MELANOMA OF THE UPPER RESPIRATORY TRACT AND ORAL CAVITY

EMORY S , MOORE,M.D.,
AND

HAYES MARTIN,M.D.

TABLE 1 investigation of malignant melanoma has gained considerable impetus GENERAL ANATOMICAL DISTRIBUTION OF MELANOMA within recent years. Numerous reports have 1.oration NO. 57, appeared describing anatomical incidence,l 1546 theories of histogenesis,l and modern concepts Total no. patients Total no. lesions 1557 100 of treat111ent.l~ These articles have two ob- Head and neck 429 27.6 Skin 274 17.7 jectives: better understanding of the natural Eye 128 8.2 Oral & upper 27 1.7 history of the disease and improvement in direspiratory Upper extremities 159 10.2 agnosis and therapy. 10.4 Trunk 161 21.6 Lower extremities 336 l h e purpose of this presentation is to sum- Anorectal 20 1.3 49 3.1 marize the experience of hlcniorial Center Genitals 26.0 Unrecorded nrimarv 403 with melanoma when it occurred primarily in the mucous membranes of the oral cavity or upper respiratory tract. The report covers frequent confusion in the recognition of the nineteen years, between 1930 and 1948 in- true pathological nature of the lesions when they occur in this area. clusive. Rarity of nielanoma in the oral cavity or upper respiratory tract limits the experience METHODS AND MATERIALS of the individual clinician. For this reason a The accession books between the years 1930 review of the incidence, symptomatology, treatand 1948 inclusive of the Pathology Laborament, and results of the Memorial Center cases appears indicated. Twenty-six such cases are torics of Memorial Center were reviewed. Thirty-three recorded cases of melanoma of analyzed. the oral cavity or upper respiratory tract were found. Seven of these either were not primary HISTOPATIIOLOGY in those sites or were found on histological The histopathology of melanotic lesions of review to lack sufficient criteria for a diagnosis mucous-membrane origin is no different than of melanoma. T h e remaining twenty-six cases that of melanotic lcsions occurring in skinwere accepted by the Pathology Laboratories the lesion is a carcinoma. The modern con- as authentic examples of primary melanoma cepts of junctional change occurring in strati- of mucous membranes of the oral cavity or fied squamous epithelium of skin apply upper respiratory tract. directly to that in squamous epithelium of Melanomas of other sites were recorded duroral mucous membrane or pseudostratified ing the review of the accession books, providepithelium of the nasal cavity, paranasal ing a comparison of the incidence of the sinuses, or larynx. The comprehensive research twenty-six cases to the over-all anatomical disof Allen and Spitz into the histopathological tribution of melanoma (Table 1). Fifteen hunnature of melanoma has clarilied certain per- dred and forty-six entries with a diagnosis of plexing problems of diagnosis. These authors melanoma were found. This facet of the study point out a higher incidence of pleomorphism is subject to some error, since the diagnosis and mitotic figures in mucous-membrane le- was not once more subjected to histological sions of the head and neck than in the lesions review and in some instances the material subof the skin. These factors may explain the mitted may not have been from the primary From the Head a i d Neck Service, Mcmoiial Center site. Thus, this latter material is used only for for Cancer and Allied Diseases, New York, New Yolk. general background in this report. A more Presented a t the Eighth Annual Cancer Symposium critical evaluation of the general anatomical of the James Ewing Society, April 16, 1954. distribution of melanoma has been published Present address: Long Beach, California. recently by Pack, Gerber, and Scharnagel. Received for publication, March 15, 1955.

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TABLE 2 SPECIFIC ANATOMICAL LOCATION OF ME1,ANOMAS OF UPPER RESPIRATORY TRACT AND ORA4L CAVITY
Location
Total no. lesions Nasal cavity Nasal septum Middle turhinate Floor of nasal cavity Anterior ethmoid Oral cavity Sunerior alveolus Hard palate Mucosa of lip Inferior alveolus Ruccal mucosa Tongne Orophatynx (palatine tomil) Larynx
age in decades

h0

0 4
1no.n

Total no. pniients

1 4 2

3.7
14.8
i.4

k~..1. ,4gc incidcncc in twenty-six cases of melanoma of the oral cavity and upper respiratory tract.

GFNFKAL INCIDENCX

T h e pattern of distribution of lesions occurring in the nasal cavity coniorms to the findings of other investigators.2 Our cases were RACE, SEX, AND AGE predominantly on the nasal septum, four, and Melanoma in the Negro occurs in areas of the middle turbinate, three (Table 2). One decreased pigment distribution, such as body tumor occurred on the floor of the nasal cavity. orifices, palms of hands, and soles of feet.11 One case of paranasal-sinus tumor was found. Until recently, the disease was considered most This lesion occurred in the anterior ethmoid. uncommon among them. However, in1 estiga- It would appear from this series and from the tors are now recording a n increase in the ab- literature that the paranasal sinuses are for solute incidence of melanoma in the Negro.12 practical purposes a very rare source of malig7, l4 This is felt to be due to improved case finding nant melanoma.2~ and a correction of the figures relative to the Subjectively, symptoms in this location were proportion of Negroes in a hospital popula- not specific of melanoma. Nasal stuffiness tion. This series contains only one example in from mechanical narrowing of the nasal aira Negro, a melanoma of the palatine tonsil in way or recurrent epistaxis from ulceration of the tumor were the prevailing complaints. a 66-year-old female nurse. There is no statistical difference between Pain or tenderness orcurrcd in only one case. the sexes in the incidence of melanoma, re- Symptoms were present from one to seventeen

As has been previously stated, primarj melanoma of the oral cavity and upper respiiatory tract is rare. I n this study the disease represents 1.7 per cent of all ta5es of melanoma recorded in the accession books of the Pathology Laboratories (Table 1). This figure is in approximate agreement with that of 2.5 per cent found by Pack. Catlin has reported from Memorial Center a 23 per cent incidence of melanoma occurring in the head and neck. This figure also agrees roughly with ours of 27 per cent (Table 1). Accordingly, approximately 2 per cent of the 27 per cent of melanomas occurring in the head and neck may be expected to be found in the oral cavity or upper respiratory tract. T h e specific anatomical incidence of melanoma in the oral cavity or upper respiratory tract is discussed later.

gardless of anatomical location. Fourteen of our patients were male and twelve female. This finding is in agreement with that reported in the literature.1, 2, 6 , 13 T h e largest percentage of cases of melanoma of the oral cavity and upper respiratory tract occurred in the sixth decade of life (30.7 per cent). T h e average age of the twenty-six patients was 59 years. No cases were found in patients less than the age of 30 (Fig. 1). This is somewhat in contradistinction to lesions occurring in othcr anatomical locations in which a definite postpubertal incidence in the second and third decades has been widely reported.1, 69 13 However, our series is small and may not be statistically significant. CLINICAL CHARACTERISTICS, TREAI-MENI-, AND RESULTS
LESIONS OF NASAL CAVITY AND PARANASAL SINUSES

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MELANOMA OF UPPER RESPIRATORY TRACT & MOUTHMoore 6 Martin

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months prior to admission, the mean being T h e latter was most marked in the patient seven months. T h e presence of a blackish dis- with the ethmoid primary. charge, as described in the literature,7 was Biopsy revealed the tumors to be melanoma in six instances. I n three patients, however, not recorded. Objectively, nasal examination frequently the exact diagnosis was not established until demonstrated a polypoid, necrotic tumor mass definitive surgery had been performed and that bled easily on contact. T h e surface was the entire lesion was available for histological described as ulcerated in five instances and study. granular in three. Only four of the nine lesions Two methods of primary treatment were demonstrated the slate-gray or blue color that utilized-roentgen-ray radiation and surgery would indicate the true nature of the lesion {Table 3). Of the nine patients, three received (Fig. 2). roentgen-ray therapy and five, radical surgery. Eight of the nine cases were clinically free One patient refused treatment. of metastasis on admission. One patient demOf the patients receiving roentgen-ray tlieronstrated subcutaneous nodules of the skin o apy, two were given 250 kv. and one 80 kv. the lace and bilateral neck node metastasis. roentgcn rays. T h e tumors of all three patients This patients primary was located on the demonstrated satisfactory regression only to nasal septum and had heen presenting symp- become clinically recurrent eight to nine toms for one and one-half years. months horn the time of completion of therKoentgenological examination of the para- apy. T h e secondary attack on the disease connasal sinuses and nasal bones demonstrated sisted of gold-filtered radon implantation in paranasal-sinus obstruction in seven of the one and Weber-Fergusson antral resection in nine patients and bone destruction in three. a second. T h e third patients conditon was too
TABLE 3 METHOD OF TREATMENT 4 N D RESULT
Primary treatment Result Secondary treatment ~__ _ _ _ _ -_____Region
Nasal cavity
No.

Method X-ray

NO.

Status Recurr. Recurr.

No.

Method None Surgery Radon seeds Re-excis. Radium tandem None Died Died Died Died Died Died Died Died Died

Result

3 3

Surgery (WeberFergusson)

1 1 1 1 1
1

1 1
1

PuIm. embolus Distant metast.

None Radon & ra. pack Surgery (U exc.) Excision

1 1

Oral cavity Lip

1
1

No recurr. Recurr. Recurr. Distant metast. No recurr. Recurr. Local & distant metast. Distant metast. Distant metast. Local Xr distant metast.
1

Re-excis. Re-eucis. None X-ray -

*Developed maxilla primary Living M yr. Died

Maxilla

1 1
2

1 1

Died
Died Developcd bronchus primary 6th yr. Died Died Died Died Died Died

Buccal mucosai Inferior alveolus Orophar ynx Tonsil Larynx Extrinsic

2 1 1 4
2

Excision & neck dissect. None Excision Mandibulect. (part.) None Laryngect.

2
1 1

4 2

*Patient developed hard-palate primary four years after treatment of lip, from which he succumbed. +Treated elsewhere.

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FIG. 2. h,fclanoma of the nasal septum. The lesion depicted is pigmented-a finding in less than 50 per cent o f melanomas in this region.

precarious for further treatment. All three were dead of disease between sixteen and twenty-four months after the original treatment. T h e primary surgical attack against the disease consistcd of the ~15eof the WeberFcrgusson procedure with preliminary external carotid ligation. This was performed in five patients. Of these, three demonstrated local recurrence between two and one-half and three and one-half months after treatment. One patient remained hee of disease eight months, and one died of pulmonary ernbolus one nionth postoperatively. Secondary procedures for local rccurrenres in the primary surgical group consisted of the use of radium tandem in one patient and reexcision in another. T h e former died of disease six months after treatment. lhe patient subjected to secondary excision lived with disease for four years after treatment but was lost to follow-up and is presumed dead. Two patients were not subjected to further treatment and were dead of disease ten and fifteen months respectively after first admiqsion. Thus, in eight melanonias of the nasal cavity receiving treatment, including one case of ethnioid piimary, no like-year cures were obtained regardless of the method or treatment (Table 3).
LLSIONS OF IHE ORAL CAVITY

FIG.3. Melanoma of the superior alveolus.

(Table 2). T h e maxilla presented by far the majority of lesions-seven (25.9 per cent). Four of the sevcn lesions occurred on the superior alveolus (Fig. 3) and three on the hard palate (Fig. 4). One patient had two primaries-on the mucosa of the lip and on the hard palate. T h e inucosa of the upper lip demonstrated two lesions; and the buccal mucosa (Fig. 5), the inferior alveolus, and the tongue, one each. T h e cause of a high incidence of melanoma of the supcrior maxilla remains unexplaincd.4 I n reviewing the subjective symptomatology of the twclve lesions occurring in the oral cavity, the authors were impressed by the darnaging effect of patient delay in seeking medical advice. T h e majority of these lesions were bulky or covered a relatively wide anatomical area within the oral cavity. A painless, nonelcvated, pigmented area was the initial symptom in all but three of the twelve lesions. IN SIX IKSTANCES THE PIGMENTATION HAD BEFN
YEARS. PRESENr FROM

ONE TO FIVE

Eleven of the twenty-six patients had twelve melanomas (44.4 per cent) of the oral cavity

A seventh patient had noted a painless mass in the upper lip for three years. It is obvious that the laity is unaware of the serious nature of pigmentation developing in the oral cavity. Culpability cannot be entirely limited to thc paticnt. I n one instance, medical

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MELANOMA OF UPPER RESPIRATORY TRACT E k MOUTH. M o o x 6Martin

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FIG.4. Melanoma of the hard palatc.

aid had heen sought within a iew months of the appearance of pigmentation. T h e patient was advised that it was of 110 significance. Subsequent physicians had gi\ en him a similar opinion. Ulceration and 501-cncss in the area for two weeks prior to admission finally resulted in diagnosis and institution of treatment. Black pigment had been observed by two of the fire patients seeking aid in less than one year after the development of the lesion. One nonpigmented lesion of the hard palate was diagnosed within two months of onset because the patient was being seen in the follow-up clinic alter treatment of a melanoma of the lip. Bleeding from a red, granular lesion of the superior alveolus forced one patient to the physician within one month oi the development of the tumor. T h e following symptoms brought to the physician those patients in whom pigmentation had been present for prolonged intervals: the development of a mass in the pigmented area, bleeding, ulceration, and rapid increase

i n the area of pigmentation. Pain was significantly absent. I n one instance (a patient with a base-oftongue lesion), the metastatic deposits forced the patient to seek medical advice. T h e symptoms consisted oT cough, chest pain, and weight loss. They had been present for one month prior to the establishment ol a diagnosis. T h e existence of the primary lesion was unknown to the patient and was lound on physical examination. Examination of the primary lesions of the oral cavity demonstrated ten of the twelve tumors to be pigmented. T h e two remaining lesions were described as being ulcerated, but there was no mention of color. Ulceration is coininon in melanoma of the oral cavity, being present in eight of our series. However, lour lesions were described as being papillary or solid masses. Both of the lip lesions were in this latter category. Induration in melanotic lesions of the oral cavity is not commonly observed. T h i s is of considerable clinical importance in two respects: its absence masks the malignant nature of the lesion; AND IT OFFERS THE SURGEON A
FALSE SENSE OF SECURITY AS TO THE ADEQUACY
OF MAKGIN OF NORMAL TISSUE SACRIFICED AT

THE TIME OF SIJRGICAI, EXTIRPATION.

FIG.5. Melanoma of the buccal mucosa.

Metastasis was present clinically in two of the eleven patients on their first visit. This is a rather low incidence in the light of the prolonged interval between the initial symptomatology and the institution of treatment. One patient (tongue) presented bilateral neck node metastasis, as well as deposits in the liver arid lung. Another patient with a superior alveolus priniary had bilateral neck node metastasis. Roentgenological examination in one case of superior-alveolus melanonia demonstrated invasion manifested by bone destruction. Biopsy was performed on the twelve melanomas of the oral cavity and correctly diagnosed all but one. T h e true nature of the base-of-the-tongue lesion was not realized until the material was reviewed lor this article. T h e suspicion of melanoma was raised during the course of the patients illness when tissue coughed u p was subjected to histological study and it presented the possibility of melanoma. Primary treatment of the lesions of the oral cavity was surgical in eight patients (Table 3). I n one instance, a melanoma of the lip, radium-element pack and radon bulbs were uti-

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FIG.6. Melanoma of the hard palate in a 42-year-old woman. The lesions were treated successfully by excision. The patient was free of discase five years, only to develop a second piiinary lesion 111 the main bronchus of the right lung in her sixth year, postoperatively. (See Fig. 7.)

FIG. 8. Melanoma of the mucosa of the upper lip.

lized. This patient remained free of disease for four years, only to develop a second primary of the hard palate from which he later succumbed. One patient refused treatment and died in six months with generalized metastasis. T h e patient with the base-of-the-tongue lesion and distant metastasis was obviously not a candidate for definitive treatment. One patient (buccal mucosa) received treatment elsewhere. Of the eight surgically treated lesions of the oral cavity, six had actual cautery excision.

FIG.7. Primary melanoma of the right main bronchus in the same patient as seen in Fig. 6 .

All of these patients had primaries of the hard palate or superior alveolus. I n two of the six cases, the cautery was combined with radical neck dissection, since they denioristrated concomitant lymph-node metastasis at the time of surgery. (One patient when originally seen had no clinical evidence of neck metastasis. He refused treatment until neck nodes had appeared.) In both of these patients, local recurrence in the region of the neck dissection appeared two months and seven months later iespectively, and both patients were dead within a year. Of the remaining four patients surgically treated, two developed local recurrence in the hard palate after one month and hiteen months respectively. T h e former was dead in two years and six months with generalized metastasis. T h e latter patient had nu~nerous local hard-palate recurrences treated surgically, only to succumb four and one-half )ears after his primary treatment. Local control of the six lesions of the maxilla treated by cautery excision occurred in only two cases. One patient died of distant pulmonary metastasis three years after initial treatment. T h e second (Fig. 6) successfully passed the five-year mark without evidence of disease, only to develop a second primary tumor of the main bronchus of the right lung in her sixth year (Fig. 7). Pneumonectomy with mediastinal 1ymph-node dissection was performed at that time. Of the eight lesions of the oral cavity treated by surgery, two had cold-knife excision. One lesion occurred on the mucous membrane of the upper lip and was removed by U excision

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MELANOMA OF UiTER RESPIRATORY TRACT& M O U T H . Moore 6 Martin

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established at Memorial. Local and distant metastasis became clinically evident two months after treatment and produced a fatal terminus in one month. Thus in summarizing the twelve melanomas of the oral cavity, only one patient survived five years free of disease and in her sixth year dewloped a new primary melanoma of the main bronchus of the right lung. One patient is free o f discase two and one-half years after a second excision for recurrence.
LESION5 OF THE. OROPHARYNX

FIG. 9. Melanoma of the lower alveolus.

(Fig. 8), only to recur four and one-half years later. Repeat excision of the lesion at that time has kept the patient free of disease two and one-half years. T h e second patient demonstrated a melanoma of the right inferior alveolus (Fig. 9). Right mandibular ramisection was successful locally. However, lour years later distant inetastasis to the mediastinum and brain became clinically apparent and produced a fatal outcome five years after the first treatment. A third patient with a melanoma 01 the buccal mucosa received definitive treatment at another institution after having been seen at Memorial Center. Surgical excision was performed two months alter the diagnosis was

Lesions of the oropharynx were limited to the palatine tonsils--Pour (14.8 per cent). No examples of lateral or posterior pharyngeal wall or nasophary ngeal tumors were found. To the best of the authors knowledge, no melanoma of these areas, exclusive of the palatine tonsils, has ever been reported. Only one patient of this group demonstrated a presenting complaint relative to the primarV lesion--loss of ability to eat or talk. T h e remaining three patients entered the hospital with symptoms produced by metastatic disease, as follows: painful mass in leg-one, painful swelling in preauricular area-one, a lender mass in the left submaxillary triangle-one.
I N ALL FOUR CASES, SYMPTOMS HAD BEEN PRES-

EUT FOR LESS THAN TWO MONTHS.

FIG. 10. Primary melanoma of the palatine tonsil.

Physical examination on admission established the primary lesion in a tonsil in two cases. I n the third, the primary became clinically apparent six months after the Iirst development of a metastatic deposit in the skin ol the forehead and in a preauricular node. T h e fourth case demonstrated the primary lesion eight months after the development 01 the submaxillary triangle node metastasis. l h e two lesions found on first adniission were nonpigmented, ulcerated, and firm (Fig. 10). One of these almost filled the pharynx, preventing articulation or swallowing. T h c primaiy lesions appearing six and eight months after clinical metastasis weie described as pigmented when they finally became apparent. Early metastasis typifies this group of melanoma. In two instances the deposits were regional to preauricular or cervical nodes. I n the third regional cervical nodes and distant rnediastinal deposits were present. I n the fourth distant metastasis was found in a n extremi ty. Chest roentgenograms of three patients were

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Cancer Novernbeu-December 1955

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negative on admission. The patient with clinical mediastinal metastasis was terminal and no roentgenograms were taken. Biopsy of the primary tumor was positive in all instances when the lesion became clinically detectable. Ireatnient, with cure in mind, was offered to the one patient with subniaxillary triangle node metastasis. This patient refused the surgery offered. She was dead one year and one month after hcr first admission. Palliation was attempted in only one patient in the form of roentgen-ray radiation, without beneficial effect. Death occurred nine months after admission. One of the two patients to whom treatment was not offered was dead eight days after admission. The patient with metastasis to an extremity was living with disease at eighteen months after her first visit but then was lost to follow-up and is presumed dead. It is therefore obvious that, when melanoma occurs in the palatine tonsil, it is a vicious disease demonstrating early metastasis and a rapid progression toward a fatal outcome (Table 3).
LESIONS OF THE LARYNX

FIG. 11. Primary melanoma of the extrinsic larynx.

Two primary melanomas of the larynx are represented (Table 2). Both lesions appear to have found origin in the extrinsic larynx in the region of the ventricular fossa and false vocal cord. Only one primary and two metastatic melanomas of the larynx hale been reported previously in the literature to the best ol our knowledge.6.10 Subjective symptoms consisted of hoarseness as an initial complaint, having been present two and six months respectively. Pain on swallowing and dyspnea had brought the patient to the physician in one instance, and hemoptysis and fullness in the throat in the other. Initial physical examination and direct laryngoscopy demonstrated a bulky, reddish, polypoid tumor mass arising from the left ventricle of the extrinsic larynx in both cases (Fig. 11). Local or distant metastasis was not clinically apparent at the time of examination. Biopsy at the time of laryngoscopy had suggested a diagnosis of nielanoma in one and a Grade-IV epidermoid carcinoma in the other. At the time of total laryngectomy both lesions were described grossly as being pigmented. Treatment in both cases consisted of total

laryngectomy, the procedure being performed within forty-eight hours of the time of biopsy (Table 3). The results of therapy were discouraging. One patient was dead from metastasis to the neck nodes, mediastinurn, and liver fourteen months after treatment. The second was dead of disseminated disease one year and nine months after surgery. Neither of these patients is free of culpability in delay, since hoarseness had been present for two and six months respectively. Further, the lesions were bulky on examination. Nevertheless distant and regional nodal metastasis were clinically absent a t the time 01 surgery. Thus, a more favorable outcornc might have been expected than was achieved. However, two cases do not allow for generalization in respect to the prognosis.
COMMENT

The marked discrepancy that exists between the net five-year end results of melanoma of the mucous membrane of the oral cavity and upper respiratory tract a5 compared to that of melanoma of the skin deserves a critical analysis. Several factors that may play a direct part in this discrepancy are worthy of emphasis. Patient delay in seeking medical advice is apparent. This delay is most marked in the oral-cavity melanomas. Failure to recognize the significance of pigmentation in the nasal

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MELANOMA OF UPPER RESPIRATORY TRACT 8e MOUTH. Moore 6Martin

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TABLE 4 FIVE-YEAR E N D RESULTS IN MELANOMA OF THE UPPER RESPIRATORY TRACT AND ORAL CAVITY
This series consists of all cases of all patients with melanoma of the upper respiratory tract and oral cavity, both early and advacced, whether previously treated or not, or whether considered susceptible of cure, who app!ied a t Memorial Hospital during the period January 1, 1930, to December 31, 1948. TCTAL Pxrrswrs lnde&erminule Cures Eventual outconie uot determined by what was done or could have been attempted a t Memorial Hosnital Consuitation only. treatment not requested Refused proferred treatment or palliative care Lost track of without recurrence after treatment Dead from other causes without recurrence
26

3 0 0

TOTAL INDETERMINATE CASES 4 Deterininate Cases 22 All patients willing & ahle to return for curative or palliative treatment in whom the eud result, whether a success or failure, could possibly have been ininfluenced by the treatment (or lack of it) a t Memorial Hospital 22 TOTAL DETERMINATE CASES (Total patients applying minus no. of Indetetminate Cases) RESULTS OF TREATMENT Failures 21 20 Dead as a result of cancer or its treatment 0 Living with cancer present Living free of cancer after treatment of recurrence but not yet 5 yr. Over 5 yr. from first admission 1 [Untreated failures considered to be too far advanced for t r e a t m ~ n t ] [41

TOTAL No. OF FAILURES 21 Successful Results (Determinate Cases minus Failures) f disease 5 yr. after 1 Total no. of patients free o admission NET FIVEYEARENDRESULTS No. of Successful Results divided by no. of Determinate Cases

4.5%

becomes apparent to the examining physician. T h e laryngeal and base-of-tongue lesions arc too few from which to draw any conclusions. However, the primary tumors in the larynx were bulky, indicative 01 the possibility of their having been present for some time. T h e danger of multiple primaries occurring in melanoma of the oral cavity and upper I espiratory tract has been demonstrated. This has been preiiously pointed out by Allen and Spitz. I n Table 4 of five-year end results we have listed one cuie. This patient developed a second primary in her sixth postoperative )ear. If the arbitrary limit of five-year results werc extended to the six-year lexel, NONE of the twen ty-six patients could be considered cured of disease. From the preceding, i t would seem that two main factors are essential for improvement in the results of treatnient of malignant melanoma of the oral cavity and upper respiratory tiact. They are: earlier diagnosis on the part of the physician first seeing the case, and, secondly, more radical extirpation of the primary lesion. Ionizing radiation in the form of roentgen rays, radium, or radon would appear to have little \ d u e in the treatment of inalignant melanoma. SUMMARY Primary malignant melanoma of the upper respiratory tract and oral cavity is a rare disease. For this reason, a statistical review of the cases secn at Memorial Center was fclt to be indicated. This paper has summarized the total experience in nielanorna of these sites between the years 1930 and 1948. Twentpsix cases have been studied. Malignant melanoma of the oral cavity and upper respiratory tract represents approximately 1.7 per cent of all melanomas arid 6.3 per cent of head and neck melanoma. It occurs with equal frequency in the male and female and is seen most commonly in the Caucasian. Subjectibe and objectil e symptomaiology in the various anatomical sites of the mucous membranes ol the oral cavity and upper respiratory tract are reviewed. Melanoma in these areas is frequent11 silent at the onset and produces insufficient symptoms to forcc the patient to the physician in the early stages ol the disease. T h e importance of early iccognition of melanoma by the phjsician is emphasized.

or oral cavities by both patient and physician has led to failure in treatment. Induration, which is typical of an infiltrating epithelial malignant tumor, is frequently lacking in melanoma, particularly in lesions o f the oral cavity. T h e examining physician is thus lulled into complacency relative to the potentiality of a pigmented lesion. Similarly, the operative surgeon in turn approaches the neoplasm too closely, since his landmark of palpable infiltration is lacking. Proof 01 the existence of this factor is presented in the frequency of local recurrences that have been re1 iewed in this series. Anatomical barriers oppose extremely radical surgical attack in lesions of the nasal cavity. This is true even for the surgeon fully aware of the potentialities of melanoma. T h e WeberFergusson procedure is considered by many to be formidable surgery. However, in our series it would appear that it was not sufficiently radical. An extension of this procedure to furnish wider margins of excision seems indicated. Melanoma of the tonsil presents a most discouraging prognosis. I t frequently metastasizes before the local lesion produces symptoms or

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Cancer November-December 1955

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Two primary melanomas of the extrinsic larynx and one primary melanoma of the base o f the tongue are reported. Palatine-tonsil melanoma is prone to demonstrate distant metastasis before the primary tumor becomes apparent. Methods of treatment and end results are

reviewed. The prognosis in melanoma occurring in these sites remains extremely guarded. One five-year cure out of twenty-six cases is reported. Early diagnosis and more radical surgical therapy appear indicated to improve the fiveyear end results of this disease.

REFERENCES 1. ALLEN,A. C., and SPITZ,S.: Malignant meIanoma; a dinicopathological analysis of the criteria for diagnosis and prognosis. Cancer 6: 1-45, 1953. W. B.: Malignant melanoma of the nasal 2. ALSUP, cavity; review of the American literature and report of a case. North Carolina M. J . 11: 76-80, 1950. 3. BAXTER, H.: Malignant melanoma in the coloured races: report of a case originating in the mouth. Canad. M . A . J . 41: 350-354, 1939. 4. BAXTER, H.: A review of malignant melanoma o f the mouth; report of a case. Am. J. Surg. 51: 379-386, 1941. 5. CATLIN, D.: Melanomas of the skin o f the head and neck. Ann. Surg. 140: 796-804, 1954. G. E.. and ODESS. 1. S.: Metastatic malia6. FISHER. nant melanoma of t h e larynx. A:M. A. Arch. Otoluryni. 54: 639-642, 1951. 7. GRACE,C. C.: Malignant melanoma of the nasal mucosa. Arch. Otolaryng. 4 6 195-210. 1947. 8. HAVENS, F. Z., and PARKHILL, E. M.: Tumors of the larynx other than squamous cell epithelioma. Arch. Otolaryng. 34: 1113-1122, 1941. W.: Malignant melanoma of tonsil 9. HOWARTH, and fauces. J. Laryng. & Otol. 58: 29, 1943. 10. LOUGHEAD, J. R.: Malignant melanoma of the larynx. Ann. Otol., Rhin. 6 Laryng. 61: 154-158, 1952. 11. MEYER, H. W., and GUMPORT, S. L.: Malignant melanoma; appraisal o f the disease and analysis of 105 cases. Ann. Surg. 138: 643-658; disc. 659-660, 1953. 12. MORRIS, G. C., JR., and HORN, R. C., JR.: Malignant melanoma in the Negro; review of the literature and report of nine cases. Surgery 29: 223-230, 1951. 13. PACK, G. T.; GERBER,D. M., and SCHARNAGEL, I. M.: End results in the treatment of malignant melanoma; a report of 1190 cases. Ann. Surg. 136: 905911, 1952. 14. STEWART, T. S.: Nasal malignant melanoma. J. Laryng. 6 Otol. 65: 560-574, 1951.