A rare case of rynopharyngeal melanoma
A-43-year old woman presented to Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy in June 2006 for evaluation. On clinical examination, she presented dysarthria of speech, with signs of cerebellar ataxia. Her general medical history was contributory; with a history of malignant melanoma involving epipharynx treated in Germany twenty years earlier (1987), with a wide local excision, followed, one year later, by a right lateral neck dissection (the histological examination results were unknown). Additional details were not available but she also claimed to be suffering from Claude Bernard Horner Syndrome.\nSince three years, the patient had experienced a progressive paralysis of the arms and legs. A few months ago, it had required hospitalization and proper neurological investigations. She had been diagnosed with a paraneoplastic cerebellar syndrome. Imaging studies used to evaluate this lesion, including positron emission tomography (PET), computed tomography (CT) and magnetic resonance imaging (MRI), revealed a large recurrence of malignant melanoma of rynopharynx []. Immediately, she underwent three cycles of adjuvant chemotherapy, waiting to be subjected to a surgical approach.\nThe latest imaging study to evaluate the clinical situation of patient, including MRI of brain and face showed no alteration of brain parenchyma, parapharynx, salivary glands and eyeballs, compared to previous studies.\nTherefore, it was decided to submit the patient to an open surgical approach in order to remove the rynopharyngeal lesion. As the nose-palatal-genieno-flap was planned, a left paralateronasal incision was performed, extending from the lip up to the nasal root []. Then, the skeletonization and the osteotomy of the zygomatic bone, with release of the pterygoid process from jaw bones were done. Following this, the osteotomy of the palatine bone from 2.2 to 2.8 dental elements and the section of the soft palate from the origin to the hard palate were carried out in order to attain the exposition of the rynopharinx. The melanoma occupied the rear wall of the nasopharynx and the lateral wall bilaterally. It was decided to remove the mucosa and submucosa. The surgical specimen was sent to the Pathology Laboratory for definitive diagnosis. The gross specimen measured 4 × 3.5 cm [] and contained part of the pharynx consisting of mucosa and submucosa and several biopsies of the surrounding areas. The microscopic examination revealed a specimen composed of fragments of mucous tissue with foci of chronic inflammation. Only the rynopharyngeal supero-posterior and superior-medial left borders were compromised by disease; other areas were free. Based on the microscopic findings and clinical history, a diagnosis of melanoma was done.\nDuring the surgery, a tracheotomy was performed to prevent airway collapse and a nasogastric tube was positioned. No complication was recorded in the post-operative period and no further surgery was performed. The follow up showed no recurrence in the same position and with the same characteristics after six years.