Association of Surgical Approach and Margin Status With Oncologic Outcomes Following Gross Total Resection for Sinonasal Melanoma | Dermatology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Lund  VJ, Chisholm  EJ, Howard  DJ, Wei  WI.  Sinonasal malignant melanoma: an analysis of 115 cases assessing outcomes of surgery, postoperative radiotherapy and endoscopic resection.  Rhinology. 2012;50(2):203-210.PubMedGoogle Scholar
Holmstrom  M, Lund  VJ.  Malignant melanomas of the nasal cavity after occupational exposure to formaldehyde.  Br J Ind Med. 1991;48(1):9-11.PubMedGoogle Scholar
Mendenhall  WM, Amdur  RJ, Hinerman  RW, Werning  JW, Villaret  DB, Mendenhall  NP.  Head and neck mucosal melanoma.  Am J Clin Oncol. 2005;28(6):626-630.PubMedGoogle ScholarCrossref
Rapini  RP, Golitz  LE, Greer  RO  Jr, Krekorian  EA, Poulson  T.  Primary malignant melanoma of the oral cavity: a review of 177 cases.  Cancer. 1985;55(7):1543-1551.PubMedGoogle ScholarCrossref
Takagi  M, Ishikawa  G, Mori  W.  Primary malignant melanoma of the oral cavity in Japan: with special reference to mucosal melanosis.  Cancer. 1974;34(2):358-370.PubMedGoogle ScholarCrossref
Lombardi  D, Bottazzoli  M, Turri-Zanoni  M,  et al.  Sinonasal mucosal melanoma: a 12-year experience of 58 cases.  Head Neck. 2016;38(suppl 1):E1737-E1745.PubMedGoogle ScholarCrossref
Marcus  DM, Marcus  RP, Prabhu  RS,  et al.  Rising incidence of mucosal melanoma of the head and neck in the United States.  J Skin Cancer. 2012;2012:231693.PubMedGoogle ScholarCrossref
Ganly  I, Patel  SG, Singh  B,  et al.  Craniofacial resection for malignant paranasal sinus tumors: report of an international collaborative study.  Head Neck. 2005;27(7):575-584.PubMedGoogle ScholarCrossref
Ganly  I, Patel  SG, Singh  B,  et al.  Craniofacial resection for malignant melanoma of the skull base: report of an international collaborative study.  Arch Otolaryngol Head Neck Surg. 2006;132(1):73-78.PubMedGoogle ScholarCrossref
Prasad  ML, Busam  KJ, Patel  SG, Hoshaw-Woodard  S, Shah  JP, Huvos  AG.  Clinicopathologic differences in malignant melanoma arising in oral squamous and sinonasal respiratory mucosa of the upper aerodigestive tract.  Arch Pathol Lab Med. 2003;127(8):997-1002.PubMedGoogle Scholar
McLean  N, Tighiouart  M, Muller  S.  Primary mucosal melanoma of the head and neck: comparison of clinical presentation and histopathologic features of oral and sinonasal melanoma.  Oral Oncol. 2008;44(11):1039-1046.PubMedGoogle ScholarCrossref
Penel  N, Mallet  Y, Mirabel  X, Van  JT, Lefebvre  J-L.  Primary mucosal melanoma of head and neck: prognostic value of clear margins.  Laryngoscope. 2006;116(6):993-995.PubMedGoogle ScholarCrossref
Chiu  AG, Ma  Y.  Accuracy of intraoperative frozen margins for sinonasal malignancies and its implications for endoscopic resection of sinonasal melanomas.  Int Forum Allergy Rhinol. 2013;3(2):157-160.PubMedGoogle ScholarCrossref
Shaw  EG, Berkey  B, Coons  SW,  et al.  Recurrence following neurosurgeon-determined gross-total resection of adult supratentorial low-grade glioma: results of a prospective clinical trial.  J Neurosurg. 2008;109(5):835-841.PubMedGoogle ScholarCrossref
Bradley  WG.  Achieving gross total resection of brain tumors: intraoperative MR imaging can make a big difference.  AJNR Am J Neuroradiol. 2002;23(3):348-349.PubMedGoogle Scholar
Morise  Z, Kawabe  N, Tomishige  H,  et al.  Recent advances in liver resection for hepatocellular carcinoma.  Front Surg. 2014;1:21.PubMedGoogle ScholarCrossref
Roth  TN, Gengler  C, Huber  GF, Holzmann  D.  Outcome of sinonasal melanoma: clinical experience and review of the literature.  Head Neck. 2010;32(10):1385-1392.PubMedGoogle ScholarCrossref
Moreno  MA, Roberts  DB, Kupferman  ME,  et al.  Mucosal melanoma of the nose and paranasal sinuses, a contemporary experience from the M. D. Anderson Cancer Center.  Cancer. 2010;116(9):2215-2223.PubMedGoogle Scholar
Bachar  G, Loh  KS, O’Sullivan  B,  et al.  Mucosal melanomas of the head and neck: experience of the Princess Margaret Hospital.  Head Neck. 2008;30(10):1325-1331.PubMedGoogle ScholarCrossref
Gore  MR, Zanation  AM.  Survival in sinonasal melanoma: a meta-analysis.  J Neurol Surg B Skull Base. 2012;73(3):157-162.PubMedGoogle ScholarCrossref
Samstein  RM, Carvajal  RD, Postow  MA,  et al.  Localized sinonasal mucosal melanoma: outcomes and associations with stage, radiotherapy, and positron emission tomography response.  Head Neck. 2016;38(9):1310-1317.PubMedGoogle ScholarCrossref
Henderson  MA, Burmeister  BH, Ainslie  J,  et al.  Adjuvant lymph-node field radiotherapy versus observation only in patients with melanoma at high risk of further lymph-node field relapse after lymphadenectomy (ANZMTG 01.02/TROG 02.01): 6-year follow-up of a phase 3, randomised controlled trial.  Lancet Oncol. 2015;16(9):1049-1060.PubMedGoogle ScholarCrossref
Schaefer  T, Satzger  I, Gutzmer  R.  Clinics, prognosis and new therapeutic options in patients with mucosal melanoma: a retrospective analysis of 75 patients.  Medicine (Baltimore). 2017;96(1):e5753.PubMedGoogle ScholarCrossref
Del Vecchio  M, Di Guardo  L, Ascierto  PA,  et al.  Efficacy and safety of ipilimumab 3mg/kg in patients with pretreated, metastatic, mucosal melanoma.  Eur J Cancer. 2014;50(1):121-127.PubMedGoogle ScholarCrossref
Larkin  J, Hodi  FS, Wolchok  JD.  Combined nivolumab and ipilimumab or monotherapy in untreated melanoma.  N Engl J Med. 2015;373(13):1270-1271.PubMedGoogle ScholarCrossref
Patel  SG, Prasad  ML, Escrig  M,  et al.  Primary mucosal malignant melanoma of the head and neck.  Head Neck. 2002;24(3):247-257.PubMedGoogle ScholarCrossref
Manolidis  S, Donald  PJ.  Malignant mucosal melanoma of the head and neck: review of the literature and report of 14 patients.  Cancer. 1997;80(8):1373-1386.PubMedGoogle ScholarCrossref
Ledderose  GJ, Leunig  A.  Surgical management of recurrent sinonasal mucosal melanoma: endoscopic or transfacial resection.  Eur Arch Otorhinolaryngol. 2015;272(2):351-356.PubMedGoogle ScholarCrossref
Arnold  A, Ziglinas  P, Ochs  K,  et al.  Therapy options and long-term results of sinonasal malignancies.  Oral Oncol. 2012;48(10):1031-1037.PubMedGoogle ScholarCrossref
Nicolai  P, Battaglia  P, Bignami  M,  et al.  Endoscopic surgery for malignant tumors of the sinonasal tract and adjacent skull base: a 10-year experience.  Am J Rhinol. 2008;22(3):308-316.PubMedGoogle ScholarCrossref
Hanna  E, DeMonte  F, Ibrahim  S, Roberts  D, Levine  N, Kupferman  M.  Endoscopic resection of sinonasal cancers with and without craniotomy: oncologic results.  Arch Otolaryngol Head Neck Surg. 2009;135(12):1219-1224.PubMedGoogle ScholarCrossref
Chen  MK.  Minimally invasive endoscopic resection of sinonasal malignancies and skull base surgery.  Acta Otolaryngol. 2006;126(9):981-986.PubMedGoogle ScholarCrossref
Kim  BJ, Kim  DW, Kim  SW,  et al.  Endoscopic versus traditional craniofacial resection for patients with sinonasal tumors involving the anterior skull base.  Clin Exp Otorhinolaryngol. 2008;1(3):148-153.PubMedGoogle ScholarCrossref
Kim  HS, Kim  EK, Jun  HJ,  et al.  Noncutaneous malignant melanoma: a prognostic model from a retrospective multicenter study.  BMC Cancer. 2010;10:167.PubMedGoogle ScholarCrossref
Chan  RC, Chan  JY, Wei  WI.  Mucosal melanoma of the head and neck: 32-year experience in a tertiary referral hospital.  Laryngoscope. 2012;122(12):2749-2753.PubMedGoogle ScholarCrossref
Original Investigation
From the American Head and Neck Society
December 2017

Association of Surgical Approach and Margin Status With Oncologic Outcomes Following Gross Total Resection for Sinonasal Melanoma

Author Affiliations
  • 1Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
  • 2Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
  • 3Neurosurgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Otolaryngol Head Neck Surg. 2017;143(12):1220-1227. doi:10.1001/jamaoto.2017.2011
Key Points

Question  What is the association of operative approach and margin status with oncologic outcomes following gross total resection of sinonasal mucosal melanoma?

Findings  In this cohort study of 72 patients with nonmetastatic sinonasal mucosal melanoma, no differences in overall survival in patients undergoing endoscopic vs open primary resection were found. Local recurrence rates in patients with positive margins following gross total resection were higher than in patients with negative margins; this was not statistically significant but may be clinically significant.

Meaning  Select patients with sinonasal mucosal melanoma may benefit from endoscopic surgical approaches whereas positive margin status, although a negative prognostic factor, is likely not the main determinant of survival outcomes.


Importance  Sinonasal mucosal melanoma (SMM) is a rare malignant neoplasm characterized by a poor prognosis despite aggressive intervention including wide surgical resection. Margin status has previously been cited as an important prognostic factor for local control and overall survival (OS) in patients who undergo either an open or endoscopic surgical approach. No comparisons have been made, however, in patients who have undergone gross total resection with or without positive margins.

Objective  To assess the association of margin status and surgical approach with oncologic outcomes in patients with SMM undergoing gross total resection.

Design, Setting, and Participants  In this cohort study, patients with SMM without evidence of regional or distant disease treated with curative intent in part or full at Memorial Sloan Kettering Cancer Center from 1998 through 2016 were retrospectively assessed. Demographic data, prognostic information, and surgical pathology were reviewed. Operative reports and imaging were used to confirm gross total resection of local disease.

Exposures  Surgical techniques including open maxillectomy, craniofacial resection, and endoscopic resection.

Main Outcomes and Measures  Three-year local recurrence-free survival (LRFS), disease-free survival (DFS), and OS were calculated using the Kaplan-Meier method. Univariate and multivariable analyses of outcomes were carried out using the Cox proportional hazard regression method.

Results  Seventy-two patients (39 [54%] female; mean [SD] age, 67 [12] years) met the eligibility criteria. Thirty-eight patients (53%) underwent open partial or total maxillectomy with or without ethmoidectomy or sphenoidectomy via a transfacial approach. Fourteen patients (19%) had a more extensive craniofacial approach, and 20 patients (28%) underwent endoscopic resection. The 3-year OS for all patients was 52%. The absolute 3-year difference between patients with open/craniofacial resection vs endoscopic resection for LRFS, DFS, and OS was 11% (95% CI, −21% to 43%), 16% (95% CI, −7% to 39%), and 12% (95% CI, −18% to 41%), respectively. The absolute 3-year difference between patients with a negative margin and patients with a positive margin for LRFS, DFS, and OS was 18% (95% CI, −9% to 45%), 5% (95% CI, −17% to 27%), and 15% (95% CI, −9% to 39%), respectively. Multivariable analysis revealed that none of the adjusted variables (margin status, tumor stage, or surgical approach) were significantly associated with OS.

Conclusions and Relevance  Outcomes for patients with SMM remain poor regardless of operative approach or postoperative margin status.