders are not

and prominent nucleoli with abundant extracellular

well defined [Figure 1(b)]. Extra oral examination

pigment. Melanin pigment was

Fig 2 (a)

Fig 1 (a)

Fig 2 (b)

Fig 3:

Fig 2 (c)

Fig 4 (a)

Vol.-9, Issue-I, Jan-June - 2015

Fig 1 (a)

Fig 4 (b)

55

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

confirmed by Masson Fontana silver stain which

confirmed it as metastatic node of mucosal malignant

recognition and subsequent delayed treatment leading

to further worsening the prognosis.

melanoma. Work for distant metastases (CT scan of

chest, brain and abdomen) was negative.

Histopathologic examination of the lesion remains

the

most

accurate

diagnostic

tool.

Adjunctive

Based on the clinical examination, radiologic and

radiologic diagnostic methods such as CT, MRI and

histopathologic features a final diagnosis of mucosal

Positron emission tomography are sometimes useful.

malignant melanoma was arrived. Medical information

The histologic appearance of the tumor is an invasive

was provided to the patient and her family regarding

pattern of growth, with the tumor cells often appearing

the

as

diagnosis,

staging,

therapeutic

options

and

densely

packed
cells

epithelioid

with

or

sometimes

eosinophilic

cytoplasm.

prognosis. The patient was referred to a cancer institute

sarcomatoid

with facility of Radio-Chemotherapy and was called for

Varying degrees of cellular pleomorphism, tumor

regular follow up. According to her attended she died

invasion of blood vessels and lymphatics are seen. The

due to complication of metastasis with in one month of

special stains (Fontana silver stain and the Prussian

starting chemotherapy after referral.

blue stain) are accurate in only about 75% of the cases.

Demonstration of the neuronal specific S-100 protein is

DISCUSSION:

a useful diagnostic indicator, especially if the tumor is

Primary oral mucosal malignant melanoma is a

of amelanotic type. More recently, the application of

rare neoplasm, demonstrate significant heterogenecity

monoclonal antibody techniques HMB-45 and Mart-1

in morphological features, developmental process and

(Melan

biological behavior that could render the clinical

diagnosis extremely difficult and represents 0.5% of all
2,8

A)13

has

increased

the

specificity

of

13

immunohistochemical diagnosis .

oral malignancies . Blacks, Japanese and Asian

Radical surgery is the treatment of choice for oral

patients tend to be disproportionately more affected

melanoma. Elective neck dissection has also been

than Whites2.

advocated along with surgery. Radical surgery in

combination with radiotherapy and chemotherapy or

The differential diagnosis includes melanotic

radiotherapy alone is preferred in inoperable tumors or in

macule, smoking associated with melanosis, post-

the elderly . Immunochemotherapy has been shown to be

inflammatory

pigmentation,

melanoplakia,

melanoacanthoma, nevi, Addisons disease, Peutz9

Vol.-9, Issue-I, Jan-June - 2015

Jeghur syndrome, amalgam tattoo, Kaposis sarcoma .

Oral melanoma presents as a dark brown, bluish

useful

as

an

adjuvant

to

surgical

resection .

Chemotherapy is generally reserved for proven metastatic

11

disease. Morton et al

demonstrated temporary tumor

regression following the intralesional injection of

12

black mucosal discoloration. The lesions may be solitary

cutaneous melanoma with BCG vaccine. Kirkwood et al

or multiple, flat and/or elevated, borders are usually

reported that melanoma is one of the human cancers

irregular, and no clear demarcation exists between the

which respond to interferon anti-tumor therapy. The

tumor and the adjacent tissues. Rarely, melanoma may

future promise of tumor-directed antibodies labeled with

present itself without clinical evidence of pigmentation, in

cytotoxic drugs may offer hope for improved survival.

10

which case it is termed as amelanotic melanoma . These

Malignant melanoma generally has been considered a

lesions are fatal because they have delayed

poorly radiosensitive malignancy.

Primary radiotherapy appeared to be more

which

leads

to

diagnostic

dilemma

of

effective than surgical treatment when the 5-year

practitioners. Considering various oral patchy

cumulative survival rates were compared.

lesions and wide range of presenting age of the

Postoperative radiotherapy could be of some

patients, all pigmented lesions in the oral cavity

use; postoperative radiotherapy using fractions

should be examined with suspicion. As in our case,

of 6 Gy twice a week for a total dose of 30 Gy

60 years of age, which presented with painless

pigmented lesion from last twelve month was

13

has to be given .

under treatment of many practitioners. Earlier

Five-year survival for oral melanoma is

investigation and confirmation of diagnosis could

very poor with a median survival about 2

have improved the prognosis of our patient.

14

better

Vigilant comprehensive analysis of published

prognosis compared to palatal (median survival

cases and recognition of new ones may be helpful

years .

Gingival

location

carries

46 vs. 22 months) . Involvement of lymph

in

nodes affects survival considerably, with a

proposing clinical features that would facilitate its

14

median survival being 46 months, when lymph

nodes are not involved, and 18 months when
they are involved14. As in our case patient
presented with hard palate lesion along with
secondarys neck which has worse prognosis.
Apart from late presentation of patients with
locally advanced disease, rich vascularity and

establishing

definite

classification

and

early diagnosis, as a prerequisite for timely

treatment and better prognosis of this rare
pathology.
Hence, the purpose of this study is to
emphasize on early diagnosis and to maintain high
index of suspicion for those pigmented lesions for
oral malignant melanoma occurring in the high
risk sites such as palate.

lymphatic drainage of the mouth favors earlier

metastatic spread to regional lymph nodes and to
distant sites such as the lungs and vertebral
10

column .

DISCLOSURES
(a) Competing interests/Interests of ConflictNone
(b) Sponsorships - None

Early diagnosis is essential for successful

treatment and is perhaps the key factor in

(c) Funding - None

improving the prognosis of OMM. Surgery is

the

mainstay

of

immunotherapeutic

therapy.

New

adjuvant

modalities

and

chemotherapy protocols have been used to

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