eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Malignant Melanoma: Follow-up

Author: Bobby Collins II, DDS, MS, Associate Professor of Oral and Maxillofacial Pathology, Department of Diagnostic Sciences, University of Pittsburgh School of Dental Medicine
Coauthor(s): E Leon Barnes Jr, MD, Professor of Pathology and Professor of Otolaryngology, University of Pittsburgh School of Medicine; John Abernethy, MD, Winston-Salem, North Carolina
Contributor Information and Disclosures

Updated: Mar 21, 2008

Follow-up

Further Inpatient Care

• Diagnosis and subsequent surgical excision of oral melanoma requires lifelong follow-up.
• Early discussions of potential problems with function, prostheses, oral fungal infection, and lesion recurrence may ensure patient compliance.

Further Outpatient Care

• Periodic follow-up for oral examination and assessment is necessary to evaluate for recurrence. Perform a thorough oral examination and imaging studies regularly for the life of the patient. Recurrence is described as long as 11 years after the initial surgery.
• At follow-up visits, dental care, nutritional status, and difficulties with the prosthesis (if necessary) can be addressed. Patient comfort and function are assessed. Treatment or the follow-up schedule can be modified.

Deterrence/Prevention

• While preventive strategies for cutaneous melanoma are well known, no such strategies for oral malignant melanoma are known.
• Encourage patients to perform a thorough oral self-examination and to report any abnormal findings to their dentist or physician. Oral lesions that are pigmented, bleed, and have mass should be evaluated early.
• The most significant findings with self-examination are pigmentary changes; however, masses, ulcers, plaques, and altered sensation also are suggestive of malignant melanoma.

Complications

• Complications stem from the loss of anatomic structure as a result of the surgical procedure.
  • The loss can result in prolonged or compromised healing, and the need for tissue grafting or prosthesis fabrication.
  • Grafts can fail, and prostheses can irritate mucosa and supporting tissues.
  • Xerostomia (ie, oral dryness), hypernasal speech, and increased incidence of oral fungal infections are possible effects of surgical treatment.
• INF-A use is associated with malaise, flulike symptoms, fever, and myalgia.
• Patient education and scheduled follow-up visits can minimize the postoperative complications.

Prognosis

• The prognosis for patients with oral malignant melanoma is poor, with the 5-year survival rate at 11-18%.
  • Early recognition and treatment greatly improves the prognosis.
  • Late discovery and diagnosis often indicate the existence of an extensive tumor with metastasis.
  • After surgical ablation, recurrence and metastasis are frequent events, and most patients die of the disease in 2 years.
  • A review of the literature indicates that the 5-year survival rate within a broad range of 4.5-48%, but a large cluster occurs at 10-25%.
• The best option for survival is the prevention of metastasis by surgical excision of any recurrent tumor.
• Eneroth and Lundberg⁹ state that patients are not cured of oral melanoma and that the risk of death always exists. Long periods of remission may be punctuated by sudden and silent recurrence.

Patient Education

• Teach the patient how to perform an effective oral examination.
  • All oral mucosal surfaces available for inspection should be visualized.
  • This examination requires a bit of dexterity and head movement to reflect light appropriately.
  • Adequate oral examination requires good lighting, a mouth mirror, and a 2 X 2-in gauze sponge (and a bathroom mirror for self-inspection).
  • The tongue is retracted and moved from side to side with the 2 X 2-in gauze to achieve an unobstructed view.
• Healthcare practitioners can reinforce this practice at follow-up appointments and ask patients to demonstrate their skill.

Miscellaneous

Medicolegal Pitfalls

• Misdiagnosis and the failure to diagnose are most commonly associated with nonpigmented oral malignant melanomas.
• Clinically, a lesion may be mistaken for a benign pigmented lesion, a reactive process, or an anatomic variation.
  • This mistake can be made especially when the examination is cursory or performed by healthcare providers who are unfamiliar with oral examination.
  • The best advice is to perform a systematic and thorough examination.
• Histologically, amelanotic melanomas require the use of special stains, because of the pathologic mimics. Appropriate immunohistochemical stains or panels can be used to distinguish possible considerations such as lymphoid, epithelial, and neuroendocrine lesions.

Special Concerns

• Historically, oral malignant melanoma was reported to progress more rapidly in pregnant females for unknown reasons. This finding was refuted by Borden,¹⁰ who reiterated that the only reliable prognostic indicator is the stage of the disease at diagnosis and not pregnancy.
• Medical therapy and radiation therapy are necessarily curtailed during pregnancy; however, those treatments usually are not an issue in patients with oral malignant melanoma.
• Surgery during pregnancy is problematic because of the requirements for anesthesia and analgesics.
• The consideration of pregnancy termination or therapeutic abortion is not clearly justified. The decision must rest with the parents, obstetrician-gynecologist, and surgeon responsible for treating the malignancy.

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