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CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 4  |  Page : 427-430
A Rare Case of Primary Oral Malignant Melanoma of Mandibular Gingiva with an Update on Clinical Staging


1 Department of Oral Pathology and Microbiology, Malabar Dental College and Research Centre, Edappal, Malappuram, India
2 Department of Oral Pathology and Microbiology, PSM Dental College and Research Centre, Bypass Road, Akkikavu, Thrissur, India
3 Department of Oral Medicine and Radiology, Malabar Dental College and Research Centre, Edappal, Malappuram, India
4 Department of Oral and Maxillofacial Surgery, Anoor Dental College and Hospital, Perumattom, Muvattupuzha, Kerala, India

Date of Web Publication17-Sep-2021

Correspondence Address:
S Akhil
Department of Oral Pathology and Microbiology, Malabar Dental College and Research Centre, Edappal, Malappuram
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_360_19

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How to cite this article:
Akhil S, Vinod K R B, Mustafa SM, Mathew J. A Rare Case of Primary Oral Malignant Melanoma of Mandibular Gingiva with an Update on Clinical Staging. Indian J Dermatol 2021;66:427-30

How to cite this URL:
Akhil S, Vinod K R B, Mustafa SM, Mathew J. A Rare Case of Primary Oral Malignant Melanoma of Mandibular Gingiva with an Update on Clinical Staging. Indian J Dermatol [serial online] 2021 [cited 2021 Dec 3];66:427-30. Available from: https://www.e-ijd.org/text.asp?2021/66/4/427/326121




Sir,

Primary malignant melanoma is a rare, aggressive, and deadly neoplasm that originates from the proliferation of melanocytes. Although 90% of melanomas occur on the skin, melanoma which occurs in the oral cavity is an extremely rare condition comprising 0.4%–1.8% of all melanomas and 0.5% of oral malignancies. Mucosal melanomas represent a diagnostic challenge than the more common skin melanomas because oral melanomas show significant heterogeneity in biological behavior and morphological features, oral melanoma occurs more frequently in the oral mucosa of the upper jaw, commonly on the palate or maxillary gingivae. Because most of the mucosal melanomas are usually painless in the early stages, delayed diagnosis and treatment planning occurs. As the prognosis is extremely poor, especially in advanced stages proper investigation of any pigmented lesion of undetermined origin should always be biopsied.

We herewith report a case of oral malignant melanoma of mandibular gingiva in a 32-year-old male patient. A 32-year-old male patient reported to the Department of Oral Medicine and Radiology with the chief complaint of swelling at the lower left back teeth region for the past 3 weeks. The patient gave a history of traumatic bite in that area. The swelling was initially small and had gradually increased to present size with a change in color. Past medical and family history was not significant.

Intraoral examination revealed a solitary mass of about 4.5 × 1 cm extending from the distal side of 36 to the retromolar region. The lesion was blackish with a smooth surface [Figure 1]. On palpation, it was soft in consistency and nontender and was fixed to the gingiva of 37 and 38 regions. The intraoral periapical radiograph showed no major changes [Figure 2]. Based on the above findings, a provisional diagnosis of malignant melanoma was made. Differential diagnosis includes Kaposi's sarcoma and hemangioma.
Figure 1: Blackish solitary mass on left mandibular gingiva

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Figure 2: Intraoral periapical radiograph of the left mandibular posterior region with no major changes

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An incisional biopsy was done under local anesthesia and was sent for histopathological examination [Figure 3]. The hematoxylin and eosin-stained section showed stratified squamous epithelium supported by connective tissue stroma. Atypical melanocytes with clear cytoplasm and prominent nucleus showed junctional activity and infiltration into the connective tissue. Sheets of melanocytes in epithelioid pattern and abundance of melanin pigments were demonstrated deep into the mesenchyme [Figure 4]. Areas of myxoid changes were also seen. Lymphovascular connective tissue showed a heavy band of mixed inflammatory cell infiltrate (predominantly of lymphocytes) deep into the connective tissue. Melanin bleaching technique was done on another section which showed loss of melanin pigmentation [Figure 5]. In correlating with clinical features, the histopathological diagnosis of malignant melanoma of gingiva was made. The lesion was classified as T3N0M0, for TNM stage, and stage III. The patient is kept under observation.
Figure 3: Surgical gross specimen

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Figure 4: Photomicrograph showing dense melanin pigmentation within the connective tissue (H&E, 4x)

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Figure 5: Photomicrograph showing connective tissue with loss of melanin pigmentation after melanin bleaching

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It was Webber who first discovered malignant melanoma in 1859. It is also known as melanocarcinoma. The etiology of OMM is obscure in contrast to its cutaneous counterpart which is linked to sun exposure. Nevi are thought to be a potential source of some oral melanomas, but the progression of events is poorly understood. Chronic irritation from ill-fitting dentures, tobacco use, and alcohol have also been put forward as possible risk factors.[1] Pain, ulceration, and bleeding are rare in oral melanoma until late in the disease.[2] During recent years, genetic alterations in melanomas including those involving BRAF and MEK pathways have been discovered. BRAF mutations were seen commonly in 40%–60% of patients with advanced melanoma, resulting in constitutive activation of BRAF. Various other activating mutations were also described, including c-kit and NRAS mutation after the discovery of BRAF. C-kit is more frequently seen in mucosal, acral, and melanoma-associated with chronic sun damage. NRAS mutations were found in approximately 20% of melanoma patients.[3] It is not exactly clear why melanocytes are seen in the mucosal epithelium. It may be due to errors in-migration from the neural crest during development, as melanocytes can play a role in the immune system in these areas.[4]

There is no well-defined pathological and clinical classification for oral melanoma. Clark's criteria of the cutaneous melanoma for the prognosis and invasion level and are not applicable to oral melanomas due to histological differences in the oral and dermal epithelium. The American Joint Committee on Cancer (AJCC) had recently put forward the 8th edition (2017) of the cancer staging manual which includes a staging system for mucosal melanoma of the head and neck [Table 1].[5]
Table 1: TNM Classification of mucosal melanoma of the head and neck, AJCC Cancer Staging Manual 8th edition (2017)

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The occurrence of the present case was in the mandibular gingiva which was a rare site of occurrence in the oral cavity, and the lesion was seen in a young patient which was also against the common finding. Primary oral mucosal melanoma is a biologically aggressive and rare malignancy. In contrast to cutaneous melanomas, the etiology, risk factors, and pathogenesis is poorly understood. Detection and treatment should be primae facie for better prognosis in malignant melanoma; hence, dentists and dermatologists should be aware of the varied presentations of oral mucosal melanoma and include inspection of the oral cavity for regular melanoma check-ups. Biopsy of all pigmented lesions are advised to rule out even a minor chance of malignancy and also more efforts should be made to create public awareness so that early detection of such lesions can be made possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gupta S, Tandon A, Ram H, Gupta OP. Oral malignant melanoma: Report of three cases with literature review. Natl J Maxillofac Surg 2015;6:103-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Tanaka N, Amagasa T, Iwaki H, Shioda S, Takeda M, Ohashi K, et al. Oral malignant melanoma in Japan. Oral Surg Oral Med Oral Pathol 1994;78:81-90.  Back to cited text no. 2
    
3.
Atkinson V. Recent advances in malignant melanoma. Intern Med J 2017;47:1114-21.  Back to cited text no. 3
    
4.
Tyrell H, Payne M. Combatting mucosal melanoma: Recent advances and future perspectives. Melanoma Manag 2018;5:MMT11.  Back to cited text no. 4
    
5.
Lydiatt MW, Gensier BM, Kraus HD, Mukaherji KS, Ridge AJ, Shah PJ. Mucosal melanoma of the head and neck. In: Amin M, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK et al., editors. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2017. p. 163-7.  Back to cited text no. 5
    


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