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      Primary Anorectal Amelanotic Melanoma: The First Case Report from Saudi Arabia

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          Abstract

          Anorectal melanomas are exceptionally uncommon and only 30% of anorectal melanomas are amelanotic. We report here a case of an anorectal amelanotic melanoma in a female patient. An 84-year-old patient complained of anal mass for 3 months. On examination, there was a 7.0 cm mass prolapsing through the anus that was pale-pink in color. Abdominal, pelvic, and chest computed tomography (CT) showed rectal wall thickening with an eccentric polypoid soft tissue density mass, and left inguinal and presacral lymph node enlargement along with a small nodule in the lower lobe of the left lung, likely representing metastatic deposit. Microscopic examination revealed a piece of skin with hyperplastic squamous epithelium with surface ulceration. The dermis and underlining tissue were showing infiltration by malignant sheets and nests of ovoid and spindle shape cells with prominent nucleolus and high mitotic s. Immuno-staining for HMB-45, S-100, and Melan-A was positive, and it was negative for P63, CK 5/6, and Pan-CK, thus confirming it as an anorectal amelanotic melanoma, and not an epithelial tumor. This is the first case of an amelanotic anorectal melanoma reported from Saudi Arabia.

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          Final version of 2009 AJCC melanoma staging and classification.

          Charles M. Balch, Jeffrey Gershenwald, Seng-jaw Soong … (2010)
          To revise the staging system for cutaneous melanoma on the basis of data from an expanded American Joint Committee on Cancer (AJCC) Melanoma Staging Database. The melanoma staging recommendations were made on the basis of a multivariate analysis of 30,946 patients with stages I, II, and III melanoma and 7,972 patients with stage IV melanoma to revise and clarify TNM classifications and stage grouping criteria. Findings and new definitions include the following: (1) in patients with localized melanoma, tumor thickness, mitotic rate (histologically defined as mitoses/mm(2)), and ulceration were the most dominant prognostic factors. (2) Mitotic rate replaces level of invasion as a primary criterion for defining T1b melanomas. (3) Among the 3,307 patients with regional metastases, components that defined the N category were the number of metastatic nodes, tumor burden, and ulceration of the primary melanoma. (4) For staging purposes, all patients with microscopic nodal metastases, regardless of extent of tumor burden, are classified as stage III. Micrometastases detected by immunohistochemistry are specifically included. (5) On the basis of a multivariate analysis of patients with distant metastases, the two dominant components in defining the M category continue to be the site of distant metastases (nonvisceral v lung v all other visceral metastatic sites) and an elevated serum lactate dehydrogenase level. Using an evidence-based approach, revisions to the AJCC melanoma staging system have been made that reflect our improved understanding of this disease. These revisions will be formally incorporated into the seventh edition (2009) of the AJCC Cancer Staging Manual and implemented by early 2010.
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            The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society.

            A E Chang, L H Karnell, H R Menck (1998)
            This study reviews the case-mix characteristics, management, and outcomes of melanoma cases occuring in the U.S. within the last decade. Analyses of the National Cancer Data Base (NCDB) were performed on cases diagnosed between 1985 through 1994. A total of 84,836 cases comprised of cutaneous and noncutaneous melanomas were evaluated. The percentages of melanomas that were cutaneous, ocular, mucosal, and unknown primaries were 91.2%, 5.2%, 1.3%, and 2.2%, respectively. For cutaneous melanomas, the proportion of patients presenting with American Joint Committee on Cancer Stages 0, I, II, III, and IV were 14.9%, 47.7%, 23.1%, 8.9%, and 5.3%, respectively. Factors associated with decreased survival included more advanced stage at diagnosis, nodular or acral lentiginous histology, increased age, male gender, nonwhite race, and lower income. Multivariate analysis identified stage, histology, gender, age, and income as independent prognostic factors. For ocular melanomas, 85.0% were uveal, 4.8% were conjunctival, and 10.2% occurred at other sites. During the study period, there was a large increase in the proportion of ocular melanoma patients treated with radiation therapy alone. For mucosal melanomas, the distribution of head and neck, female genital tract, anal/rectal, and urinary tract sites was 55.4%, 18.0%, 23.8%, and 2.8%, respectively. Patients with lymph node involvement had a poor prognosis. For unknown primary melanomas, the distribution of metastases as localized to a region or multiple sites at presentation was 43.0% and 57.0%, respectively. Surgical treatment of patients with unknown primary site of the melanoma resulted in better survival compared with no treatment. Treatment of early stage cutaneous melanoma resulted in excellent patient outcomes. In addition to conventional prognostic factors, socioeconomic factors were found to be associated with survival.
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              Anorectal melanoma. A 64-year experience at Memorial Sloan-Kettering Cancer Center.

              Emer Brady, Allison S. Quan, J P Kavolius (1995)
              Operative management of patients with anorectal melanoma is controversial. To formulate a rational approach to patients with this disease, we reviewed our experience from 1929 to 1993. Records of all patients treated at our center with anorectal melanoma from 1929 to the present were reviewed. Survival analyses were graphically displayed using the Kaplan-Meier product-limit method, and distributions were compared using the log-rank test. Fisher's exact test was used to compare groups with small sample sizes. Survival for the entire group (n = 85) was poor, 17 percent at 5 years (median, 19 months). Among the 71 patients with resectable disease, the five-year, disease-free survival distribution of patients who underwent abdominoperineal resection (APR) was more favorable than that of patients who underwent local procedures only, although this was not statistically significant (27 percent vs. 5 percent, APR vs. local procedures, respectively; P = 0.11). However, those who had an APR were more likely to survive long term than those who did not (P < 0.05). All ten long-term survivors were women. Nine had undergone APR, and one had a wide local excision. Of the nine survivors following APR, eight had negative and one had positive mesenteric nodes. Median size of the primary tumor in survivors following APR was 2.5 cm, compared with 4.0 cm for patients who did not survive long term following APR. APR should be considered in patients with localized anorectal melanoma, particularly those with smaller tumors and no evidence of nodal metastases.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Middle East J Dig Dis
                Journal ID (publisher-id): Middle East J Dig Dis
                Journal ID (publisher-id): MEJDD
                Title: Middle East Journal of Digestive Diseases
                Publisher: Iranian Association of Gastroerterology and Hepatology
                ISSN (Print): 2008-5230
                ISSN (Electronic): 2008-5249
                Publication date (Print): July 2019
                Publication date (Electronic): 22 May 2019
                Volume: 11
                Issue: 3
                Pages: 166-173
                Affiliations
                1 Histopathology Division, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
                2 Faculty of Medicine, Umm-Al-Qura University, Makkah, Saudi Arabia
                3 Histopathology Division, King Fahad Central Hospital, Jazan, Saudi Arabia
                4 Department of Radiology, Al-Noor Specialty Hospital, Makkah, Saudi Arabia
                5 Medicine and Medical Sciences Research Center, Deanship of Scientific Research, Umm-Al-Qura University, Makkah, Saudi Arabia
                6 Department of Medical Genetics, Umm-Al-Qura University, Saudi Arabia
                7 Science and Technology Unit, UmmAl-Qura University, Makkah, Saudi Arabia
                Author notes
                [* ] Corresponding Author: Mohiuddin M. Taher, Ph.D. College of Medicine, Al-Abidiya Campus, Umm-Al-Qura University, Taif Road, Makkah-21955, Saudi Arabia Tel: + 96 6580149556 Fax: + 96 6125586279. Email: TMMohiuddin@ 123456uqu.edu.sa
                Article
                DOI: 10.15171/mejdd.2019.144
                PMC ID: 6819967
                SO-VID: 23405f80-bae4-4c4d-bc3d-cfc3310dfb1c
                Copyright © © 2019 The Author(s)
                License:

                This work is published by Middle East Journal of Digestive Diseaes as an open access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited.

                History
                Date received : 20 December 2018
                Date accepted : 19 May 2019
                Page count
                Figures: 7, Tables: 17, References: 60, Pages: 8
                Categories
                Subject: Case Series

                Keywords: anorectal cancer,anorectal melanoma,amelanotic melanoma,lung metastasis,saudi arabia
                Data availability:
                Keywords: anorectal cancer, anorectal melanoma, amelanotic melanoma, lung metastasis, saudi arabia

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