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222–227

Oral Malignant Melanoma: A Case Report

Suman Sen1, Sheuli Sen2, M. Geetha Kumari3, Sufia Khan3,
Subhasini Singh3
1
Department of Oral Medicine and Radiology, Haldia Institute of Dental Sciences
and Research, Haldia, West Bengal, India;
2
Department of Pediatric Nursing, Sumandeep Nursing College, Sumandeep
University, Vadodara, Gujarat, India;
3
Department of Oral Pathology and Microbiology, Awadh Dental College
and Hospital, Jamshedpur, Jharkhand, India
Re ce i ved J une 3 0 , 2020; Accepted August 3, 2021.
Key words: Malignant melanoma – Palate – Pigmentation – Melanocytes
Abstract: Melanoma is a malignant neoplasm of the epidermal melanocytes.
Awareness and early recognition of pigmented lesion inside oral cavity helps in initial
diagnosis and further investigation and treatment. Oral malignant melanoma is a rare
aggressive neoplasm commonly seen among middle age. The diagnosis of melanoma
initiates from the pre-existing pigmented lesions. The poor prognosis of oral
melanomas requires that pigmented lesions of undetermined origin be routinely
biopsied. A case of malignant melanoma of hard palate with its clinical, radiological
and histopathological presentation along with brief review is presented. Prognosis
of these lesion is poor with survival rate of 5 years.

Mailing Address: Dr. Suman Sen, A-4/6, Purbasha, 160 manicktala main road,
Kolkata, West Bengal, India; e-mail: [email protected]

https://doi.org/10.14712/23362936.2021.20
Sen S.; Sen S.; Kumari M. G.; Khan S.; Singh S.
© 2021 The Authors. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0).
Prague Medical Report / Vol. 122 (2021) No. 3, p. 222–227 223)

Introduction
Oral malignant melanomas are extremely rare lesions and occur commonly in
the maxillary gingival and palatal region. Malignant melanoma is the third most
common skin malignancy, yet it comprises of only 3 to 5% of all cutaneous
malignancies (Boulaadas et al., 2007). Malignant melanomas of the oral cavity are
extremely rare accounting for 0.2–8% of all malignant melanomas (Ebenezer, 2006;
Guevara-Canales et al., 2012). Lesions are mainly very aggressive in nature but
mostly go unnoticed as these lesions are clinically asymptomatic in the early stages
and noted as hyperpigmented patch. Melanoma is a malignant tumour comprise
of melanocytes in which cells are derived from the neural crest that constitute the
melanin pigment in the basal and suprabasal layers of the epithelium (Ashok et al.,
2020). Although most melanomas arise in the skin, they may also arise from mucosal
surfaces (Deyhimi et al., 2017).

Case report
A 59-year-old male patient came to the department of oral medicine and radiology
with the chief complaint of blackish pigmented area over the palate. Patient does not
have symptom like pain or burning sensation, his main concern was aesthetic. Initially
he noticed small patches of dark black pigmented area 6 months ago which increases
to present size. There was a rapid spread of the hyperpigmented lesions which
covered the entire palatal region. There was no familial history of carcinomas.
On clinical examination, the lesion was dark blackish to brownish in colour with
irregular borders clearly demarcated from the adjacent area. Lesion covering left
to centre part of hard palate extending from middle third to junction of hard and

Figure 1 – A well-defined blackish brownish

irregular shaped lesion with a nodular elevation
in middle seen over hard palate.

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R L
Figure 2 – Orthopantomograph showing a well-defined radiolucent oval right side of palate.

soft palate. Irregular in shape with ragged borders measuring around 3×3.5 cm. The
surface appeared wrinkled, granular with a proliferative elevated area seen in midline
palate (Figure 1). On palpation, the lesion was fibrotic non-scrapable and non-tender.
The regional lymphnodes were not palpable.
Orthopantomograph (OPG) revels there is a well-defined radiolucency in right
middle part of hard palate suggestive of bone erosion appearing as palatal loss
(Figure 2). Under local anaesthesia a biopsy sample collected from proliferative
region of hard palate.
In histopathological examination revels the given sift tissue H and E (haematoxylin
and eosin) stained section shows parakeratininzed stratified squamous epithelium

Figure 3 – Malignant melanocytes

in epithelium and in stroma
(under 4× microscope).

Sen S.; Sen S.; Kumari M. G.; Khan S.; Singh S.

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Figure 4 – Malignant melanocytes with dysplastic features in the epithelium as well as in stroma (under 10×
microscope).

with dark brown coloured cells resembling melanocytes and are present throughout
the epithelium and are arranged in nests and islands. Melanocytes are large and
shows cellular pleomorphism, anisonucleosis and anisocytosis. Basal cell layer
degeneration is seen with melanocytes invading into the connective tissue stroma. In
the connective tissue, melanocytes are forming islands, and some are singly present.
Stroma is dense with collagen fibres, fibroblasts and fibrocytes. Dilated blood vessels
have also been reported with extravasated red blood cells. Focal areas of chronic
inflammatory chiefly lymphocytes are also seen. Pigmentation is also noted in
various places (Figures 3 and 4). Based on clinical, radiological and histopathological
presentation its final diagnosed as malignant melanoma. Chest X-ray did not show
any metastasis to lungs. A PET (position emission tomography) scan was performed,
which did not show any distant metastasis. The patient was referred to oral and
maxillofacial surgeon for excision of the lesion for further treatment and the
prognosis of the lesion was explained. The patient wanted treatment in a different
city and was referred for further management.

Discussion
Melanin is an endogenous non hematogenous pigment. It is initially formed by
melanocytes in the basal layer of the epithelium and is transferred to adjacent
keratinocytes via membrane-bound organelles called melanosomes. Benign lesions
like common acquired nevus, congenital nevus, dysplastic nevus and cellular blue
nevus are said to undergo a malignant transformation to melanoma. Mucosal
melanoma was first described by Weber in 1895. Cigarette smoking, denture
irritation and alcohol consumption are some of the suggested risk factors (Wu
et al., 2016). Tobacco and formaldehyde exposures have also been suggested
as causative agents for intraoral melanomas. Risk factors for melanoma include

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Caucasian ancestry, fair skin, light hair and a history of intense sun exposure, and
moles that are unusually numerous, large, irregular (Feller et al., 2017). Mostly it is
seen between the ages of 40 to 70 years (Smith et al., 2016). Malignant melanoma is
commonly seen in men compared to women (Singh et al., 2019). Most common site
inside oral cavity is the palate followed by maxillary gingiva with an incidence of 80%
and 91.4%, respectively (Lamichhane et al., 2015). It tends to rapidly spread to other
parts of the body causing death.

Criteria for clinical diagnosis of melanoma (rule of ABCDE)

n Asymmetry – is when one-half of the lesion does not match the other half
of lesion;
n Border irregularity – is when the edges are, notched, ragged or blurred;
n Colour irregularity – various coloured pigmentation is seen ranging from black,
brown, tan, red, blue and white;
n Diameter – more than 6 mm;
n Elevation from the adjacent surface.

Melanoma can be categorised as different types as superficial spreading, nodular

melanoma, lentigo maligna melanoma, acrallentiginous melanoma and mucosal
lentiginous melanoma. Among these acrallentiginous and mucosal lentiginous
melanoma commonly occur in the oral cavity. Hard palate is the most commonly
involved site where it presents as a brown to black macule with irregular borders.
Surgery, chemotherapy, radiotherapy, and immunotherapy are preferred treatment.
It has been shown that recent surgical excision followed by immuno-chemotherapy
has reduced or prevented the recurrence of the lesion. The prognosis of oral
melanoma is poor with a five-year survival of 15–38% of cases (Aloua et al., 2021).
Cases where there is metastasis has already involved then the disease is considered
as classically incurable, surgery, radiotherapy and chemotherapy could be considered
under the palliative care.

Conclusion
A small, pigmented lesion inside oral cavity is very much misleading as it does not
have any symptoms unless it became big and noted by the patient. Its early proper
diagnosis can be life saving for the patient as it can be very aggressive and a invade to
adjacent area.

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