Year : 2006 | Volume
: 17 | Issue : 2 | Page : 94--6
Malignant melanoma of the oral cavity
Department of Dental and Oral Surgery, Christian Medical College, Vellore, Tamilnadu 632 004, India
Department of Dental and Oral Surgery, Christian Medical College, Vellore, Tamilnadu 632 004
Oral malignant melanoma is a rare disease. The common sites of its occurrence are the palate and gingiva with the maxillary arch being affected 80% of the time. Because of their presence at relatively obscure areas in the oral cavity, most of the malignant melanomas of the oral cavity are diagnosed at a late stage. These lesions are associated with poor prognosis. The dental clinician must therefore carefully examine the head, neck, and oral cavity, and any pigmented lesion that may exhibit growth potential must be biopsied. This article describes a case of malignant melanoma that was present in the oral cavity and briefly reviews the relevant literature that explains the nature of this lesion.
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Ebenezer J. Malignant melanoma of the oral cavity.Indian J Dent Res 2006;17:94-6
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Ebenezer J. Malignant melanoma of the oral cavity. Indian J Dent Res [serial online] 2006 [cited 2020 Nov 23 ];17:94-6
Available from: https://www.ijdr.in/text.asp?2006/17/2/94/29882
Malignant melanomas of the oral cavity are extremely rare, accounting for 0.2% to 8% of all malignant melanomas . The relative incidence of malignant melanoma among mucosal neoplasms of the head and neck had been reviewed by Hormia and Vuori . In a total of 7253 cases of malignancies of the upper respiratory and gastrointestinal tracts between 1953 and 1964, five cases of malignant melanoma were found in the oral cavity- an incidence of 0.07%.
The age range for patients with oral malignant melanoma is from 40 to 70 years, the average age being 55 years ,. Rapini et al  found that the highest percentage of oral melanomas occurred in the age range of 41 to 60 years (45% of 332 patients). Oral malignant melanoma is rare before the age of 20 years ,.
The most frequent site of occurrence is the hard palate followed by the maxillary gingiva , . Other oral sites include the mandibular gingiva, buccal mucosa and floor of the mouth . Greene et al  described the criteria for primary oral melanoma which includes demonstration of melanoma in the oral mucosa, presence ofjunctional activity and inability to demonstrate extra oral primary melanoma
Intra oral malignant melanomas are easy to diagnose clinically as they are pigmented and have an irregular shape and outline . These lesions usually remain asymptomatic and may be detected only when there is ulceration of the overlying epithelium and/or hemorrhage . This delayed detection may be the reason for the poor prognosis of oral malignant melanomas with the 5-year survival rate being between 15% to 38% ,. Invasion of the bone may occur, increasing the likelihood of metastasis . In addition, the rich vascular supply present in the oral cavity may further contribute to the dissemination of the melanomas .
A 36-year old male patient presented with the chief complaint of swelling and occasional pain in the right upper gums. The swelling was present for the last six months, with pain at the site being present for the past two weeks. On clinical examination, a large growth of4cm x 2 cm size was present on the buccal aspect of the right maxillary alveolus involving the marginal, attached and inter dental gingiva [Figure 1]. The growth was blackish blue in color with an intact and irregular surface. The margins were well defined. Superiorly, the lesions extended into the upper buccal vestibule. Anteriorly, it extended from the gingiva of 21 and extended posteriorly to the gingiva in relation to 16. Medially the lesion extended to involve the palatal mucosa It did not cross the midline [Figure 2]. 13 was missing clinically and 12 appeared to be displaced laterally.
None of the teeth in the vicinity of the growth exhibited much mobility. A small satellite like lesion of the same color was present on the posterior lateral aspect of the right hard palate. It was independent of the large growth, with its size being about 0.5 cm in diameter.
Palpation revealed a firm consistency of the growth without any tenderness. The regional lymph nodes were not palpable. A complete examination of the patient was done, but no other primary site of the lesion was found. Correlating all these clinical features, a diagnosis of primary malignant melanoma of the oral cavity was made and the patient was then referred for further investigations.
Radiographically, no involvement of the underlying bone was detected. Distant metastasis was not found on clinical, radiographic and ultra sonographic examination of the patient.
An incisional biopsy of the lesion was done under local anaesthesia and the specimen was sent for histopathological examination. The histopathology showed squamous mucosaextensively infiltrated bynests of large cells with pleomorphic vesicular nuclei, prominent nucleoli and abundant cytoplasm with brown pigment [Figure 3], confirming the diagnosis of malignant melanoma. The patient was then advised surgical treatment but did not report for the same.
The first oral symptoms of an infra oral melanoma identified by Berthelsen et al  were those of asymptomatic swelling and occasional bleeding. Only two patients (14%) had pain. In 9 (64%) of the oral melanomas, the tumor was located in the palate . Because most melanomas are painless in their early stages, the diagnosis is unfortunately often delayed until symptoms resulting from ulceration, growth and / or bleeding are noted.
The international union against cancer (UICO) has no proposal of clinical TNM classification for malignant melanomas, but Westbury  describes a clinical classification as follows: I-only primary tumor present. II-metastasis present (IIa-adjacent skin involved, IIb-regional lymphnodes involved, fl ab adjacent skin and regional lymph nodes involved) and III-metastasis beyond regional lymph nodes. The patient presented here falls into the classification of IIa because satellite lesions were present at the time of initial presentation.
Melanoma is notorious for its unpredictable and widespread metastasis. Metastatic spread to bone, usually the vertebrae, is a frequent finding in terminal disease and may be accompanied by multiple metastasis to the lymph nodes, central nervous system, lungs and liver ,. Metastasis to the oral regions is uncommon and usually involves soft tissues, notably the tongue.
The need for biopsy of infra oral melanomas cannot be emphasized too strenuously. In many cases, melanomas may appear relatively irmocuous ,,. Often an excisional biopsy can be accomplished. However an incisional biopsy is acceptable for large lesions and must beperformedinthedarkestandthickest area of the lesion.
According to Batsakis , "there is no evidence that a preliminary biopsy of theprimary lesion increases therisk of metastatic dissemination or unfavourably affects the prognosis". Any pigmented growth that may appear innocuous needs to be biopsied at the earliest.
Regression in melanoma is a well-recognized phenomenon and may account for many cases of metastatic melanoma with occult primaries . Partial regression of melanoma is relatively common, but complete regression is considered rare and relatively few cases are well documented ,. Solitary metastasis with aregressedprimary has beenreported inthe head and neckregion. Regressionisconsideredtobemediated by the immune system  and usually occurs only in the primary cutaneous region , although in rare cases regression of metastasis have also been observed ,. A further feature of regression is its association with a poor rather than a good prognosis. The rather nonspecific features of regressed melanoma (apparently inflammatory nodules, depigmented patches and flat or slightly depressed scars) are easily missed or discounted unless the patient has noticed there gression, .
The primary mode of if treatment for malignant melanoma is wide surgical resection ,. In a review of the outcome of primary mucosal melanomas treated only with radiation , 44% of patients survived for a period of 4.5 years of follow-up. Even though these results appear to be encouraging, radiation is most often used as a supplementary mode of treatment after surgery or after a failure of previous management. When metastasis is not present after examination and investigations, surgery would be the preferred option for treatment. Advances in surgical technique may allow more extensive resection and reconstruction. Consideration should also be given to radiation therapy or combined therapy.
A careful oral examination and early biopsy will usually result in an early diagnosis thus improving the prognosis to a significant extent .
Early diagnosis and treatment is mandatory for better prognosis with regard to malignant melanoma of the oral cavity. Clinicians must carefully examine the oral cavity and any growing pigmented lesion must be biopsied. Amelanotic melanomas can be diagnosed by immunohistochemical examination of tissue from the lesion. In addition, public education about self examination of the oral cavity with periodic oral checkup is important for early detection of such lesions .
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