Scientific letter
Anorectal melanoma: An atypical cause of rectorrhagia
Causa atípica de rectorragia: melanoma anorrectal
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(C) Estenosis ileal ulcerada e infranqueable durante la enteroscopia con cápsula.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Francisco Juanmartiñena Fernández, Iñaki Fernández-Urién, Rosa Iglesias Picazo, María Rosario Aznárez Barrio, Marta Montes Díaz, Alba Cebrian García, Juan José Vila Costas" "autores" => array:7 [ 0 => array:2 [ "nombre" => "José Francisco" "apellidos" => "Juanmartiñena Fernández" ] 1 => array:2 [ "nombre" => "Iñaki" "apellidos" => "Fernández-Urién" ] 2 => array:2 [ "nombre" => "Rosa" "apellidos" => "Iglesias Picazo" ] 3 => array:2 [ "nombre" => "María Rosario" "apellidos" => "Aznárez Barrio" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "Montes Díaz" ] 5 => array:2 [ "nombre" => "Alba" "apellidos" => "Cebrian García" ] 6 => array:2 [ "nombre" => "Juan José" "apellidos" => "Vila Costas" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382417301578" "doi" => "10.1016/j.gastre.2016.07.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382417301578?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570516301224?idApp=UINPBA00004N" "url" => "/02105705/0000004000000009/v1_201710270226/S0210570516301224/v1_201710270226/es/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Anorectal melanoma: An atypical cause of rectorrhagia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "623" "paginaFinal" => "625" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristina Saldaña Dueñas, Silvia Goñi Esarte, Jose Francisco Juanmartiñena Fernández, Marta Montes Diaz, Rosa Iglesias Picazo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Cristina" "apellidos" => "Saldaña Dueñas" "email" => array:1 [ 0 => "crisaldu@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Silvia" "apellidos" => "Goñi Esarte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Jose Francisco" "apellidos" => "Juanmartiñena Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Marta" "apellidos" => "Montes Diaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Rosa" "apellidos" => "Iglesias Picazo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Digestive Department, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Causa atípica de rectorragia: melanoma anorrectal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 656 "Ancho" => 1600 "Tamanyo" => 416010 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Histology image of the biopsies with medium size epithelioid cells with plasmacytoid habit and (B) the immunophenotype positive to Melan A.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of an 81-year-old man with previous diagnose of hypercholesterolemia, benign prostate hyperplasia and seborrheic keratosis. He presented a two-months history of rectorrhagia episodes without any other symptoms. In the laboratory tests there was no anemia and the tumor markers were negative. A rectoscopy was performed identifying from the anus to 6<span class="elsevierStyleHsp" style=""></span>cm beyond the dental line a pseudo-polyp mameloned tumor with hyperpigmented base evolving a quarter of the whole circumference of the rectum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The biopsies showed extended small round cells proliferation with necrosis. Neither melanic pigment nor mucosa was observed probably because superficial biopses where taken on the surface of the tumor. The immunophenotype was negative to S-100 and positive to Melan-A and MITF (microphthalmia-associated transcription factor) so the diagnose of a rectal melanoma was performed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B). The study was completed with colonoscopy (three adenomatous polyps were removed), pelvic magnetic resonance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and computed tomography of the thorax and abdomen without mesorectal lymph nodes or distal metastasis. The case was presented in the multidisciplinary comity and a surgical approach was chosen. An endoanal resection was performed, because of the absence of distal or local invasion and the patient age and comorbility, without complications. The surgical piece showed deep infiltration even throws muscular propia, an ulcerated mucosa and the presence of melanophages. The patient remains asymptomatic and with good quality of life.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Mucosal melanomas (MM) are rare (0.4–1.6% of total malignant melanomas). Both cutaneous and mucosal melanomas contain melanocytes, but have important differences such as the exposure of ultraviolet light (clearly related with cutaneous melanoma), localization, appearance (40% in MM are amelanotic) age of presentation and prognosis (poorly in the case of MM).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The anus is the third most common location of melanomas after the skin and the eyes.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,3,4</span></a> MM arise primarily in the head and neck (55%), anorectal (24%) and vulvovaginal (18%) regions and are in 20% of cases multifocal.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,3,5</span></a> They are frequently found within 6<span class="elsevierStyleHsp" style=""></span>cm of the anal rim: rectum (42%), anal canal (33%) or both. Other infrequent sites include urinary tract, gall bladder and small intestine. The median age of presentation is 70 years (except those located in oral cavity found in younger people). There is a female preponderance of cases and HIV infection has been implicated as a risk factor for anal localization in young male patients.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2,6</span></a> The incidence of anorectal melanoma (AM) increases over time, and it remains highly lethal, with a 5-year survival rate of 6% to 22%. The simplified staging system which was originally developed for melanomas of the head and neck in 1970 by Ballantyne is used for the primary site including three stages Stage I: Localized disease; Stage II: Locoregional nodal involvement and Stage III: distant metastatic involvement.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> The most common presenting symptoms are nonspecific and include rectal bleeding followed by pain, the sensation of a mass, constipation, diarrhea, abdominal pain, weight loss, and tenesmus. All of them present in such common conditions as are hemorrhoids, rectal polyp or prolapse. As the diagnose is usually late the tumors may attain a large size before being correctly diagnosed. Metastases are present at the time of diagnosis in more than half of patients.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,4,5,7-9</span></a> Although melanomas develop throughout the anus, two thirds arise in the proximal portion of the pecten and transitional zone around the dentate line (within 6<span class="elsevierStyleHsp" style=""></span>cm of the anal rim). Twenty to fifty percent of tumors are pigmented but others remain amelanotic.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2</span></a> Histologically the cells are often large with an epithelioid appearance and finely distributed pigment giving the cytoplasm a dusty-tan appearance. We can find large hyperchromatic nuclei with well-dispersed chromatin, multinucleated and polymorphic giant cells. Some melanomas (small round cell melanomas) contain atypical round cells resembling lymphocytes. Intraepithelial extensions of malignant melanoma may be confused with Paget disease. Immunohistochemistry studies can be useful, as AM stains positive for anti S-100 protein, HMB-45 (as the S-100 is a monoclonal antibody, HMB-45 that reacts against an antigen present in melanocytic tumors such as melanomas, and stands for human melanoma black 45) and Melan-A, while are usually negative for AE1/AE3 cytokeratines.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A correct diagnose includes radiological exams including tomography scan (for the evaluation of distal dissemination), magnetic resonance (for local evolving) and even endoscopic procedures such as ecoendoscopy for a detailed examination of the area in order to a better surgical approach.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the rarity of this neoplasia, optimal treatment is still controversial and surgery seems to be the only curative treatment. Surgical approaches include wide local excision (WLE) and abdominoperineal resection (APR), although no one has demonstrated survival advantage. However with the wide and complete resection (R0 oncological criteria) the surveillance of patients for 5 years rounds the 19% in contrast to the 6% if the margins are affected.<span class="elsevierStyleSup">7,</span><a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,10,11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">WLE is the procedure of choice when the complete excision of the tumor is possible, as it is accompanied by a less morbidity rate and less functional limitations. In contrast, it presents higher rates of local recurrence. If is not possible the complete excision with WLE, in this situation, APR and local radiotherapy may improve loco-regional control, despite a lack of demonstrable impact upon overall survival.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8–11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, primary anorectal melanoma is an extremely rare and aggressive malignancy with poor prognosis that it is often misdiagnosed. High suspicious is mandatory to achieve early-diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,8,9</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 900 "Ancho" => 1600 "Tamanyo" => 208820 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Endoscopic image with a pseudo polyp mameloned tumor with hyperpigmented base and (B) the corresponding image in the magnetic resonance identifying a round hipointense tumor in the rectum.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 656 "Ancho" => 1600 "Tamanyo" => 416010 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Histology image of the biopsies with medium size epithelioid cells with plasmacytoid habit and (B) the immunophenotype positive to Melan A.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comparative study of melanoma and epidermoid carcinoma of the anal canal: a review of 20 melanomas and 29 epidermoid carcinomas (1930 to 1965)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 14 | 2 | 16 |
| 2024 September | 22 | 6 | 28 |
| 2024 August | 20 | 6 | 26 |
| 2024 July | 15 | 2 | 17 |
| 2024 June | 23 | 1 | 24 |
| 2024 May | 16 | 6 | 22 |
| 2024 April | 19 | 8 | 27 |
| 2024 March | 46 | 3 | 49 |
| 2024 February | 46 | 3 | 49 |
| 2024 January | 62 | 2 | 64 |
| 2023 December | 50 | 3 | 53 |
| 2023 November | 56 | 3 | 59 |
| 2023 October | 77 | 5 | 82 |
| 2023 September | 31 | 1 | 32 |
| 2023 August | 13 | 1 | 14 |
| 2023 July | 21 | 6 | 27 |
| 2023 June | 42 | 2 | 44 |
| 2023 May | 53 | 0 | 53 |
| 2023 April | 52 | 5 | 57 |
| 2023 March | 46 | 6 | 52 |
| 2023 February | 50 | 6 | 56 |
| 2023 January | 34 | 5 | 39 |
| 2022 December | 26 | 19 | 45 |
| 2022 November | 27 | 12 | 39 |
| 2022 October | 25 | 22 | 47 |
| 2022 September | 30 | 9 | 39 |
| 2022 August | 20 | 20 | 40 |
| 2022 July | 30 | 16 | 46 |
| 2022 June | 26 | 23 | 49 |
| 2022 May | 28 | 24 | 52 |
| 2022 April | 39 | 28 | 67 |
| 2022 March | 59 | 30 | 89 |
| 2022 February | 48 | 8 | 56 |
| 2022 January | 74 | 12 | 86 |
| 2021 December | 50 | 16 | 66 |
| 2021 November | 40 | 12 | 52 |
| 2021 October | 72 | 11 | 83 |
| 2021 September | 56 | 12 | 68 |
| 2021 August | 35 | 7 | 42 |
| 2021 July | 18 | 3 | 21 |
| 2021 June | 27 | 12 | 39 |
| 2021 May | 29 | 3 | 32 |
| 2021 April | 84 | 15 | 99 |
| 2021 March | 60 | 32 | 92 |
| 2021 February | 27 | 14 | 41 |
| 2021 January | 22 | 7 | 29 |
| 2020 December | 11 | 10 | 21 |
| 2020 November | 16 | 6 | 22 |
| 2020 October | 14 | 6 | 20 |
| 2020 September | 17 | 7 | 24 |
| 2020 August | 23 | 8 | 31 |
| 2020 July | 29 | 13 | 42 |
| 2020 June | 14 | 14 | 28 |
| 2020 May | 14 | 9 | 23 |
| 2020 April | 14 | 1 | 15 |
| 2020 March | 14 | 7 | 21 |
| 2020 February | 16 | 4 | 20 |
| 2020 January | 13 | 7 | 20 |
| 2019 December | 27 | 10 | 37 |
| 2019 November | 16 | 10 | 26 |
| 2019 March | 1 | 2 | 3 |
| 2019 January | 1 | 2 | 3 |
| 2018 August | 3 | 1 | 4 |
| 2018 July | 2 | 0 | 2 |
| 2018 June | 1 | 0 | 1 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 3 | 0 | 3 |
| 2018 March | 5 | 0 | 5 |
| 2018 February | 3 | 0 | 3 |
| 2018 January | 2 | 0 | 2 |
| 2017 December | 4 | 1 | 5 |
| 2017 November | 42 | 25 | 67 |
| 2017 October | 2 | 0 | 2 |
| 2016 October | 0 | 1 | 1 |
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