Cervix melanoma (4).ppt
- 1. Shiksha, Pallavi Agrawal, K M Prasad, N K Bariar, Geeta Sinha Departments of Pathology (S, PA, KMP, NKB,), Obstretics and Gyanecology (GS) Patna Medical College and Hospital Patna
- 2. ď˝ Malignant melanoma is a common neoplasm of skin and mucous membrane ď˝ Incidence Female genital tract <2% Vulva 76.7% Vagina 19.8% Cervix 3-9% ď Amelanotic 50% of mucosal melanomas ď Disease was accepted in 1960 when Cid described presence of melanotic cells in cervix
- 3. ď˝ Awareness of this rare entity to be included in the differential diagnosis of poorly differentiated carcinomas of cervix
- 4. ď˝ 46-year-old postmenopausal woman presented with bleeding per vagina for past 15 days ď˝ She was on treatment of asthma, inhaler SOS ď˝ Per vaginal examination revealed a hard polypoidal growth the root of which could not be reached ď˝ Ultrasound abdomen revealed a well defined hypoechoic cystic lesion involving posteroinferior margin of cervix ď˝ She was advised for CECT pelvis and planned for cervical biopsy ď˝ Under Total intravenous anesthesia (TIVA) an enhanced visual assessment (EVA) was done ď˝ EVA revealed a caulifower like growth involving cervix which was pimented and keratinisation of vaginal mucosa
- 5. ď˝ Per rectal examination revealed rectal mucosa free with involved bilateral parametrium ď˝ She was staged as FIGO Stage IIB ď˝ Cervical biopsy was done and sent for histopathological examination ď˝ Gross examination revealed already bisected cervical polypoidal lesion ď˝ Microscopy confirmed the diagnosis of malignant melanoma ď˝ Primary MM was confirmed by IHC and exclusion of other primary sites ď˝ She was planned for radical hysterectomy with adjuvent chemotherapy
- 6. ď˝ Cervical epithelium forms complete spectrum of melanotic lesions from benign lentigenes to blue nevi to melanoma ď˝ Due to rarity of the disease it is staged according to FIGO staging system rather than the Clark and Breslow scales as it correlates better with the survival 5 year survival rate ďź 18.8% for stage I ďź 11.1% for stage II ďź 0% for stages IIIâIV
- 7. ď˝ MRI can distinguish between melanoma and other tumors due to a distinct signal pattern from the paramagnetic properties of melanin (high signal intensity on T1-weighted image and low signal intensity on T2-weighted images) ď˝ PAP smear shows bizarre cells with melanin pigment ď˝ Etiology is unknown ď˝ Risk factors HPV infection/Hormonal influence
- 8. ďś melanocytes migrate from neural crest to the uterine cervix ďś melanocytes differentiate from the endocervical epithelium
- 9. ďź presence of melanin in the cervical epithelium ďź absence of melanoma in another site of the body ďź Demonstration of junctional change in the cervix ďź if metastatic disease is found, it should be according to the cervical carcinoma pattern
- 10. Lesion Immunohistochemistry Poorly differentiated SCC p63 Poorly differentiated Adenocarcinoma Pan CK High grade Lymphoma LCA Anaplastic carcinoma Pan CK Stromal sarcoma Vimentin Rhabdomyosarcoma Myogenin, MyoD1 LMS (D/D with desmoplastic varient) SMA Blue Nevus (D/D with desmoplastic varient) HMB45, MART1,SOX10
- 11. ď˝ Treatment include radical hysterectomy with pelvic lymph node dissection and partial vaginectomy followed by radiation therapy, either intracavitary or external beam radiation or both ď˝ C-kit alteration identified in 2006 responded well to imatinib but still on clinical trial
- 12. Fig 1 Gross examination showing dark brown lesion near epithelium and deep cervical stroma
- 13. Fig 2Melanoma cells invading cervical stroma reaching close to epithelium (H&E 40x)
- 14. Fig 3Melanoma cells involving epithelium (H&E 40x) (Inset Brown coloured non-refractile intracytoplasmic pigment H&E100x)
- 15. Fig 4 Massonâs- Fontana stain demonstrating intracytoplasmic pigment in melanoma cells
- 16. Fig 5 HMB45 positive melanoma cells
- 17. Fig 6 S-100 positive melanoma cells
- 18. Fig 7 Melan A/MART -1 positive melanoma cells
- 19. Fig 8 Vimentin positive melanoma cells
- 20. Fig 9 CD117 negative melanoma cells
- 21. ď˝ Poor prognosis ď˝ Aggressive due to local recurrence and extensive early metastasis ď˝ Treatment differs so early diagnosis important to differentiate from squamous cell carcinoma ď˝ Radio-resistant tumor ď˝ Due to rarity no consensus have been made on standard protocol of treatment ď˝ Collaborative studies and follow up is recommended to establish a definite protocol for treatment of such unfortunate patients
- 22. ď˝ JuliĂŁo I, Carvalho SD, Patricio V, Raimundo A. Primary malignant melanoma of the cervix: a rare disease. BMJ Case Rep. 2017 Apr 21;2017. pii: bcr-2017-219361. doi: 10.1136/bcr-2017-219361. ď˝ Noguchi T, Ota N, Mabuchi Y, Yagi S, Minami S, Okuhira H, Yamamoto Y, Nakamura Y, Ino K. A Case of Malignant Melanoma of the Uterine Cervix with Disseminated Metastases throughout the Vaginal Wall. ď˝ Case Rep Obstet Gynecol. 2017;2017:5656340. doi: 10.1155/2017/5656340. Epub 2017 Jan 18. ď˝ Gupta M. Malignant melanoma of cervix. BMJ Case Rep. 2016 Nov 28;2016. pii: bcr2016217970. doi: 10.1136/bcr-2016- 217970. PMID: 27895081 ď˝ Lee JH, Yun J, Seo JW, Bae GE, Lee JW, Kim SW. Primary malignant melanoma of cervix and vagina. Obstet Gynecol Sci. 2016 Sep;59(5):415-20. doi: 10.5468/ogs.2016.59.5.415. Epub 2016 Sep 13. ď˝ Lim KH, Tay SK, Ng AX, Mantoo S. Primary Melanoma of the Uterine Cervix: A Case Report, With Key Points on Recognition and Pathological Diagnosis.J Low Genit Tract Dis. 2017 Jan;21(1):e1-e4. doi: 10.1097/LGT.0000000000000264.