- Case report
- Open Access
Solitary pulmonary metastasis from primary melanoma of the oesophagus 5 years after resection of the primary tumor
© Dionigi et al; licensee BioMed Central Ltd. 2006
- Received: 31 October 2005
- Accepted: 13 April 2006
- Published: 13 April 2006
Primary malignant melanoma of the oesophagus (PMME) is an uncommon tumor. PMME has an aggressive biological behavior, similar to melanomas developed elsewhere in the body. Most patients die from distant metastases, and the overall 5 year survival rate is approximately 4%.
We report a rare case of a solitary pulmonary metastasis found 5 years after curative resection of primary esophageal melanoma. No other sites of metastatic disease were identified. Video-assisted lung wedge resection of the lung nodule was carried out successfully.
This supports the concept that patients with primary melanoma of the oesophagus treated should be carefully followed up.
- Curative Resection
- Primary Melanoma
- Solitary Pulmonary Nodule
- Aggressive Biological Behavior
Primary melanoma of the oesophagus (PMME) is an uncommon tumor with an incidence of 0.1% of esophageal cancer and represents about 0.5% of noncutaneous melanomas . Firstly Baur reported a case in 1906 . PMME was not widely accepted until de la Pava in 1963 demostrated the presence of melanocytes in normal oesophageal mucosa in 4 of 100 normal esophagus at autopsy examination. Tateshi reported an incidence of 8% for the presence of melanocytes in the stratum basale of normal esophagi of Japanese subjects . Although the presence of normal melanocytes in the esophagus has been largely demonstrated, their origin is still debatable . Suzuki in a large study on surgical and autopsied specimens reported a 0.1% and 0.14% incidence respectively . Two-hundreds cases are described in literature. Almost 90% of PMME are located in the lower third of the esophagus and melanosis seems to be a predisposing factor since it as been found in almost 25% of the patients suffering for PMME . Diagnosis is made by exclusion criteria with no other primary cutaneous, ocular, mucosal lesion detected. Histologically, the tumor is considered as primary when it presents with a characteristic structure of melanoma and contains pigment (melanin), neighboring melanosis or melanocytic dysplasia is generally required to distinguish it from metastatic disease, the tumor is often polypoid and arise in an area of junctional changes in the squamous epithelium . Histopathological examination is usually mandatory to reach a definitive diagnosis since symptoms are not different from those of other malignant tumors of the esophagus. It is associated with a poor survival, also when resected at an early stage. In fact the tumor has an aggressive biological behavior, similar to melanomas occurred elsewhere in the body. Most patients die from distant metastases, and the 5 year survival rate is approximately 4%. At the time of presentation, 40% of patients have already metastatized, primarily to regional lymph nodes, liver, lung, or bones . Although pulmonary metastasis from melanoma is not uncommon, the case we report of a solitary pulmonary metastasis found 5 years after curative resection of the primary esophageal tumor is extremely unusual [9, 10]. A review of recent literature is also presented.
Several explanations have been postulated for delayed metastasis of differentiated tumors. Alexander presented an intriguing pathogenic hypothesis proposing that clusters of dividing cells lead to an equilibrium between cell death and proliferation, or that the tumor cells remain in a state of rest for long periods without losing their viability before renewed tumor growth is induced by the somatic transformation of the cancer cells . We report a rare case of a solitary pulmonary metastasis found 5 years after curative resection of primary esophageal melanoma. Radical surgical resection with en bloc lymphadenectomy is the treatment of choice of primary melanoma of the oesophagus, with a five year survival of 4.25% . Although laser, radiotherapy, chemotherapy, immunotherapy have not proven to be beneficial, they may play a palliative role if surgery is not applicable for advanced stages or poor functional status . Of the approximately 200 cases that have been reported to date, only about 30% of the patients survived more than 1 year after the initial diagnosis . The aggressive biological behavior of this disease, the advanced stage at the time of diagnosis and the lack of effective therapy contribute to its poor prognosis. PMME is a very aggressive tumor and esophagogastroduodenoscopy, endoscopic ultrasonography and CT scan are required to complete the preoperative staging. Chalkiadakis demonstrated that distant metastases are present in 78% of the patients suffering from PMME . The most common site of metastases is the liver (31%), followed by mediastinum (29%), lung (17%), brain (13%) and other intra-abdominal organs. Detection rate of metastatic disease identification using immunoscintigraphy with 99 mTc-labeled melanoma monoclonal AB is 95% for bone lesions, 91% for liver, 78% for lymph node metastases, 62% for brain, 62% for spleen and 58% for lung [14, 15]. This technique cannot identify deposits of 1 cm or less in size [14, 15]. Although it has been demonstrated that radical resection increases the survival compared to local treatment, 5-year survival is less than 5%, mainly due to the advanced state of the disease at the time of diagnosis . Various drugs, alone or in combination, including vinblastine, bleomycin, lomustine, vincristine and recently recombinant interferon-alpha and interleukin-2, have been used with varying results as palliative treatment of cutaneous melanoma [17–20]. Combination of cisplatin, carmustine, dacarbazine and tamoxifen have also been studied with promising results in cutaneous melanoma patients with advanced disease . Several investigators have supported the above findings and the role of tamoxifene as drugs modulator [22–24]. Nevertherless, none of these regimens have been used in esophageal melanomas which is considered to be a radioresistant tumor, and chemotherapy, external beam and intracavitary radiotherapy may only have a palliative role . At the time of diagnosis, clinically, surgically or pathologically detectable metastases were present in 40.9% of patients. The overall survival is 9.8 months with five year survival rate of 1.69%. Only 33% of patients survive for more than 1 year after diagnosis. Deaths are disease-related in 75–85% of cases .
Although the reason for the delayed presentation of the metastatic lesion remains unclear, the case report we described demonstrates that patients with primary melanoma of the oesophagus surgically treated should be carefully followed up.
Written consent of the patient was obtained for publication of this case report
- Cadwell CB: Unusual malignant neoplasm of the esophagus. J Thorac Cardiovasc Surg. 1991, 101: 100-107.Google Scholar
- Baur EH: Ein Fall von primarem melanom des esophagus. Arb Geb Pathol Anat Inst Tubingen. 1906, 5: 343-354.Google Scholar
- De la Pava S, Nigogosyan G, Pickren JW, Cabrera A: Melanosis of the esophagus. Cancer. 1963, 16: 48-50.View ArticlePubMedGoogle Scholar
- Tateshi R: Argyophil cells and melanocytes in esophageal mucosa. Arch Pathol. 1997, 98: 87-89.Google Scholar
- Suzuki H, Nagayo T: Primary tumor of the esophagus other than squamous cell carcinoma: histological classification and statistics in the surgical and autopsied material in Japan. Int Adv Surg Oncol. 1980, 3: 73-109.PubMedGoogle Scholar
- Di Costanzo DP, Urmacher C: Primary malignant melanoma of the esophagus. Am J Surg Pathol. 1987, 11: 46-52.View ArticleGoogle Scholar
- Allen AC, Spitz S: Malignant melanoma: a clinicopathological analysis of the criteria for diagnosis and prognosis. Cancer. 1953, 6: 1-45.View ArticlePubMedGoogle Scholar
- Sabanathan S, Eng J, Pradhan GN: Primary malignant melanoma of the esophagus. Am J Gastroenterol. 1989, 84: 1475-1481.PubMedGoogle Scholar
- Boni L, Benevento A, Dionigi G, Dionigi R: Primary malignant melanoma of the esophagus: a case report. Surg Endosc. 2002, 16: 359-360.View ArticlePubMedGoogle Scholar
- Boni L, Benevento A, Cabrini L, Dionigi G, Dionigi R: Primary melanoma of the esophagus. J Am Coll Surg. 2002, 194: 840-10.1016/S1072-7515(02)01168-7.View ArticlePubMedGoogle Scholar
- Alexander P: Dormant metastases – studies in experimental animals. J Pathol. 1983, 141: 379-383. 10.1002/path.1711410314.View ArticlePubMedGoogle Scholar
- Lin CY: Primary malignant melanoma of the oesophagus presenting with massive melena and hypovolemic shock. ANZ J Surg. 2002, 72: 62-64. 10.1046/j.1445-2197.2002.02297.x.View ArticlePubMedGoogle Scholar
- Chalkiadakis G, Wihlm JM, Morand G, Weill-bousson M, Witz JP: Primary malignant melanoma of the esophagus. Ann Thorac Surg. 1985, 39: 472-475.View ArticlePubMedGoogle Scholar
- Salk D: Technetium-labeled monoclonal antibodies for imaging metastatic melanoma: results of a multicenter clinical study. Semin Oncol. 1988, 15: 608-618.PubMedGoogle Scholar
- Lamki LM, Zukiwski AA, Shanken LJ: Radioimaging of melanoma using 99 mTc-labeled Fab fragment reactive with a high molecular weight melanoma antigen. Cancer Res. 1990, 50: 904-908.Google Scholar
- Hamdy FC, Smith JFH, Kennedy A, Thorpe JAC: Long survival after excision of primary malignant melanoma of the oesophagus. Thorax. 1991, 46: 397-398.PubMed CentralView ArticlePubMedGoogle Scholar
- Philip PA, Flaberty L: Treatment of malignant melanoma with interleukin-2. Semin Oncol. 1997, 24: S32-S38.PubMedGoogle Scholar
- Rusciani L, Petraglia S, Alotto M, Calvieri S, Vezzoni G: Postsurgical adjuvant therapy for melanoma Evaluation of a 3-year randomized trial with recombinant interferon-alpha after 3 and 5 years of follow-up. Cancer. 1997, 79: 2354-2360. 10.1002/(SICI)1097-0142(19970615)79:12<2354::AID-CNCR9>3.0.CO;2-L.View ArticlePubMedGoogle Scholar
- Seigler HF, Lucas V, Pickett NJ: DTIC, CCNU, bleomycin and vincristine. Cancer. 1980, 46: 2346-2348.View ArticlePubMedGoogle Scholar
- York RM, Foltz A: Bleomycin, vincristine, lomustine and DTIC chemotherapy for metastatic melanoma. Cancer. 1988, 61: 2183-2186.View ArticlePubMedGoogle Scholar
- Del Prete SA, Maurer LH, O'Donell J, Forcier RJ, LeMarbre P: Combination chemotherapy with cisplatin, carmustine, dacarbazine and tamoxifen in metastatic melanoma. Cancer Treat Rep. 1984, 68: 1403-1405.PubMedGoogle Scholar
- Mc Clay EF, Mastrange MJ, Berd D, Bellet RE: Effective combination chemo/hormonal therapy for malignant melanoma; experience with three consecutive trials. Int J Cancer. 1992, 50: 553-556.View ArticleGoogle Scholar
- Mills SE, Cooper PH: Malignant melanoma of the digestive system. Pathol Annu. 1983, 18: 1-26.PubMedGoogle Scholar
- Saba HI, Cruse CW, Wells KE, Klein CJ, Reintgen DS: Treatment of stage IV malignant melanoma with dacarbazine, carmustine, cisplatin and tamoxifen regimens: a University of South Florida and H. Lee Moffitt Melanoma Center study. Ann Plast Surg. 1992, 28: 65-69.View ArticlePubMedGoogle Scholar
- Jawalekar K, Tretter P: Primary malignant melanoma of the esophagus. J Surg Oncol. 1979, 12: 19-25.View ArticlePubMedGoogle Scholar
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