engleski

Two independent primary melanomas- a case report.

In 2003, a patient, M.I., age 63, underwent radical excision of malignant melanoma on the upper right dorsal region at the Department for Plastic and Reconstructive Surgery, Clinical Hospital Dubrava, Zagreb, Croatia. In the last 6 years, regular control exams showed no signs of relapse or dissemination of the disease. In January 2009, the patient was admitted to the ORL Department of that same hospital due to clarifying symptoms he had for the last few months, including mostly dyspnea and increased nasal secretion, but the patient also complained about an unspecific feeling of tension and fullness within the nasal cavity. Rinoscopy showed bilateral polipously changed mucous membrane of the nose and a tumorous growth (tumor mass) under the inferior nasal concha. The MSCT scan of the paranasal sinuses confirmed the presence of a tumor in the left nasal cavity. Biopsy results indicated the presence of malignant melanoma, most probably of the metatstatic nature. The patient was transferred to the Department for Maxillofacial Surgery where left-sided medial maxillectomy was performed. An uncertain PH finding indicates a composite tumor: one of the components was mucous melanoma and another, spindle component appeared as sarcoma, but did not show the immunophenotype of desmoplastic melanoma. The material was sent to the Department of Pathology (School of Medicine, University of Zagreb) for further analysis. Molecular tests for SYT-SSX translocation came up positive, which is characteristic of synovial sarcoma, so the definitive PHD was: melanoma malignum et sarcoma synoviale (tumor colisionis). Primarily the pathohistological finding (immunohistochemistry, flow cytometry), but also the course of the disease showed this tumor was a de novo process, completely independent from the melanoma the patient was treated for 6 years ago. Postoperative PET-CT scan showed no signs of active/residual illness. The patient was referred to the University Hospital for Tumors where the radiation oncology consultation group discussed the case and indications for further treatment. Since there was a sarcoma component in the PH finding, adjuvant radiotherapy was indicated. Considering the localization and nature of the tumor, it was decided to use the 3D conformal radiotherapy technique. RADIOTHERAPY PLAN The tumor dose was 60Gy, delivered in 30 fractions. As no tumor was present, CTV was determined by adding 5 mm borders around the contour. Due to the presence of air in PTV, inhomogenity corrections were used in the dose calculation algorithm. Special consideration was given to protection of optical nerves, lenses and optic chiasma, which influenced the final beam arrangement.  To achieve the desired protection of the optic chiasma (maximum dose of 45Gy), it was necessary to reduce the PTV coverage, due to the limitations of 3D conformal radiotherapy, as IMRT has not yet been routinely used in our Hospital. CONCLUSION Immunohistochemical analysis of the tumor tissue from the nasal cavity enabled the detection and differentiation of another, sarcoma component of the tumor. The finding of this other component is a proof that this tumor is not a metastasis of skin melanoma the patient was treated for few years ago, but rather a de novo tumorous growth within the nasal cavity. This finding also played a crucial role when discussing the treatment options: by exclusion of metastatic disease, radical treatment was possible (radical surgery + adjuvant radiotherapy), in which case the outcome prognosis is excellent and no relapse is expected in this patient.

independent primary tumors; melanoma; therapy

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