1. Mucosal Melanoma
Samantha Hauff

2. Epidemiology Make up about 10% of all H&N melanomas
Make up about 1% of all melanomas
More aggressive behavior  15% 5-yr survival
Aside from H&N, can occur in GU tract or anus
Usually affect ages 60s-80s
More common in Japan (usually oral cavity)

3. Etiology Melanocytes = cells that contain the pigment melanin
Located in basal layer of epidermis, mucosa and eyes
Derived from neural crest cells
Chemical and physical stimulation are known to causer hyperproduction of melanin, causing pigmented lesions
Sun exposure is not a risk factor; inhalants may be a risk factor
Melanocytes in the nasal upper aerodigestive tract
Septum
Inferior and middle turbinates
Respiratory epithelium
Funtion is unknown

4. Clinical Presentation
Nasal cavity most common:
Anterior nasal septum
Middle turbinate
Inferior turbinate
Typically p/w unilateral nasal obstruction and/or epistaxis
Oral cavity less common:
Palate
Gingiva
Typically p/w painless mass, frequently with bleeding

5. Differential Oral nevi Melanotic macule Amalgam tattoos
Melanoacanthoma

6. Oral Nevi
Fairly rare (prevalence = 0.1%)
More common in patients with darker skin tones
May be precursors to malignant melanoma

7. Melanotic macule
Usually on the vermillion
No malignant potential

8. Amalgam Tattoos
Blue-black discoloration due to deposition of amalgam during dental procedures
Much more common than macules and nevi

9. Melanoacanthoma
Reactive process
Can develop/spread quickly

10. Workup
Usually appears to be a violaceous, almost polypoid, friable mass
Biopsy: inject local  if significant bleeding from injection site, do biopsy in OR given risk for severe epistaxis
Imaging: CT with contrast, +/- MRI with gad

11. Immunostains Mucosal melanomas will typically be positive for S-100
HMB-45
NK1/C-3
Antivimentin
Recall that cutaneous melanoma usually positive for:
Mart1
Melan-A

12. Staging No widely accepted staging system (per medscape)
Stage I = localized disease
Stage II = regional spread
Stage III = distant mets
NCCN guidelines
T3 – mucosa only
T4a – cartilage and/or bone involvement
T4b – very locally advanced (skull base, dura, brain, lower CNs, masticator space, carotid, prevertebral space, mediastinum)
Starts at stage III
T3N0  stage III
T4aN0 stage IVa
T4aN1  stage IVa
T4banyN  stage IVb
M1  stage Ivc

13. Treatment Surgical excision with negative margins
Neck dissection for cN+ disease
Sentinel LN biopsy has not been studied
Better local control with adjuvant RT (26% vs 62% in one study)
Likely not improved survival
Chemo and immunotherapy not frequently used unless palliative

14. NCCN Guidelines Nasal cavity/paranasal sinuses All other mucosal sites
Stage III – resection +/- RT
Stage IVa-b – resection + RT
All other mucosal sites
Stage III – resection + SND +/- RT
Stage IVa – resection + SND + RT