melanoma of the respiratory tract and oral cavity

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M E L A N O M A OF ‘THE UPPER RESPIRATORY T R A C T

A N D ORAL CAVITY

EMORY MOORE,M.D.,” AND HAYESMARTIN,M.D.

LINICAL investigation of malignant mela-C noma has gained considerable impetus

within recent years. Numerous reports have

appeared describing anatomical incidence,l”

theories of histogenesis,l and modern concepts

of treat111ent.l~ These articles have two ob-

jectives: better understanding of the natural

history of the disease and improvement in di-

agnosis and therapy.

l h e purpose of this presentation is to sum-marize the experience of hlcniorial Center

with melanoma when it occurred primarily in

the mucous membranes of the oral cavity or

upper respiratory tract. The report covers

nineteen years, between 1930 and 1948 in-

clusive.

Rarity of nielanoma in the oral cavity or

upper respiratory tract limits the experience

of the individual clinician. For this reason a

review of the incidence, symptomatology, treat-

ment, and results of the Memorial Center cases

appears indicated. Twenty-six such cases are

analyzed.

HISTOPATIIOLOGY

The histopathology of melanotic lesions of

mucous-membrane origin is no different than

that of melanotic lcsions occurring in skin-

the lesion is a carcinoma. The modern con-

cepts of junctional change occurring in strati-

fied squamous epithelium of skin apply

directly to that in squamous epithelium oforal mucous membrane or pseudostratified

epithelium of the nasal cavity, paranasal

sinuses, or larynx. The comprehensive research

of Allen and Spitz into the histopathological

nature of melanoma has clarilied certain per-

plexing problems of diagnosis. These authors

point out a higher incidence of pleomorphism

and mitotic figures in mucous-membrane le-

sions of the head and neck than in the lesions

of the skin. These factors may explain the

From the Head aid Neck Service, Mcmoiial Centerfor Cancer and Allied Diseases, New York, New Yolk.

Presented a t the Eighth Annual Cancer Symposiumof the James Ewing Society, April 16, 1954.

“Present address: Long Beach, California.Received for publication, March 15, 1955.

TABLE

GENERAL A N A T O MIC A L DI S TRI BUTI ON OFMELANOMA

1.oration NO. 57,

Total no. pat ients 1546Total no lesions 1557 100Head and neck 429 27.6

Skin 274 17.7Eye 1 2 8 8 . 2Oral upper 2 7 1 . 7

respiratoryUpper extremities 159Trunk 161Lower extremities 336Anorectal 20Genitals 49Unrecorded nrimarv 403

10.210.42 1 . 6

1 . 33 . 1

2 6 . 0

frequent confusion in the recognition of the

true pathological nature of the lesions when

they occur in this area.

METHODSND MATERIALS

The accession books between the years 1930

and 1948 inclusive of the Pathology Labora-

torics of Memorial Center were reviewed.Thirty-three recorded cases of melanoma of

the oral cavity or upper respiratory tract were

found. Seven of these either were not primary

in those sites or were found on histological

review to lack sufficient criteria for a diagnosis

of melanoma. The remaining twenty-six cases

were accepted by the Pathology Laboratories

as authentic examples of primary melanoma

of mucous membranes of the oral cavity or

upper respiratory tract.

Melanomas of other sites were recorded dur-ing the review of the accession books, provid-

ing a comparison of the incidence of the

twenty-six cases to the over-all anatomical dis-

tribution of melanoma (Table 1). Fifteen hun-

dred and forty-six entries with a diagnosis of

melanoma were found. This facet of the study

is subject to some error, since the diagnosis

was not once more subjected to histological

review and in some instances the material sub-

mitted may not have been from the primary

site. Thus, this latter material is used only forgeneral background in this report. A more

critical evaluation of the general anatomical

distribution of melanoma has been published

recently by Pack, Gerber, and Scharnagel.

1167



1168 Cancer ouembe

age i n d e c a d e s

k ~ . ,4gc incidcncc in twenty-six cases of melanoma

of the oral cavity and upper respiratory tract.

G F N F K A LNCIDENCX

As has been previously stated, primarj mela-

noma of the oral cavity and upper respiiatory

tract is rare. In this study the disease represents

1.7 per cent of all ta5es of melanoma recorded

in the accession books of the Pathology Lab-

oratories (Table 1). This figure is in approxi-

mate agreement with that of 2.5 per cent found

by Pack. Catlin has reported from Memorial

Center a 23 per cent incidence of melanomaoccurring 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 occur-

ring in the head and neck may be expected

to be found in the oral cavity or upper respira-

tory tract.

The specific anatomical incidence of mela-

noma in the oral cavity or upper respiratory

tract is discussed later.

RACE,EX, AND AGE

Melanoma in the Negro occurs in areas of

decreased pigment distribution, such as body

orifices, palms of hands, and soles of feet.11

Until recently, the disease was considered most

uncommon among them. However, in1 estiga-

tors are now recording an increase in the ab-

solute incidence of melanoma in the Negro.12

This is felt to be due to improved case finding

and a correction of the figures relative to the

proportion of Negroes in a hospital popula-

tion. Th is series contains only one example in

a Negro, a melanoma of the palatine tonsil in

a 66-year-old female nurse.

There is no statistical difference between

the sexes in the incidence of melanoma, re-

r-December 1955 Vol. 8

TABLE

S P E C IF IC A N A T O MIC A L L O C A T IO N O F ME1,-A N O M A S OF U P P E R R E S P I R A T O R Y T R A C T

A N D ORA4LC A V IT Y

Location h0 4

Total no. pniientsTotal no lesions

Nasal cavityNasal septumMiddle turhinateFloor of nasal cavityAnterior ethmoid

Sunerior alveolusOral cavity

Ha’rd palateMucosa of lipInferior alveolusRuccal mucosaTongne 1 3 . 7

Orophatynx palatine tomil) 4 1 4 . 8Larynx 2 i 4

1no.n

gardless of anatomical location. Fourteen of

our patients were male and twelve female.This finding is in agreement with that re-

ported in the literature.1, 2, 6, 13

The 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). The average age of the twenty-six pa-

tients was 59 years. No cases were found in

patients less than the age of 30 (Fig. 1). This

is somewhat in contradistinction to lesions oc-

curring in othcr anatomical locations in which

a definite postpubertal incidence in the secondand third decades has been widely reported.1,

9 13 However, our series is small and may not

be statistically significant.

CLINICALHARACTERISTICS, TRE AI- MENI-

AND RESULTS

LESIONS O F NASAL CAVITY AND

PARANASAL SINUSES

The pattern of distribution of lesions oc-

curring in the nasal cavity coniorms to the

findings of other investigators.2 Our cases were

predominantly on the nasal septum, four, and

the middle turbinate, three (Table 2). One

tumor occurred on the floor of the nasal cavity.

One case of paranasal-sinus tumor was found.

This lesion occurred in the anterior ethmoid.

It would appear from this series and from the

literature that the paranasal sinuses are for

practical purposes a very rare source of malig-

nant melanoma.2~ l4

Subjectively, symptoms in this location were

not specific of melanoma. Nasal “stuffiness”

from mechanical narrowing of the nasal air-

way or recurrent epistaxis from ulceration of

the tumor were the prevailing complaints.

Pain or tenderness orcurrcd in only one case.

Symptoms were present from one to seventeen



No. 6 MELANOMAF UPPERRESPIRATORYRACTMOUTHMoore Mart in 1169

months prior to admission, the mean being

seven months. T he presence of a “blackish dis-

charge,” as described in the literature,7 wasnot recorded.

Objectively, nasal examination frequentlydemonstrated a polypoid, necrotic tumor mass

that bled easily on contact. T he surface was

described as ulcerated in five instances and

granular in three. Only four of the nine lesions

demonstrated the slate-gray or blue color that

would indicate the true nature of the lesion

(Fig. 2).Eight of the nine cases were clinically free

of metastasis on admission. One pat ient dem-

onstrated subcutaneous nodules of the skin o€

the lace and bilateral neck node metastasis.

This patient’s primary was located on the

nasal septum and had heen presenting symp-

toms for one and one-half years.

Koentgenological examination of the para-

nasal sinuses and nasal bones demonstrated

paranasal-sinus obstruction in seven of the

nine patients and bone destruction in three.

The latter was most marked in the patient

with the ethmoid primary.

Biopsy revealed the tumors to be melanoma

in six instances. In three patients, however,

the exact diagnosis was not established untildefinitive surgery had been performed and

the entire lesion was available for histological

study.

Tw o methods of primary treatment were

utilized-roentgen-ray radiation and surgery

{Table 3 . Of the nine patients, three received

roentgen-ray therapy and five, radical surgery.

One patient refused treatment.

Of the patients receiving roentgen-ray tlier-

apy, two were given 250 kv. and one 80 kv.

roentgcn rays. The tumors of all three patients

demonstrated satisfactory regression only to

become clinically recurrent eight to nine

months horn the time of completion of ther-

apy. The secondary attack on the disease con-

sisted of gold-filtered radon implantation in

one and Weber-Fergusson antral resection in

a second. Th e third patient’s conditon was too

TABLE

METHOD OF TREATMENT 4ND RESULT

Primary treatment

Region No. Method

Nasal cavity 3 X-ray

5 Surgery(Weber-Fergusson)

Oral cavityLip

Maxilla

1 None

1 Radon ra.pack

1 SurgeryU exc.)

4 Excision

2 Excisionneck dissect.

2 NoneBuccal mucosai 1 Excision

Inferior alveolus 1 Mandibulect.

(part.)Orophar ynx

LarynxTonsil 4 None

Extrinsic 2 Laryngect.

Result Secondary treatment~ _ _ _ _ _ _ _____

NO. Status No. Method Result

3 Recurr. 1 None Died1 Surgery Died1 Radon seeds Died

3 Recurr. 1 Re-excis. Died1 Radium

tandem Died1 None Died

1 PuIm. embolus Died1 Distant metast. Died

Died

1 No recurr. *Developed maxilla

1 Recurr. 1 Re-excis. Living M yr.

2 Recurr. 1 Re-eucis. Died1 None Died

1 Distant metast. Died1 No recurr. Developcd bronchus

2 Recurr. 2 X-ray Died

Died1 Local distant Died

1 Distant metast. Died

primary

primary 6th yr.

metast.

4 Distant metast. Died

2 Local r distant Diedmetast.

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



I170 Cancer November -December 1955 Vol. 8

FIG. 2. h,fclanoma of the nasal septum. The lesiondepicted is pigmented-a finding in less than 50 percent of melanomas in this region.

precarious for further treatment. All three

were dead of disease between sixteen and

twenty-four months after the original treat-

ment.

The primary surgical attack against the

disease consistcd of the ~15eof the Weber-Fcrgusson procedure with preliminary ex-

ternal 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 re-excision in another. The former died of dis-

ease 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 treat-

ment and were dead of disease ten a nd fifteen

months respectively after first admiqsion.

Thus, in eight melanonias of the nasal cav-

ity 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

Eleven of the twenty-six patients had twelve

melanomas 44.4 per cent) of the oral cavity

F I G.3. Melanoma of the superior alveolus.

(Table 2). The 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 ha rd palate

(Fig. 4). One patient had two primaries-on

the mucosa of the lip and on the hard palate.

The inucosa of the upper l ip demonstrated

two lesions; and the buccal mucosa (Fig. 5),the inferior alveolus, and the tongue, one each.

The cause of a high incidence of melanoma of

the supcrior maxilla remains unexplaincd.4

In 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. The majority of these lesions

were bulky or covered a relatively wide an-

atomical area within the oral cavity.

A painless, nonelcvated, pigmented area was

the initial symptom in all but three of the

twelve lesions. INSIX IKSTANCES THE PIGMENTA-

YEARS. A seventh patient had noted a painless

mass in the upper l ip 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. In one instance, medical

TION HAD BEFN PRESENr FROM ONE TO FIVE



MELANOMAF UPPER ESPIRATORY TRACTk MOUTH. o o x a r t i n 1171o . G

FIG.4. Melanoma of the hard palatc.

aid had heen sought within a iew months ofthe appearance of pigmentation. The patient

was advised that i t 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 re-

sulted in diagnosis and institution of treat-

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 super ior alveolus forced one patient to the

physician within one month oi the develop-

ment of the tumor.

The following symptoms brought to the

physician those patients in whom pigmenta-

tion had been present for prolonged intervals:

the development of a mass in the pigmented

area, bleeding, ulceration, and rapid increase

ment.

FIG.5. Melanoma of the buccal mucosa.

i n the area of pigmentation. Pain was signifi-

cantly absent.

I n one instance (a patient with a base-of-

tongue lesion), the metastatic deposits forced

the patient to seek medical advice. Th e symp-toms consisted oT cough, chest pain, and weight

loss. They had been present for one month

prior to the establishment ol a diagnosis. The

existence of the primary lesion was unknown

to the patient and was lound on physical ex-

amination.

Examination of the primary lesions of the

oral cavity demonstrated ten of the twelve

tumors to be pigmented. The 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 le-

sions 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 re-

spects: 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.

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 symp-

tomatology and the insti tution of treatment.

One patient (tongue) presented bilateral neck

node metastasis, as well as deposits in the

liver arid lung. Another patient with a su-

perior 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 mela-

nomas of the oral cavity and correctly diag-

nosed all but one. The true nature of the

base-of-the-tongue lesion was not realized until

the material was reviewed lor this article. The

suspicion of melanoma was raised during the

course of the patient’s illness when tissue

coughed up was subjected to histologicalstudy and i t presented the possibility of mela-

noma.

Primary treatment of the lesions of the oral

cavity was surgical in eight patients (Table 3 .

In one instance, a melanoma of the lip, ra-

dium-element pack and radon bulbs were uti-



1172 Cancer November December 1955 Vol. 8

FIG.6. Melanoma of the ha rd palate in a 42-year-oldwoman. The lesions were treated successfully by ex-cision. The patient was free of discase five years, onlyto develop a second piiinary lesion 111 the main bron-chus of the right lung in her sixth year, postoperatively.(See Fig. 7.)

lized. Th is patient remained free of disease for

four years, only to develop a second primary

of the hard palate from which he later suc-

cumbed. One patient refused treatment anddied 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 pat ient

(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 bronchusin the same patient as seen in Fig. 6.

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

All of these patients had primaries of the hard

palate or superior alveolus. In two of the six

cases, the cautery was combined with radical

neck dissection, since they denioristrated con-

comitant 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 ap-peared.) In both of these patients, local re-

currence in the region of the neck dissection

appeared two months and seven months later

iespectively, and both patients were dead with-

in a year. Of the remaining four patients

surgically treated, two developed local recur-

rence in the hard palate after one month and

hiteen months respectively. T he former wasdead in two years and six months with gen-

eralized metastasis. The latter patient had

nu~nerousocal hard-palate recurrences treatedsurgically, 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 pul-

monary metastasis three years after initial

treatment. The 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



No MELANOMAF UiTER RESPIRATORYRACT O U T H . Moore Mar t i n 1173

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 melanomasof the oral cavity, only one pat ient 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.

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.

The second patient demonstrated a mela-

noma of the right inferior alveolus (Fig. 9).Right mandibular ramisection was successful

locally. However, lour years later distant ine-tastasis to the mediastinum and brain became

clinically apparent and produced a fatal out-

come 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 per-

formed two months alter the diagnosis was

FIG. 10. Primary melanoma of the palatine tonsil.

LESION5 OF THE. OROPHARYNX

Lesions of the oropharynx were limited to

the palatine tonsils--Pour 14.8 per cent). Noexamples 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 re-

maining 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 lendermass in the left submaxillary triangle-one.

I N ALL FOUR CASES, SYMPTOMS HAD BEEN PRES-

EUT FOR LESS THAN TWO MONTHS.

Physical examination on admission estab-

lished the primary lesion in a tonsil in two

cases. I n the third, the primary became clin-

ically apparent six months after the Iirst de-

velopment of a metastatic deposit in the skin

ol the forehead and in a preauricular node.

The fourth case demonstrated the primary

lesion eight months after the development 1the submaxillary triangle node metastasis.

l’he two lesions found on first adniission

were nonpigmented, ulcerated, and firm Fig.10). One of these almost filled the pharynx,

preventing articulation or swallowing. Thc

primaiy lesions appearing six and eight

months after clinical metastasis weie described

as pigmented when they finally became ap-

parent.

Early metastasis typifies this group of mela-

noma. In two instances the deposits were re-

gional to preauricular or cervical nodes. In

the third regional cervical nodes and distant

rnediastinal deposits were present. I n the

fourth distant metastasis was found in an ex-

tremi ty.Chest roentgenograms of three patients were



1174 Cancer Novernbeu-December 1955 Vol. 8

negative on admission. The patient with clin-

ical mediastinal metastasis was terminal and no

roentgenograms were taken.

Biopsy of the primary tumor was positive

in all instances when the lesion became clin-ically detectable.

‘I’reatnient, with cure in mind, was offered

to the one patient with subniaxillary triangle

node metastasis. This patient refused the sur-

gery offered. She was dead one year and one

month after hcr first admission.

Palliation was attempted in only one pa-

tient in the form of roentgen-ray radiation,

without beneficial effect. Death occurred nine

months after admission. One of the two pa-

tients 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

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 meta-

static 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 presenttwo and six months respectively. Pain on swal-

lowing and dyspnea had brought the patient

to the physician in one instance, and hemop-

tysis 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 sug-gested a diagnosis of nielanoma in one and a

Grade-IV epidermoid carcinoma in the other.

At the time of total laryngectomy both le-

sions were described grossly as being pig-

mented.

Treatment in both cases consisted of total

FIG. 11. Primary melanoma of the extrinsic larynx.

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 fourteenmonths after treatment. The second was dead

of disseminated disease one year and nine

months after surgery.

Neither of these patients is free of culpabil-

ity in delay, since hoarseness had been present

for two and six months respectively. Further,

the lesions were bulky on examination. Never-

theless 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 em-

phasis.

Patient delay in seeking medical advice isapparent. This delay i s most marked in the

oral-cavity melanomas. Failure to recognize

the significance of pigmentation in the nasal



No. MELANOMAF UPPERRESPIRATORYRACTe MOUTH. oore art in 1175

TABLE

O F THE U P P E R R E S P I R A T O R Y TRACT A N DORAL CAVITY

FI VE- YEAR END RESULTS IN MELANOMA

This series consists of all cases of all pati ents w ith melanoma

of the upper respiratory tract and oral cavity, both early andadvacced, whether previously treated or not, or whether con-sidered susceptible of cure, who app ied a t Memorial Hospitalduring the period January 1, 1930, to December 31 1948.

TCTAL xr r sw r s 2 6lnde erminule Cure s 4

Eventual outconie uot determined by what wasdone or could have been attempted at MemorialHosnital

Consuitation only. treatment not requestedRefused proferred treatment or palliative care

13

ost track of without recurrence after treatmentDead from other causes without recurrence 0

TOTALNDETERMINATEASES 4

Deterininate Cases 22All patients willing ahle to ret urn for curative orpalliative treatment in whom the eud result, whethera success or failure, could possibly have been in-influenced by the treatment (or lack of it) at

Memorial HospitalTOTALDETERMINATE CASES 22(To tal patients applying minus no. of Indetet-

minate Cases)RESULTSF TREATMENTFailures 21Dead as a result of cancer or its treatmentLiving with cancer presentLiving free of cancer after treatment of recurrence

but not yet 5 yr. Over 5 yr. from first admission[Untreated failures considered to be too far ad-

2

1

vanced for t rea tm~nt ] [41

TOTALo. OF FAILURES 2 1

1

Successful Results 1

(Determinate Cases minus Failures)Tot al no. of patients free of disease 5 yr. after

admission

minate Cases

NET FIVEYEARENDRESULTSNo. of Successful Resul ts divided by no. of Deter- 4 . 5

or oral cavities by both patient and physician

has led to failure in treatment.

Induration, which is typical of an infiltrat-

ing epithelial malignant tumor, is frequently

lacking in melanoma, particularly in lesions

o f the oral cavity. The 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 ofpalpable 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 radi-

cal surgical attack in lesions of the nasal cavity.

This is true even for the surgeon fully aware

of the potentialities of melanoma. The Weber-

Fergusson procedure is considered by many to

be formidable surgery. However, in our series

i t would appear that it was not sufficiently

radical. An extension of this procedure to

furnish wider margins of excision seems indi-

cated.

Melanoma of the tonsil presents a most dis-

couraging prognosis. I t frequently metastasizes

before the local lesion produces symptoms or

becomes apparent to the examining physician.

The laryngeal and base-of-tongue lesions

arc too few from which to draw any conclu-

sions. However, the primary tumors in the

larynx were bulky, indicative 01 the possibilityof their having been present for some time.

The 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. In Table 4 of five-year end results wehave 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, it would seem that two

main factors are essential for improvement in

the results of treatnient of malignant mela-

noma 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 ext irpation of the pri-

mary lesion. Ionizing radiation in the form

of roentgen rays, radium, or radon would ap-

pear to have little \ d u e in the treatment of

inalignant melanoma.

S U M M A R Y

Primary malignant melanoma of the upper

respiratory tract and oral cavity is a rare dis-

ease. For this reason, a statistical review of the

cases secn at Memorial Center was fclt to be

indicated. This paper h a s summarized the

total experience in nielanorna of these

sites between the years 1930 and 1948. Twentp-

six cases have been studied.

Malignant melanoma of the oral cavity and

upper respiratory tract represents approxi-

mately 1.7 per cent of all melanomas arid 6.3per cent of head and neck melanoma. It oc-

curs 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 respir-

atory tract are reviewed. Melanoma in these

areas is frequent11 silent at the onset and pro-

duces insufficient symptoms to forcc the pa-

tient to the physician in the early stages ol

the disease. The importance of early iccogni-

tion of melanoma by the phjsician is empha-

sized.



1176 Cancer November-December 1955 Vol. 8

reviewed. The prognosis in melanoma occur-

ring 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 five-

year end results of this disease.

T w o primary melanomas of the extrinsic

larynx and one primary melanoma of the base

of the tongue are reported.

Palatine-tonsil melanoma is prone to dem-

onstrate distant metastasis before the primary

tumor becomes apparent.

Methods of treatment and end results are

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melanoma of the respiratory tract and oral cavity

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