Atsumi, Kazushige

Hirata, Hideki

Honda, Hiroshi

Matsuura, Shuji

Nakamura, Katsumasa

Nomoto, Satoshi

Nonoshita, Takeshi

Ohga, Saiji

Ohnishi, Kayoko

Shioyama, Yoshiyuki

Terashima, Kotaro

English

PubMed

Takeshi Nonoshita

Yoshiyuki Shioyama

Satoshi Nomoto

Saiji Ohga

Kayoko Ohnishi

Kazushige Atsumi

Kotaro Terashima

Shuji Matsuura

Katsumasa Nakamura

Hideki Hirata

Hiroshi Honda

Springer - Publisher Connector

Effective palliative radiotherapy in primary malignant melanoma of the esophagus: a case report

Crossref

Case report
Open Access
Effective palliative radiotherapy in primary malignant melanoma
of the esophagus: a case report
Takeshi Nonoshita1*, Yoshiyuki Shioyama1, Satoshi Nomoto1, Saiji Ohga1,
Kayoko Ohnishi1, Kazushige Atsumi1, Kotaro Terashima1, Shuji Matsuura1,
Katsumasa Nakamura2, Hideki Hirata3 and Hiroshi Honda1
Addresses: 1Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
2Department of Radiology, Fukuoka University School of Medicine, Fukuoka, Japan
3Department of Radiologic Technology, School of Health Sciences, Kyushu University, Fukuoka, Japan
Email: TN* - takenono@radiol.med.kyushu-u.ac.jp; YS - shioyama@radiol.med.kyushu-u.ac.jp; SN - s-nomoto@radiol.med.kyushu-u.ac.jp;
SO - saiji@radiol.med.kyushu-u.ac.jp; KO - konishi@radiol.med.kyushu-u.ac.jp; KA - kaatsumi@radiol.med.kyushu-u.ac.jp;
KT - kohta_t@radiol.med.kyushu-u.ac.jp; SM - smatsu@radiol.med.kyushu-u.ac.jp; KN - nakam@giga.ocn.ne.jp;
HH - hideki@radiol.med.kyushu-u.ac.jp; HH - honda@radiol.med.kyushu-u.ac.jp
*Corresponding author
Received: 27 March 2009 Accepted: 3 August 2009 Published: 19 August 2009
Cases Journal 2009, 2:6928 doi: 10.4076/1757-1626-2-6928
This article is available from: http://casesjournal.com/casesjournal/article/view/6928
© 2009 Nonoshita et al.; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction: Primary malignant melanoma of the esophagus is a rare but highly aggressive tumor
with poor prognosis. Surgical resection is the treatment of choice. However, some cases may be
diagnosed with advanced inoperable disease. Palliative radiotherapy may be used to relieve symptoms
caused by the esophageal tumor.
Case presentation: We report on a case of advanced inoperable primary malignant melanoma of the
esophagus treated with palliative radiotherapy. The patient’s dysphagia resolved with radiotherapy.
Conclusion: Malignant melanoma of the esophagus is rare. Patients with advanced inoperable
malignant melanomas of the esophagus benefit from radiation therapy. Radiation therapy is effective
for palliation.
Introduction
Primary malignant melanoma of the esophagus is an
uncommon disease accounting for only 0.1 % to 0.5 % of
all esophageal carcinomas [1-3]. It has a highly aggressive
tumor behavior with a median survival of about 10months
[4]. Some patients are inoperable at presentation. Radiation
therapy has been used to relieve symptoms. Malignant
melanomas are generally considered radioresistant,
requiring higher dose per fraction. We report on a case of
primary malignant melanoma of the esophagus treated
with palliative radiotherapy.
Case presentation
A 71-year-old male subject presented to us in very poor
general condition (Eastern Cooperative Oncology Group
performance status 3) with a history of hoarseness
Page 1 of 4
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(3 months) and dysphagia (1 month). Clinically, the left
supraclavicular lymph node (3 × 3 cms) was palpable.
Computed tomography (CT) scan of the chest and
abdomen demonstrated extensive swelling of the med-
iastinal lymph nodes extending from 4 cm above the
level of the upper margin of the sternum to 2 cm below
the carina, the esophagus was compressed and trachea
shifted to the right of the midline. Primary esophageal
tumor was not separately identifiable from the mediast-
inal lymph nodes. Lymph nodes in the superior and
middle mediastinum measured approximately 12 × 7.7 ×
6.0 cm (Figure 1A). Left supraclavicular (3.3 × 3.0 cm)
and abdominal node (1.9 × 1.5 cm) metastases were also
observed (Figure 1B, 1C). Esophagoscopy demonstrated a
10 mm pigmented polypoidal lesion (25 cm from the
inscisor) and multiple pigmented flat lesions (Figure 2).
Esophageal narrowing due to extrinsic compression was
seen from 19 cm to 24 cm. Histopathology of the biopsy
specimen from the esophagus showed diffuse prolifera-
tion of atypical polygonal cells with hyperchromatic oval
to round nuclei, eosinophilic cytoplasm, and prominent
nucleoli, accompanied by various amounts of melanin
pigments and immunohistochemically - positive for S-100
protein. These findings were all compatible with malig-
nant melanoma of the esophagus. A final diagnosis
malignant melanoma of the esophagus T4N1M1a, stage
IVa (UICC-TNM classification [5]) was made.
Due to the fact that PS was 3, palliative radiotherapy
was offered for palliation of dysphagia and tracheal
compression and chemotherapy was not administrated.
He received radiation therapy for primary tumor and
mediastinal and left supraclavicular lymph nodes in a dose
of 45 Gy (gray) in 15 fractions over 3weeks at 5 fractions
per week, using anteroposterior and posteroanterior field
with10-MV photon. Patient tolerated the radiotherapy
well. The patient’s dysphagia resolved completely shortly
after radiotherapy. 1 week after radiotherapy there was a
marked decrease in the size of the mediastinal lymph
nodes and subject improved symptomatically. The axial
dimensions of the lymph node were maximal around the
level of the aortic arch where it measured approximately
4.5 × 3.5 cm 1week following completion of radiotherapy
(Figure 3). Patient had sustained palliation i.e, continuous
relief of dysphagia for 4 months after radiotherapy.
Discussion
Primary malignant melanoma affecting the esophagus is
a rare and fatal disease with a poor prognosis. Sabanathan
et al. documented that approximately 50% of patients
have metastatic disease at presentation and long-term
survival is extremely rare [6]. The clinical presentation of
primary malignant melanoma of the esophagus is similar
to the common forms of primary esophageal malignan-
cies. The tumor most commonly occurs in the 6th and 7th
decade, and the male to female ratio is 2:1. Subtotal
esophagectomy is recommended as the treatment of first
choice for primary malignant melanoma of the esophagus.
Sabanathan et al. reported a median survival of between
7 and 12 months in patients who underwent radical
Figure 1. Contrast enhanced CT showed 7.7 cms mediastinal
lymph nodes compressing the esophagus and trachea at the
level of the aortic arch (A), 3.3 × 3.0 cms left supraclavicular
(B) and 1.9 × 1.5 cms abdominal lymph nodes (C).
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Cases Journal 2009, 2:6928 http://casesjournal.com/casesjournal/article/view/6928
resection and a 5 year survival of 4.2 % [7]. Chalkiadakis
et al. reported, in a series of 110 patients, a mean survival
of 13 months [8]. However, at the time of diagnosis, some
cases may be diagnosed as having inoperable carcinoma.
Chemotherapy is one of the treatment options for
malignant melanoma. However, it is difficult to use
chemotherapy to elderly or poor performance status
patients. Paul et al. reported that the response rate for
dacarbazine alone was 16.9 % and was 21.5% for
dacarbazine plus immunotherapy [9]. Although radio-
therapymay have a palliative role if surgery is not possible,
malignant melanoma has been considered radioresistant
[10]. At the time of diagnosis of the present case, multiple
lymph node metastases were observed and the perfor-
mance status was 3. Therefore, radical surgery and
chemotherapy were not considered. There have been
several case reports of effective palliation with photon
radiotherapy [11,12]. Forgarty et al. reported that a patient
with malignant melanoma of the esophagus received
36 Gy with a photon beam in six fractions given twice
weekly, and CT after 4 months following completion of
radiotherapy showed no residual mass [11]. In the present
case, palliative radiotherapy using a once-daily fractiona-
tion of 3.0 Gy was offered, and the tumor markedly
decreased in size and partial response was achieved.
Conclusion
Malignant melanoma of the esophagus is rare. Patients
with advanced inoperable melanomas of the esophagus
benefit from radiation therapy. Radiation therapy is
effective for palliation.
Consent
Written informed consent was obtained from the daughter
of the patient for publication of this case report and
accompanying images. A copy of the written consent
is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors contributed to acquisition of the case details
and the analysis and interpretation of those details. All
authors read and approved the final manuscript.
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Cases Journal 2009, 2:6928 http://casesjournal.com/casesjournal/article/view/6928


A: A case of earlystage primary malignant melanoma of the esophagus. Gastrointest Endosc

Against Cancer. TNM Classification of Malignant Tumours. 6th edition.

GN: Primary malignant melanoma of the esophagus.

JP: Primary malignant melanoma of the esophagus. Ann Thorac Surg

Primary malignant melanoma of the oesophagus. Scand J Thor Cardiobovasc Surg

Tanaka N: Primary malignant melanoma of the esophagus: report of a case successfully treated with pre- and post-operative adjuvant hormonechemotherapy.

Tsujimoto M: Early stage primary malignant melanoma of the esophagus. Gastrointest Endosc

Unusual malignant neoplasms of the esophagus. Oat cell carcinoma, melanoma, and sarcoma. J Thorac Cardiovasc Surg

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Effective palliative radiotherapy in primary malignant melanoma of the esophagus: a case report

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