Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Dentistry
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1314 - 1317

An Amelanotic Melanoma of the Oral Cavity- A Rare Entity; Case Report

Darshana J. Patil, Amit Gandhi, Freny R. Karjodkar, Mohan D. Deshpande, Sangeeta B. Desai

Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai, Maharashtra- 400 008, India Department of Oral Maxillofacial Surgery, Nair Hospital Dental College, Mumbai, Maharashtra- 400 008, India Professor and Head, Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai, Maharashtra- 400 008, India Associate Professor, Department of Oral Maxillofacial Surgery, Nair Hospital Dental College, Mumbai, Maharashtra- 400 008, India Professor and Pathologist Tata Memorial Hospital, Mumbai

Correspondence Address :
Darshana Patil
5, Vikas Nagar, Sakri, 424304
Dhule, Maharashtra, India
Mobile : 09860989148
Email : drpatildarshana@gmail.com

Abstract

Introduction/ Objectives: Amelanotic oral malignant melanoma (AOMM) is a rare tumour that is difficult to diagnose as it lacks melanin pigmentation. The prognosis is poorer than that of pigmented melanomas because of delays in establishing the correct diagnosis and in the initiation of treatment. Amelanotic forms are also thought to be biologically more aggressive than pigmented melanomas.

Methods: A case which reported to our hospital was investigated by taking a through case history, clinical, extra oral, intraoral examination and radiological and laboratory investigations.

Results: at each stage of reporting the feature pointed to a different diagnosis, which was finally confirmed on immunohistochemical examination.

Conclusions : AOMM without radial growth phase may be misdiagnosed as epulis or squamous cell carcinoma. Questionable lesions, particularly maxillary and palatal lesions, must be biopsied for histopathologic and possibly immunohistochemical examinations followed by rapid treatment as the prognosis of AOMM is poor. Advances in knowledge; The oral cavity being the most accessible area for examination, all the medical personnel should examine the oral cavity without fail and should be able to elicit the changes within it. Since the amelanotic variant may present diagnostic dilemma, proper investigations have to be performed to come to a definitive diagnosis and to plan the treatment thereafter.

Keywords

amelanotic, melanoma, prognosis, HMB45

Introduction
Melanoma is a major health problem. When discovered early and fully excised, melanoma is highly curable. However, once the metastatic disease develops, the treatment options are limited and the survival is generally measured in months(1).

Primary mucosal melanomas of the head and neck are a rare entity, accounting for 0.2% to 8% of all the malignant melanomas (2).

In the head and neck region, the nasal and oral cavities are the most commonly affected sites.

Oral amelanotic melanomas are rare and the prognosis is poorer than that of pigmented melanomas, because of delays in establishing the correct diagnosis and in the initiation of the treatment.

Case Report

A 75 years old, debilitated, female patient presented to us in February 2011; with a history of swelling with pain and bleeding in the lower anterior teeth region since 2 months, followed by a history of extraction. The swelling had gradually increased over a period of time, leading to inability in closing the mouth.

On clinical examination, a pink, proliferative, sessile growth (5 x 5cm) with focal areas of ulceration, involving the lower alveolarridge and the buccal and lingual vestibules, was present. (Table/Fig 1).The upper and lower anterior teeth were missing and the remaining teeth were not mobile.

The swelling was soft on palpation, with no blanching. The submandibular lymph nodes were palpable.

A provisional diagnosis of pyogenic granuloma (3) was made and the patient was referred for investigations.

Her panoramic radiograph showed osteolytic changes with respect to the mandibular anterior edentulous region. (Table/Fig 2).

Her CT scan showed an ill defined, heterogeneously enhancing, soft tissue lesion (3.29 x1.46 cm) involving the gingivobuccal sulcus, along with the destruction of the alveolar ridge. (Table/Fig 3) and B] The anterior parts of the genioglossus and the mylohyoid were lost. [Table/Fig 3C] An enlarged lymph node on the left side was compressing the left jugular vein. [Table/Fig 3D].

The provisional radiographic diagnosis was malignancy.

Distant metastasis was not found on the clinical, radiographic and ultra sonographic examinations of the patient.

Distant metastasis was not found on the clinical, radiographic and ultra sonographic examinations of the patient.

An incisional biopsy of the lesion was done under local anaesthesia, after taking the consent of the patient. The H and E stained sectionsshowed blue, round cells with hyper chromatic nuclei and scanty cytoplasm (Table/Fig 4), which were suggestive of Blue Round Cell Neoplasm with a differential diagnosis of• Anaplastic large-cell lymphoma(4).

• Poorly differentiated squamous cell carcinoma. (4) and • Malignant melanoma.

Immuno histochemistry was performed by running a panel that showed tumour cells which were focally positive for HMB45 (Table/Fig 5) and were negative for the S100 protein, CK, LCA, CD20 and CD138.

This helped us to reach the final diagnosis of ORAL AMELANOTIC MELANOMA.

The patient was referred to the oncosurgeons. As the disease was in its advanced stage with the involvement of the level 2 and level 3 lymph nodes and considering the age of the patient, theoncosurgeons opted for radiotherapy instead of surgical treatment. Unfortunately, the patient refused the treatment. At present, there is no change in her condition, but she has reported an increased bleeding from the lesion.

Discussion

Oral mucosal melanoma accounts for only 0.5% of all the oral neoplasms (5).

These are highly malignant tumours with a tendency to metastasize or locally invade tissues more readily than other malignant tumours of the oral cavity (5) Rapini et al (6) found that the highest percentage of oral melanomas occurred in the age range of 41 to 60 years and that they were rare before the age of 20 years; males being more frequently affected. (6), (7) Oral melanoma can be expected to exist in the following types; Superficial spreading, Acral- lentiginous or Nodular. The most frequent site of their occurrence is the hard palate, followed by the maxillary gingival (5), the mandible, tongue, buccal mucosa and the upper and lower lips.

Intra oral malignant melanomas usually remain asymptomatic and may be detected only when there is ulceration of the overlying epithelium and/or haemorrhage (8); this may be the reason for the poor prognosis of oral malignant melanomas, with the 5-year survival rate being between 15% to 38% (7). In addition, the rich vascular supply which is present in the oral cavity may further contribute to the dissemination of the melanomas (9).

Rarely may melanoma present itself without clinically evident pigmentation; which is termed as amelanotic melanoma. These lesions tend to have a worse prognosis because of their delayed recognition and subsequent treatment (10). Amelanotic melanoma accounts for 5-35% of all the oral melanomas, which appears as a white, mucosa-coloured, or red mass. Its prognosis is poorer than that of pigmented melanomas because of the delays in establishing the correct diagnosis, due to histological misdiagnosis and due to delays in the initiation of the treatment. The common sites of metastasis are the lymph nodes, the liver and the lung, with a widespread involvement occurring in advanced disease (11)

While the recommended treatment is ablative surgery with tumourfree margins in combination with chemotherapy and to a lesser extent, immunotherapy or irradiation, there is a recognized need for an evidence-based treatment protocol choice. but probably, multimodal therapy may prove to be more effective in the treatment of oral mucosal melanoma (5).

Westbury (12) describes a clinical classification as follows: I-only primary tumour present. II- metastasis present (IIa-adjacent skin involved, IIb-regional lymph nodes involved, II-ab adjacent skin and regional lymph nodes involved) and III-metastasis beyond regional lymph nodes. The patient who has been presented here falls into the classification of IIb, because satellite lesions were present at the time of the initial presentation. Melanoma is notorious for its unpredictable and widespread metastasis. The metastasis in the oral regions usually involves the soft tissues, notably the tongue (13). The need for biopsies of infra oral melanomas cannot be emphasized. In many cases, the melanomas may appear to be relatively innocuous (7); often an excisional biopsy can be accomplished. However, an incisional biopsy is acceptable for the larger lesions and must be performed in the darkest and thickest areas of the lesion. According to Batsakis (7), “there is no evidence that a preliminary biopsy of the primary lesion increases the risk of metastatic dissemination or that it unfavourably affectsthe prognosis”. Any pigmented growth that may appear to be innocuous needs to be biopsied at the earliest. Regression in melanoma is a well-recognized phenomenon (13). The rather nonspecific features of regressed melanoma (apparently inflammatory nodules, depigmented patches and flat or slightly depressed scars) are easily missed or discounted, unless the patient has noticed the regression(14) The primary mode of treatment for malignant melanoma is wide surgical resection (10). In a review on the outcome of primary mucosal melanomas which were treated only with radiation (15), it was found that 44% of the patients survived for a period of 4.5 years of follow-up. Even though these results appear to be encouraging, radiation is most often used as a supplementary mode of treatment after surgery or after the failure of a previous management. When metastasis is not present after the examination and investigations, surgery would be the preferred option for the treatment. Advances in surgical techniques may allow a more extensive resection and reconstruction. Consideration should also be given to radiation therapy or combined therapy.

In the present case, as the patient was in a debilitated state, and as the disease was in its advanced stage with the involvement of the level 2 and level 3 lymph nodes and considering the age of the patient, the oncosurgeons opted for radiotherapy instead of surgical treatment. The prognosis was so poor (although death might not ensure for many years) that it seemed unjustifiable to embark on a massive removal, especially as the tumour had already metastasized.

Conclusion

The main contribution of this case report is an alarm to the oral physicians and the medical personnel who may not be able to diagnose these lesions because of their asymptomatic behaviour. The oral cavity being the most accessible area for examination, all the medical personnel should examine the oral cavity without fail and they should be able to elicit the changes within it. Since the amelanotic variant may present a diagnostic dilemma, proper investigations have to be performed to come to a definitive diagnosis and to plan the treatment.

Key Message

Oral mucosal melanomas have a ‘chameleonic’ presentation of a mainly asymptomatic condition. The rarity of these lesions, the poor prognosis and the necessity of a highly specialized treatment are the factors that should be seriously considered.

References

1.
Aloia TA, Gershenwald JE,. Andtbacka RH,. Johnson MM, Schacherer CW, Ng CW, et al. Utility of computed tomography and the staging of magnetic resonance imaging before the completion of lymphadenectomy in patients with sentinel lymph node–positive melanoma. J Clin Oncol 2006;24:2858- 65.
2.
Garzino-Demo P, Fasolis M, Maggiore GM, Pagano M, Berrone S: Oral mucosal melanoma: a series of case reports. J Craniomaxillofac Surg 2004; 32(4):251-7.
3.
Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997; 37: 887-19.
4.
Notani K, Shindoh M, Yamazaki Y, Nakamura H, Watanabe M, Kogoh T, Ferguson M, Fukuda H: Amelanotic malignant melanomas of the oral mucosa. British Journal of Oral and Maxillofacial Surgery 2002; 40(3):195-200.
5.
Garzino-Demo P, Fasolis M, Maggiore GM, Pagano M, Berrone S: Oral mucosal melanoma: a series of case reports. J Craniomaxillofac Surg 2004; 32(4):251-7.
6.
Rapini RP, Golitz LE, Greer RO, Krekorian EA. Paulson T: Primary malignant melanoma of the oral cavity. Cancer 1985; 55:1543-51.
7.
Batsakis JG: Tumours of the head and neck. Clinical and pathological considerations,(2’Ed.), Williams and Wilkins Co. Baltimore, pages: 1979; 431-47.
8.
Snow GB, Van der Esch EP, Van Slooten EM,: Mucosal melanoma of the head and neck. Head Neck Sorg 1978;1:24-30.
9.
Eisen D, Voorhees IT: Oral melanoma and other pigmented lesions ofthe oral cavity. J Am Acad Dermatol 1991; 24:527-37.
10.
Ducic Y, Pulsipher DA. Amelanotic melanoma of the palate: Report of a case. J Oral Maxillofac Surg 2001; 59:580-3.
11.
Barker BF, Carpenter WM, Daniels TE, Kahn MA, Leider AS, Lozada- Nur F, Lynch DP, Melrose R, Merrell P, Morton T, Peters E, Regezi JA, Richards SD, Rick GM, Rohrer MD, Slater L, Stewart JC, Tomich CE, Vickers RA, Wood NK, Young SK: Oral mucosal melanomas: the WESTOP Banff workshop proceedings. Western Society of Teachers of Oral Pathology.
12.
Smith IF, Steblin JS: Spontaneous regression of primary malignant melanomas with regional metastasis. Cancer 1965;18:1399-415.
13.
Welch RD, Hirsh SA, Davis RG: Melanoma with metastasis to an apical periodental cyst. Oral Surg Oral Med Oral Pathol 1985; 59:189-93.
14.
Avril ME, Charpentier P, Margolis A, Guillanme JC: Regression of primary melanoma with metastasis. Cancer1992; 69:1377-81.
15.
Harwood AR, Cummings BL Radiotherapy for mucosal melanomas. Int J Radiat Oncol Bio Phys 1982; 8:1121-6.

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