A lfio Jose T incani, A ntonio S antos M artins, H enriette de T oledo Lage, Lincoln S antos S ouza
M e la n o m a G a n g lio n ic M e ta s ta s is 3 0 y e a r s a f te r tr e a tm e n t o f
th e p r im a r y tu m o r - A c a s e r e p o r t
H e a d a n d N e c k S u r g e r y S e r v i c e s o f t h e D e p a r t m e n t o f S u r g e r y a t t h e S c h o o l f o r M e d i c a l S c i e n c e a t t h e S t a t e U n i v e r s i t y o f C a m p i n a s ( U N / C A M P ) - C a m p i n a s , B r a z i l
T h e re cu rre n ce o f m e la n o m a in p a tie n ts is w e ll-d o cu m e n te d , a n d is d e p e n d e n t o n a n u m b e r o f fa cto rs. W e re p o rt a ca se in w h ich a p a tie n t h a d a ca se o f g a n g lio n a r m e ta sta sis in th e n e ck a fte r a 3 0 -ye a r d ise a se -fre e in te rva l fo llo w in g p rim a ry tre a tm e n t.
U N IT E R M S : L a te m e ta sta sis o f cu ta n e o u s m e la n o m a . C u ta n e o u s m e la n o m a . H e a d a n d n e ck m e la n o m a .
IN T R O D U C T IO N
T
h ec l i n i c a lr e c u r r e n c ef a c t i n t h e m e d i c a l l i t e r a t u r e .o f m e l a n o m a i s a w e l l - d o c u m e n t e d3 A t t h e H e a d a n d N e c k S u r g e r y S e r v i c e s o f t h e D e p a r t m e n t o fS u r g e r y a t U N I C A M P , w e h a d a c a s e i n w h i c h a p a t i e n t
s h o w e d c e r v i c a l l y m p h a t i c m e t a s t a s i s 3 0 y e a r s a f t e r b e i n g
d i a g n o s e d a n d t r e a t e d f o r a p r i m a r y l e s i o n s i t u a t e d o n t h e
s k i n i n t h e s u p r a s c a p u l a r r e g i o n .
C A S E R E P O R T
I n 1 9 6 3 , M . R . V . , a n 1 8 - y e a r o l d w o m a n , d i s p l a y e d a
d a r k n o d u l a r l e s i o n 1 . 0 c m i n d i a m e t e r o n t h e s k i n i n t h e
A d d re ss fo r co rre sp o n d e n ce :
A lfio Jose T incani
R ua Luverci P ereira de S ouza, 1765
C am pinas/S P - B rasil - C E P 13084-031
r i g h t s u p r a s c a p u l a r r e g i o n . S h e w a s t r e a t e d a t a n o t h e r
c l i n i c . A n a m p l e r e s e c t i o n o f t h e l e s i o n w a s p e r f o r m e d
a n d a n a n a t o m o p a t h o l o g i c a l h i s t o l o g i c a l t e s t r e v e a l e d i t
t o b e a C l a r k I I I a n d B r e s l o w 1 . 2 m m m e l a n o m a . T h e
p a t i e n t w a s f o l l o w e d f o r s i x c o n s e . c u t i v e y e a r s w i t h o u t
e v i d e n c e o f l o c a l r e c u r r e n c e o r m e t a s t a s i s .
I n 1 9 9 3 , a t t h e a g e o f 4 8 , t h e p a t i e n t c o n t a c t e d u s o n
a c c o u n t o f t h e a p p e a r a n c e o f a h a r d e n e d n o d u l e i n t h e
r i g h t s u p r a c l a v i c u l a r f o s s a e . T h e t u m o r a p p e a r e d i n t h e
a r e a o f d r a i n a g e o f t h e p r e v i o u s n o d u l e .
L a b o r a t o r y e x a m s a n d i m a g i n g w e r e c o m p l e t e d n o t
o n l y t o d e t e r m i n e t h e p a t i e n t 's s t a g e , b u t a l s o t o e x c l u d e a
s e c o n d p r i m a r y t u m o r . T h e d i a g n o s i s o f m e t a s t a s i s o f t h e
m e l a n o m a w a s c o n f i r m e d b y a n a s p i r a t e o f t h e c e r v i c a l
g a n g l i o n w i t h a f i n e n e e d l e . I n M a y o f 1 9 9 3 ; a c e r v i c a l
g a n g l i o n i c r e m o v a l o f t h e u p p e r , m i d , a n d l o w e r j u g u l a r
c a r o t i d c h a i n w a s p e r f o r m e d o n t h e p a t i e n t , a s w e l l a s o n
t h e s u p r a c l a v i c u l a r f o s s a e o n t h e r i g h t s i d e ( l e v e l s I I , I I I ,
I V a n d V ) . T h e f i n a l h i s t o l o g i c a l e x a m i n a t i o n r e v e a l e d
m e t a s t a s i s m e l a n o m a w i t h e x t r a c a p s u l a r i n v a s i o n i n
I
c e r v i c a l l y m p h n o d e a m o n g 2 1 e x a m i n e d . T h e p a t i e n t h a s
b e e n i n a m b u l a t o r y f o l l o w - u p f o r 1 5 m o n t h s w i t h o u t
e v i d e n c e o f d i s e a s e .
T IN C A N I, A .J.; M A R T IN S , A .S .; L A G E , H .T . & S O U Z A , L .S . - M e la n o m a g a n g lio n ic m e ta sta sis
3 0 ye a rs a fte r tre a tm e n t o f th e p rim a ry tu m o r - A ca se re p o rt
1132
D IS C U S S IO N
The
majority
of recurrences
and
deaths
from
cutaneous
melanoma
occur
within
the first
1 0years of
diagnosis
and treatment
of the primary
lesion,
and are
common
after this period.
3.6
In the medical
literature,?
there has only been one
description
of late recurrence
with a disease-free
interval
of 30 years, as in the case of our patient. The majority of
recurrences
described
occurred
between
10 and 20 years
later.1.
2.3.6.7
The slight possibility
of a recurrence
after 30
years leads us to consider
that this may be the case of a
second
primary
tumor.
2Most late recurrences
involving
lymph
nodes
occur
in the area of the drainage
of the
primary tumor. However, SHAW et al.
6describe 47 percent
of their cases of late recurrences
in areas distant from the
primary lesion (distant lymph nodes, subcutaneous
nodules
or visceral metastasis
or in the central nervous system).
A review of the cases described in the literature reveal
common
characteristics
in the patients
with cutaneous
melanoma
with late recurrences.
The majority of patients
are premenopausal
women
under the age of 50, which
suggests that natural steroid tumors may affect the natural
history of the patients.
IAlso, occurrence
in the lower limbs
is more common
in women,
and has a more favorable
prognosis.
1.6KOH et al.
3describe
two cases of recurrences
of
melanoma
1 4and
1 8years after treatment
of the primary
tumor. A possible explanation
for this phenomenon
of late
recurrence
could be that a small portion
of tumor cells
could have a potential
for metastasis,
and in individuals
with a subsequent
recurrence,
these cells could have been
dormant for years before becoming
evident.
MASTRANGELO
et al.
4believe
that
there
is a
connection
to the immune system of the host. There could
be a loss of antingenic
manifestation
altering
the tumor
immunogenicity
or of the immune
system
of the host,
therefore
causing the late metastasis.
REINTGAN
et al.
5believe
that
immunological
factors
could
also cause
a second
primary
metacronic
tum0.r, and this would recede spontaneously
leaving only
the metastatic
disease. This can be observed
in 5 percent
of the cases of metastatic
melanoma.
C O N C L U S IO N
The occurrence
after an interval of 30 years between
treatment
of the primary
tumor and the appearance
of a
ganglioma
metastasis
is extremely
rare in all malignant
. tumors,
especially
in the case of cutaneous
melanoma.
Only
from
1to 7 percent
of the patients
treated
for
cutaneous
melanoma
develop
a recurrence
1 0years after
the initial
treatment.
Premenopausal
women
with
a
melanoma located in the lower limbs have a greater chance
of late recurrence.
A follow-up
of the patient over a long period (more
than
1 0years)
is essential
for identification
and early
treatment
of recurrences.
RESUMO
A re c id iv a d e m e la n o m a e m p a c ie n te s p re v ia m e n te tra ta d o s
e
b a s ta n te d e s c rito n a lite ra tu ra e e s t a re c id iv a d e p e n d e d e v a rio sfa to re s . A p re s e n ta m o s u m c a s o d e m e la n o m a c u ta n e o m e ta s ta tic o p a ra re g ia o c e rv ic a l o n d e a p a c ie n te te v e u m in te rv a lo liv re
d a d o e n < ;:a d e 3 0 a n o s e n tre s e u tra ta m e n to in ic ia l e0 a p a re c im e n to d a m e ta s ta s e g a n g lio n a r.
1133
REFERENCES
1 . B r i e l e H A , B e a t t i e C W , R o n a n S G , C h a u d h u r i P K , D a s G u p t a T K . L a t e r e c u r r e n c e o f c u t a n e o u s m e l a n o m a . A r c h S u r g
1 9 8 3 ; 1 1 8 : 8 0 0 - 3 .
2 . C a l l a w a y M P , B r i g g s J c . T h e i n c i d e n c e o f l a t e r e c u r r e n c e ( g r e a t e r t h a n t e n y e a r s ) : A n a n a l y s i s o f 5 3 6 c o n s e c u t i v e c a s e s o f c u t a n e o u s m e l a n o m a . B r J P l a s t S u r g 1 9 8 9 ; 4 2 : 4 6 - 9 . 3 . K o h H K , S o b e r A J , F i t z p a t r i c k T B . L a t e r e c u r r e n c e ( b e y o n d
t e n y e a r s ) o f c u t a n e o u s m a l i g n a n t m e l a n o m a . J A M A 1 9 8 4 ; 2 5 .J : 1 8 5 9 - 6 2 .
4 . M a s t r a n g e l o M J , B e l l e t R E , B e r d D . I m m u n o l o g y a n d I m m u n o t h e r a p y o n h u m a n c u t a n e o u s m a l i g n a n t m e l a n o m a . I n : C l a r k W H , G o l a d m a n L I , M a t r a n g l e o M J , e d s . H u m a n M a l i g a n t M e l a n o m a . N e w Y o r k : G r u n e & S t r a t t o n I n c .,
1 9 7 9 : 3 5 5 - 4 1 6 .
5 . R e i n t g e n D S , M c C a r t y K S , W o o d a r d B . M e t a s t a t i c m a l i g n a n t m e l a n o m a w i t h u n k n o w n p r i m a r y . S u r g G y n e c o l O b s t e t 1 9 8 2 ; 1 5 6 : 3 3 5 - 4 0 .
6 . S h a w H M , B e a t t i e C W , M c C a r t h y W H , M i l t o n G W . L a t e r e l a p s e f r o m c u t a n e o u s S t a g e I m a l i g n a n t m e l a n o m a . A r c h S u r g 1 9 8 5 ; 1 2 0 : 1 1 5 5 - 9 .
7 . T a h e r y D P , M o y R L . R e c u r r e n t M a l i g n a n t M e l a n o m a f o l l o w i n g a 3 5 - y e a r d i s e a s e - f r e e i n t e r v a l . I n t J D e r m l S u r g O n c o l 1 9 9 3 ; 1 9 : 1 6 1 - 3 .
T IN C A N I, A .J.; M A R T IN S , A .S .; LA G E , H .T . & S O U Z A , L.S . - M elanom a ganglionic m etastasis 30 years after treatm ent of the prim ary tum or - A case report
