Cancer Res Treat.  2016 Jan;48(1):240-249. 10.4143/crt.2014.305.

Preliminary Suggestion about Staging of Anorectal Malignant Melanoma May Be Used to Predict Prognosis

• Chae WY
• Lee JL
• Cho DH
• Yu CS
• Roh J
• Kim JC

• KMID: 2152281
• DOI: http://doi.org/10.4143/crt.2014.305

Abstract

PURPOSE
Anorectal malignant melanomas (AMM) are rare and have poor survival. The study aims to evaluate the clinicopathologic characteristics and outcomes of patients with AMM, and to devise a staging system predictive of survival outcome.
MATERIALS AND METHODS
This was a retrospective study of 28 patients diagnosed with, and treated for AMM. Patients classified by clinical staging of mucosal melanoma (MM) were reclassified via rectal and anal TNM staging. Survival outcomes were compared among patients grouped by the three different staging systems.
RESULTS
The three staging systems were equated with similar figures for 5-year overall survival (OS) and 5-year disease-free survival (DFS) of patients diagnosed with stage I disease. Patients (n=19) diagnosed with MM stage II disease were reclassified by rectal TNM staging into three subgroups: IIIA, IIIB, and IIIC. For these patients, both 5-year OS and 5-year DFS differed significantly between the subgroups IIIA and IIIC (OS: IIIA vs. IIIC, 66.7% vs. 0%, p=0.002; DFS: IIIA vs. IIIC, 51.4% vs. 0%, p < 0.001).
CONCLUSION
The accuracy of prognosis in patients diagnosed with AMM and lymph node metastasis has improved by using rectal TNM staging, which includes information regarding the number of lymph node metastases.

Keyword

Anus canal; Rectum; Melanoma; Neoplasm staging

MeSH Terms

Disease-Free Survival
Humans
Lymph Nodes
Melanoma*
Neoplasm Metastasis
Neoplasm Staging
Prognosis*
Rectum
Retrospective Studies

Figure

• 

  Fig. 1. Representative images of anorectal melanoma. (A) Case 25 shows 7.3-cm-sized well-demarcated black ulcerofungating mass in the rectum. (B) The cut surface of the mass is homogeneously black and soft. It extends to the proper muscle layer and invades dentate line. (C) Microscopically, tumor contains highly anaplastic discohesive cells without specific growth pattern. Individual cells have abundant acidophilic, finely granular dense cytoplasm. Prominent macronucleoli is also identified. Occasionally, multinucleated giant cells and cytoplasmic melanin pigments are present (H&E staining, ×400). (D) Immunohistochemically, tumor cells are reactive for Melan-A (×400).

• 

  Fig. 2. Detailed changes in 28 patients with clinical stage I or stage II anorectal malignant melanoma, as classified by rectal TNM and anal TNM. Rectal TNM, tumor node metastasis (TNM) staging of rectal cancer based on the 7th American Joint Committee on Cancer (AJCC) staging system; anal TNM, TNM staging of anal cancer based on the 7th AJCC staging system. a)T1 invades submucosa, T2 invades muscularis propria, T3 invades into perirectal tissues, T4a penetrates to the surface of the visceral peritoneum, T4b invades to other organs, b)N1a, metastasis in 1 regional lymph nodes; N1b, metastasis in 2-3 regional lymph nodes; N1c, tumor deposit; N2a, metastasis in 4-6 regional lymph nodes; N2b, metastasis in 7 or more regional lymph nodes, c)M, distant metastasis, d)T1 < 2 cm; T2 ≥ 2 cm, < 5 cm; T3 ≥ 5 cm; T4, invades other organ, e)N1, metastasis in perirectal lymph node; N2, metastasis in unilateral internal iliac and/or inguinal lymph node; N3, metastasis in perirectal and inguinal lymph node and/or bilateral internal iliac and/or inguinal lymph nodes.

• 

  Fig. 3. (A-D) Overall survival (OS) (A) and disease-free survival (DFS) (B) of patients with local disease (malignant melanoma [MM] stage I) grouped by anal TNM after converting MM stage to anal TNM, OS (C) and DFS (D) of patients with regional disease (MM stage II) grouped by rectal TNM after converting MM stage to rectal TNM. Anal TNM, tumor node metastasis (TNM) staging of anal cancer based on the 7th American Joint Committee on Cancer (AJCC) staging system; rectal TNM, TNM staging of rectal cancer based on the 7th AJCC staging system.

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  Fig. 4. (A-F) Overall survival (OS) and disease-free survival (DFS) according to the operative type, whether received adjuvant treatment or not, and type of melanosis. The 5-year OS (A) and the 5-year DFS (D) of patients with local disease (malignant melanoma [MM] stage I) grouped by operative type (wide local excision [WLE] vs. abdominoperineal resection [APR]), the 5-year OS (B) and the 5-year DFS (E) of patients with regional disease (MM stage II) grouped by adjuvant therapy (received adjuvant chemotherapy or immunotherapy, adj [+] vs. not received adjuvant therapy, adj [–]), the 5-year OS (C) and the 5-year DFS (F) of patients with malignant anorectal melanoma grouped by melanosis (amelanotic melanoma vs. melanotic melanoma).

Reference

References

1. Belbaraka R, Elharroudi T, Ismaili N, Fetohi M, Tijami F, Jalil A, et al. Management of anorectal melanoma:report of 17 cases and literature review. J Gastrointest Cancer. 2012; 43:31–5.

2. Chang AE, Karnell LH, Menck HR. 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. Cancer. 1998; 83:1664–78.

3. Falch C, Stojadinovic A, Hann-von-Weyhern C, Protic M, Nissan A, Faries MB, et al. Anorectal malignant melanoma: extensive 45-year review and proposal for a novel staging classification. J Am Coll Surg. 2013; 217:324–35.

4. Banerjee SS, Harris M. Morphological and immunophenotypic variations in malignant melanoma. Histopathology. 2000; 36:387–402.

5. Roumen RM. Anorectal melanoma in The Netherlands: a report of 63 patients. Eur J Surg Oncol. 1996; 22:598–601.

6. Kubo K, Fujiyoshi T, Yokoyama MM, Kamei K, Richt JA, Kitze B, et al. Lack of association of Borna disease virus and human T-cell leukemia virus type 1 infections with psychiatric disorders among Japanese patients. Clin Diagn Lab Immunol. 1997; 4:189–94.

7. Iddings DM, Fleisig AJ, Chen SL, Faries MB, Morton DL. Practice patterns and outcomes for anorectal melanoma in the USA, reviewing three decades of treatment: is more extensive surgical resection beneficial in all patients? Ann Surg Oncol. 2010; 17:40–4.

8. Talsma K, van Hagen P, Grotenhuis BA, Steyerberg EW, Tilanus HW, van Lanschot JJ, et al. Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer. Ann Surg Oncol. 2012; 19:2142–8.

9. Ward MW, Romano G, Nicholls RJ. The surgical treatment of anorectal malignant melanoma. Br J Surg. 1986; 73:68–9.

10. Antoniuk PM, Tjandra JJ, Webb BW, Petras RE, Milsom JW, Fazio VW. Anorectal malignant melanoma has a poor prognosis. Int J Colorectal Dis. 1993; 8:81–6.

11. Ishizone S, Koide N, Karasawa F, Akita N, Muranaka F, Uhara H, et al. Surgical treatment for anorectal malignant melanoma: report of five cases and review of 79 Japanese cases. Int J Colorectal Dis. 2008; 23:1257–62.

12. Nilsson PJ, Ragnarsson-Olding BK. Importance of clear resection margins in anorectal malignant melanoma. Br J Surg. 2010; 97:98–103.

13. Podnos YD, Tsai NC, Smith D, Ellenhorn JD. Factors affecting survival in patients with anal melanoma. Am Surg. 2006; 72:917–20.

14. Cagir B, Whiteford MH, Topham A, Rakinic J, Fry RD. Changing epidemiology of anorectal melanoma. Dis Colon Rectum. 1999; 42:1203–8.

15. Luna-Perez P, Rodriguez DF, Macouzet JG, Labastida S. Anorectal malignant melanoma. Surg Oncol. 1996; 5:165–8.

16. Weinstock MA. Epidemiology and prognosis of anorectal melanoma. Gastroenterology. 1993; 104:174–8.

17. Ben-Izhak O, Levy R, Weill S, Groisman G, Cohen H, Stajerman S, et al. Anorectal malignant melanoma. A clinicopathologic study, including immunohistochemistry and DNA flow cytometry. Cancer. 1997; 79:18–25.

18. Goldman S, Glimelius B, Pahlman L. Anorectal malignant melanoma in Sweden. Report of 49 patients. Dis Colon Rectum. 1990; 33:874–7.

19. Cooper PH, Mills SE, Allen MS Jr. Malignant melanoma of the anus: report of 12 patients and analysis of 255 additional cases. Dis Colon Rectum. 1982; 25:693–703.

20. Pessaux P, Pocard M, Elias D, Duvillard P, Avril MF, Zimmerman P, et al. Surgical management of primary anorectal melanoma. Br J Surg. 2004; 91:1183–7.

21. Brady MS, Kavolius JP, Quan SH. Anorectal melanoma. A 64-year experience at Memorial Sloan-Kettering Cancer Center. Dis Colon Rectum. 1995; 38:146–51.

22. Yap LB, Neary P. A comparison of wide local excision with abdominoperineal resection in anorectal melanoma. Melanoma Res. 2004; 14:147–50.

23. Bullard KM, Tuttle TM, Rothenberger DA, Madoff RD, Baxter NN, Finne CO, et al. Surgical therapy for anorectal melanoma. J Am Coll Surg. 2003; 196:206–11.

24. Bujko K, Nowacki MP, Liszka-Dalecki P. Radiation therapy for anorectal melanoma: a report of three cases. Acta Oncol. 1998; 37:497–9.