Case and Research Letter
Metastatic Melanoma of the Tongue: A Rare Case
Melanoma metastásico de la lengua: un caso raro
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Compilato, S. Amato, G. Campisi" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Compilato" "email" => array:1 [ 0 => "compilato@odonto.unipa.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Amato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Campisi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Surgical and Oncological Disciplines, V. Margiotta Oral Medicine Unit, Palermo University Hospital, Palermo, Italy" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Dermatology Unit, ARNAS, Ospedale Civico e Fatebenefratelli G. Di Cristina e Maurizio Ascoli, Palermo, Italy" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Melanoma metastásico de la lengua: un caso raro" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1068 "Ancho" => 1585 "Tamanyo" => 158088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Macular lesion on the dorsum of the tongue associated with small, stiff nodules with an ulcerated-surface located on the left margin and the midline of the anterior third of the tongue.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous melanoma is an extremely aggressive malignant tumor arising from melanocytes and accounting some 15% of all cancers. Incidence varies from 3–5 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants and year in the Mediterranean region to 12–20 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants and year in Nordic countries, and is still increasing worldwide. Cutaneous melanoma is believed to be a cancer that primarily affects white skin, and the risk of developing these tumors is 10 times higher in white-skinned populations than in those with darker skin.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Melanoma is known for its aggressiveness, and metastases to bones, lungs, brain, liver, or lymph nodes are expected. However, there have been very few reports of oral metastases,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which mainly affect the gingiva, tongue, tonsils, and mandible.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of an 86-year-old white man admitted with a black lesion on the tongue that had persisted for about 2 months. During the consultation, the patient rejected the idea that he had a disease and complained about the appearance, concurrently with the lingual lesions, of dark nodules on his neck and upper limbs associated with intense and persistent itching, which had on occasion spread to the trunk. These skin lesions had been treated with antihistamines and topical corticosteroids prescribed initially by his family physician and subsequently by a dermatologist, without clinical improvement. Intraoral examination revealed the presence of a wide, irregularly shaped, sepia-black macular lesion that was firm to the touch and asymptomatic, extending from the dorsal to the ventral surface of the tongue. This was associated with small stiff nodules with an ulcerated surface on the left margin and the midline of the anterior third of the tongue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Extraoral examination (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B) revealed the presence of blackish oval nodular lesions, palpable and painless, localized to the neck and upper limbs. A diffuse cervical lymphadenopathy was also detected. These clinical findings gave rise to a suspected diagnosis of oral melanoma. While considering it important to establish whether the oral lesions were primary or metastatic, we preferred to start the diagnostic work-up of the suspected melanoma with an examination of the skin lesions. The results of routine blood tests were within normal limits, with the exception of an increased erythrocyte sedimentation rate. Tests for neoplastic markers revealed the carcino-embryogenic antigen. A more detailed clinical and dermoscopic examination of the skin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C) revealed the following findings: <span class="elsevierStyleItalic">a</span>) a brown-black variegated pigmented nevus on the spinal column between the shoulders, irregular in shape and color measuring 21<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C, third arrow) and characterized by a blue–gray veil and irregularly shaped globules; the presumptive diagnosis was melanoma with in-transit metastases (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A); <span class="elsevierStyleItalic">b</span>) 3 pigmented blue-brown lesions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, C, second arrow) situated 14<span class="elsevierStyleHsp" style=""></span>mm from the first lesion; and <span class="elsevierStyleItalic">c</span>) an irregularly shaped variegated brown lesion on the right parascapular region, of 14<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C, first arrow) characterized by a fragmented thickened network and areas of regression, consistent with the diagnosis of melanoma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B and C). Histopathology examination of an incisional biopsy of the parascapular lesion showed a dermis colonized by atypical epithelioid cells indicating a melanoma (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Unexpectedly, after the diagnosis of cutaneous melanoma was confirmed, the patient refused to undergo oral biopsy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A diagnosis of cutaneous melanoma with oral metastases was confirmed on the basis of the clinical, dermoscopic, and histological data. A chest radiograph demonstrated no active parenchymal lesions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A computed tomography scan of the maxillofacial region, neck, brain, thorax and abdomen revealed no further metastases, but generalized lymphadenopathy. Due to the presence of in-transit metastases, sentinel lymph-node biopsy was not performed, as recently reported.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was referred to an oncology unit, but no therapeutic regimen was undertaken given his age, his refusal to consent to treatment, and the number and extent of his lesions.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Melanoma is a tumor caused by the malignant transformation of melanocytes, a cell line derived from the neuroectoderm. Although the skin continues to be the most frequent site of primary disease (95% of cases), the embryologic origin of melanocytes explains why melanoma is not exclusively a skin cancer.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In fact, melanomas may also arise in extracutaneous sites, including the mucosal surfaces of the respiratory, gastrointestinal, and genitourinary tracts and other sites where neural crest cells migrate.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The appearance of a primary melanoma located in the oral cavity is very rare, accounting for only 1–2% of all mucosal melanomas and 0.5% of all oral malignancies; secondary or metastatic forms are even more rare.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8</span></a> When the maxillofacial region is involved, metastases of cutaneous melanoma are mainly reported in the tongue, tonsils, mandible, gingiva, and parotid glands.</p><p id="par0040" class="elsevierStylePara elsevierViewall">When a patient presents with a pigmented oral lesion, an extraoral clinical examination should be performed; in fact, according to Greene and coworkers,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> in order to consider an oral melanoma as primary, the following 3 criteria must be met: <span class="elsevierStyleItalic">a</span>) demonstration of melanoma only in the oral cavity; <span class="elsevierStyleItalic">b</span>) presence of junctional activity; and <span class="elsevierStyleItalic">c</span>) inability to demonstrate extra-oral primary melanoma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case, the presence of a cutaneous lesion with a histopathological diagnosis of melanoma allowed us to consider the oral lesions as metastatic.</p><p id="par0050" class="elsevierStylePara elsevierViewall">When analyzing a suspicious skin lesion, it is important to bear in mind the ABCD rule in which A refers to asymmetry, B to border irregularities, C to color heterogeneity, and D to dynamics (in color, elevation, or size).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Furthermore, it has been noted, that dermoscopy always enhances the diagnostic accuracy and identifies lesions that must be biopsied,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> as was the case in this patient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the appearance of a metastatic lingual melanoma is a very rare event, hence close collaboration among different specialists is very important in case of suspicious pigmented lesions to ensure their early detection and a prompt treatment of such aggressive neoplasm.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1068 "Ancho" => 1585 "Tamanyo" => 158088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Macular lesion on the dorsum of the tongue associated with small, stiff nodules with an ulcerated-surface located on the left margin and the midline of the anterior third of the tongue.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1672 "Ancho" => 2335 "Tamanyo" => 297641 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) and (B) Oval, blackish, palpable, and painless nodular lesions on the neck and upper limbs. (C) Pigmented skin lesions localized on the spinal column and parascapular region (arrows, from the top to the bottom).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 608 "Ancho" => 3333 "Tamanyo" => 168627 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Dermoscopic image of the lesion localized on the spinal column and parascapular region; note the in-transit metastases. (B) and (C) Dermoscopic images of the parascapular brown lesion with regression areas.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1183 "Ancho" => 1585 "Tamanyo" => 275423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Histological features of a biopsied specimen of the parascapular lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 19 | 11 | 30 |
| 2024 October | 77 | 49 | 126 |
| 2024 September | 96 | 27 | 123 |
| 2024 August | 114 | 93 | 207 |
| 2024 July | 85 | 28 | 113 |
| 2024 June | 86 | 38 | 124 |
| 2024 May | 103 | 42 | 145 |
| 2024 April | 78 | 32 | 110 |
| 2024 March | 93 | 28 | 121 |
| 2024 February | 117 | 43 | 160 |
| 2024 January | 86 | 34 | 120 |
| 2023 December | 90 | 29 | 119 |
| 2023 November | 115 | 33 | 148 |
| 2023 October | 74 | 34 | 108 |
| 2023 September | 94 | 38 | 132 |
| 2023 August | 94 | 30 | 124 |
| 2023 July | 110 | 34 | 144 |
| 2023 June | 108 | 29 | 137 |
| 2023 May | 123 | 28 | 151 |
| 2023 April | 92 | 22 | 114 |
| 2023 March | 97 | 20 | 117 |
| 2023 February | 87 | 21 | 108 |
| 2023 January | 96 | 40 | 136 |
| 2022 December | 59 | 33 | 92 |
| 2022 November | 52 | 26 | 78 |
| 2022 October | 37 | 35 | 72 |
| 2022 September | 37 | 35 | 72 |
| 2022 August | 52 | 32 | 84 |
| 2022 July | 35 | 30 | 65 |
| 2022 June | 46 | 21 | 67 |
| 2022 May | 123 | 27 | 150 |
| 2022 April | 121 | 50 | 171 |
| 2022 March | 130 | 41 | 171 |
| 2022 February | 103 | 34 | 137 |
| 2022 January | 174 | 36 | 210 |
| 2021 December | 78 | 37 | 115 |
| 2021 November | 91 | 43 | 134 |
| 2021 October | 86 | 49 | 135 |
| 2021 September | 86 | 32 | 118 |
| 2021 August | 82 | 29 | 111 |
| 2021 July | 65 | 32 | 97 |
| 2021 June | 69 | 24 | 93 |
| 2021 May | 73 | 27 | 100 |
| 2021 April | 217 | 44 | 261 |
| 2021 March | 134 | 28 | 162 |
| 2021 February | 112 | 23 | 135 |
| 2021 January | 74 | 20 | 94 |
| 2020 December | 54 | 12 | 66 |
| 2020 November | 63 | 9 | 72 |
| 2020 October | 46 | 6 | 52 |
| 2020 September | 44 | 11 | 55 |
| 2020 August | 56 | 18 | 74 |
| 2020 July | 45 | 13 | 58 |
| 2020 June | 43 | 25 | 68 |
| 2020 May | 22 | 13 | 35 |
| 2020 April | 29 | 20 | 49 |
| 2020 March | 20 | 17 | 37 |
| 2020 February | 5 | 3 | 8 |
| 2020 January | 4 | 3 | 7 |
| 2019 December | 8 | 3 | 11 |
| 2019 November | 4 | 4 | 8 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 8 | 1 | 9 |
| 2019 August | 4 | 4 | 8 |
| 2019 July | 4 | 2 | 6 |
| 2019 June | 6 | 8 | 14 |
| 2019 May | 5 | 8 | 13 |
| 2019 April | 2 | 7 | 9 |
| 2019 March | 2 | 6 | 8 |
| 2019 February | 2 | 3 | 5 |
| 2019 January | 6 | 1 | 7 |
| 2018 December | 4 | 5 | 9 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 19 | 0 | 19 |
| 2018 September | 7 | 0 | 7 |
| 2018 May | 0 | 9 | 9 |
| 2018 March | 5 | 5 | 10 |
| 2018 February | 99 | 5 | 104 |
| 2018 January | 118 | 6 | 124 |
| 2017 December | 104 | 7 | 111 |
| 2017 November | 120 | 13 | 133 |
| 2017 October | 115 | 2 | 117 |
| 2017 September | 110 | 13 | 123 |
| 2017 August | 160 | 13 | 173 |
| 2017 July | 2733 | 6 | 2739 |
| 2017 June | 111 | 19 | 130 |
| 2017 May | 70 | 12 | 82 |
| 2017 April | 51 | 7 | 58 |
| 2017 March | 45 | 23 | 68 |
| 2017 February | 136 | 11 | 147 |
| 2017 January | 59 | 6 | 65 |
| 2016 December | 98 | 11 | 109 |
| 2016 November | 128 | 9 | 137 |
| 2016 October | 161 | 9 | 170 |
| 2016 September | 190 | 14 | 204 |
| 2016 August | 150 | 10 | 160 |
| 2016 July | 69 | 10 | 79 |
| 2016 June | 5 | 16 | 21 |
| 2016 May | 7 | 7 | 14 |
| 2016 April | 5 | 6 | 11 |
| 2016 March | 6 | 0 | 6 |
| 2016 February | 3 | 2 | 5 |
| 2016 January | 5 | 3 | 8 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 25 | 1 | 26 |
| 2015 October | 55 | 2 | 57 |
| 2015 September | 17 | 6 | 23 |
| 2015 August | 8 | 3 | 11 |
| 2015 July | 162 | 14 | 176 |
| 2015 June | 118 | 8 | 126 |
| 2015 May | 64 | 5 | 69 |
| 2015 April | 78 | 9 | 87 |
| 2015 March | 67 | 5 | 72 |
| 2015 February | 96 | 6 | 102 |
| 2015 January | 67 | 14 | 81 |
| 2014 December | 73 | 10 | 83 |
| 2014 November | 61 | 7 | 68 |
| 2014 October | 58 | 2 | 60 |
| 2014 September | 33 | 2 | 35 |
| 2014 August | 52 | 1 | 53 |
| 2014 July | 46 | 4 | 50 |
| 2014 June | 46 | 1 | 47 |
| 2014 May | 55 | 8 | 63 |
| 2014 April | 49 | 2 | 51 |
| 2014 March | 48 | 4 | 52 |
| 2014 February | 35 | 5 | 40 |
| 2014 January | 43 | 3 | 46 |
| 2013 December | 37 | 8 | 45 |
| 2013 November | 37 | 7 | 44 |
| 2013 October | 10 | 6 | 16 |
| 2013 September | 12 | 1 | 13 |
| 2013 August | 8 | 6 | 14 |
| 2013 July | 9 | 10 | 19 |
| 2013 June | 6 | 3 | 9 |
| 2013 May | 2 | 2 | 4 |
| 2013 April | 6 | 10 | 16 |
| 2013 March | 10 | 3 | 13 |
| 2013 February | 18 | 4 | 22 |
| 2013 January | 63 | 4 | 67 |
| 2012 December | 32 | 5 | 37 |
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