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" => 641 "Ancho" => 950 "Tamanyo" => 98354 ] ] "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" => 641 "Ancho" => 950 "Tamanyo" => 98354 ] ] "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" => 1003 "Ancho" => 1400 "Tamanyo" => 186875 ] ] "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" => 365 "Ancho" => 2000 "Tamanyo" => 109976 ] ] "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" => 710 "Ancho" => 950 "Tamanyo" => 246925 ] ] "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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 5 | 10 |
| 2024 Octubre | 63 | 51 | 114 |
| 2024 Septiembre | 62 | 23 | 85 |
| 2024 Agosto | 106 | 67 | 173 |
| 2024 Julio | 81 | 31 | 112 |
| 2024 Junio | 103 | 49 | 152 |
| 2024 Mayo | 104 | 38 | 142 |
| 2024 Abril | 69 | 28 | 97 |
| 2024 Marzo | 85 | 28 | 113 |
| 2024 Febrero | 46 | 32 | 78 |
| 2024 Enero | 49 | 29 | 78 |
| 2023 Diciembre | 84 | 31 | 115 |
| 2023 Noviembre | 76 | 31 | 107 |
| 2023 Octubre | 81 | 26 | 107 |
| 2023 Septiembre | 79 | 37 | 116 |
| 2023 Agosto | 66 | 16 | 82 |
| 2023 Julio | 100 | 34 | 134 |
| 2023 Junio | 94 | 19 | 113 |
| 2023 Mayo | 109 | 15 | 124 |
| 2023 Abril | 96 | 19 | 115 |
| 2023 Marzo | 119 | 23 | 142 |
| 2023 Febrero | 119 | 22 | 141 |
| 2023 Enero | 92 | 34 | 126 |
| 2022 Diciembre | 110 | 35 | 145 |
| 2022 Noviembre | 111 | 37 | 148 |
| 2022 Octubre | 124 | 33 | 157 |
| 2022 Septiembre | 119 | 42 | 161 |
| 2022 Agosto | 107 | 43 | 150 |
| 2022 Julio | 89 | 45 | 134 |
| 2022 Junio | 89 | 31 | 120 |
| 2022 Mayo | 148 | 36 | 184 |
| 2022 Abril | 99 | 44 | 143 |
| 2022 Marzo | 72 | 52 | 124 |
| 2022 Febrero | 70 | 32 | 102 |
| 2022 Enero | 96 | 42 | 138 |
| 2021 Diciembre | 51 | 43 | 94 |
| 2021 Noviembre | 66 | 54 | 120 |
| 2021 Octubre | 76 | 65 | 141 |
| 2021 Septiembre | 46 | 45 | 91 |
| 2021 Agosto | 37 | 33 | 70 |
| 2021 Julio | 37 | 32 | 69 |
| 2021 Junio | 40 | 23 | 63 |
| 2021 Mayo | 34 | 33 | 67 |
| 2021 Abril | 100 | 28 | 128 |
| 2021 Marzo | 100 | 31 | 131 |
| 2021 Febrero | 58 | 25 | 83 |
| 2021 Enero | 57 | 21 | 78 |
| 2020 Diciembre | 44 | 23 | 67 |
| 2020 Noviembre | 25 | 10 | 35 |
| 2020 Octubre | 39 | 8 | 47 |
| 2020 Septiembre | 28 | 10 | 38 |
| 2020 Agosto | 35 | 18 | 53 |
| 2020 Julio | 29 | 7 | 36 |
| 2020 Junio | 26 | 28 | 54 |
| 2020 Mayo | 23 | 18 | 41 |
| 2020 Abril | 28 | 22 | 50 |
| 2020 Marzo | 26 | 31 | 57 |
| 2020 Febrero | 3 | 6 | 9 |
| 2020 Enero | 6 | 1 | 7 |
| 2019 Diciembre | 8 | 2 | 10 |
| 2019 Noviembre | 4 | 2 | 6 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 1 | 5 |
| 2019 Agosto | 4 | 9 | 13 |
| 2019 Julio | 4 | 13 | 17 |
| 2019 Junio | 6 | 21 | 27 |
| 2019 Mayo | 4 | 34 | 38 |
| 2019 Abril | 2 | 6 | 8 |
| 2019 Marzo | 4 | 7 | 11 |
| 2019 Febrero | 0 | 4 | 4 |
| 2019 Enero | 3 | 1 | 4 |
| 2018 Diciembre | 2 | 1 | 3 |
| 2018 Noviembre | 1 | 7 | 8 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Abril | 1 | 0 | 1 |
| 2018 Marzo | 4 | 1 | 5 |
| 2018 Febrero | 25 | 1 | 26 |
| 2018 Enero | 38 | 4 | 42 |
| 2017 Diciembre | 42 | 5 | 47 |
| 2017 Noviembre | 25 | 5 | 30 |
| 2017 Octubre | 34 | 1 | 35 |
| 2017 Septiembre | 31 | 8 | 39 |
| 2017 Agosto | 46 | 15 | 61 |
| 2017 Julio | 61 | 4 | 65 |
| 2017 Junio | 75 | 16 | 91 |
| 2017 Mayo | 41 | 6 | 47 |
| 2017 Abril | 32 | 11 | 43 |
| 2017 Marzo | 29 | 12 | 41 |
| 2017 Febrero | 122 | 10 | 132 |
| 2017 Enero | 55 | 3 | 58 |
| 2016 Diciembre | 62 | 12 | 74 |
| 2016 Noviembre | 99 | 10 | 109 |
| 2016 Octubre | 140 | 26 | 166 |
| 2016 Septiembre | 170 | 11 | 181 |
| 2016 Agosto | 40 | 3 | 43 |
| 2016 Julio | 51 | 7 | 58 |
| 2016 Junio | 19 | 19 | 38 |
| 2016 Mayo | 9 | 0 | 9 |
| 2016 Abril | 7 | 4 | 11 |
| 2016 Marzo | 7 | 2 | 9 |
| 2016 Febrero | 7 | 3 | 10 |
| 2016 Enero | 9 | 19 | 28 |
| 2015 Diciembre | 9 | 9 | 18 |
| 2015 Noviembre | 22 | 12 | 34 |
| 2015 Octubre | 44 | 12 | 56 |
| 2015 Septiembre | 63 | 10 | 73 |
| 2015 Agosto | 48 | 12 | 60 |
| 2015 Julio | 295 | 2 | 297 |
| 2015 Junio | 175 | 10 | 185 |
| 2015 Mayo | 166 | 14 | 180 |
| 2015 Abril | 215 | 10 | 225 |
| 2015 Marzo | 187 | 4 | 191 |
| 2015 Febrero | 132 | 1 | 133 |
| 2015 Enero | 143 | 0 | 143 |
| 2014 Diciembre | 108 | 0 | 108 |
| 2014 Noviembre | 115 | 0 | 115 |
| 2014 Octubre | 115 | 0 | 115 |
| 2014 Septiembre | 62 | 0 | 62 |
| 2014 Agosto | 80 | 0 | 80 |
| 2014 Julio | 70 | 0 | 70 |
| 2014 Junio | 73 | 0 | 73 |
| 2014 Mayo | 87 | 0 | 87 |
| 2014 Abril | 55 | 0 | 55 |
| 2014 Marzo | 110 | 9 | 119 |
| 2014 Febrero | 91 | 12 | 103 |
| 2014 Enero | 127 | 10 | 137 |
| 2013 Diciembre | 124 | 20 | 144 |
| 2013 Noviembre | 120 | 24 | 144 |
| 2013 Octubre | 77 | 12 | 89 |
| 2013 Septiembre | 65 | 14 | 79 |
| 2013 Agosto | 85 | 17 | 102 |
| 2013 Julio | 50 | 30 | 80 |
| 2013 Junio | 49 | 21 | 70 |
| 2013 Mayo | 59 | 18 | 77 |
| 2013 Abril | 57 | 25 | 82 |
| 2013 Marzo | 57 | 20 | 77 |
| 2013 Febrero | 41 | 11 | 52 |
| 2013 Enero | 66 | 11 | 77 |
| 2012 Diciembre | 39 | 15 | 54 |
| 2012 Noviembre | 8 | 10 | 18 |
| 2012 Octubre | 2 | 1 | 3 |
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