Med Oncol (2015) 32:445 DOI 10.1007/s12032-014-0445-2
SHORT COMMUNICATION
Anorectal malignant melanoma: retrospective analysis of management and outcome in a single Portuguese Institution Isa´lia Miguel • Joa˜o Freire • Maria Jose´ Passos Anto´nio Moreira
•
Received: 6 December 2014 / Accepted: 7 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Anorectal melanoma is an uncommon cancer with a poor prognosis. We aim to describe the clinical presentation, treatment and outcome of patients with anorectal melanoma in our center. Retrospective study of patients with anorectal melanoma treated between 2000 and 2011 at a cancer center in Lisbon. Ten patients were identified, eight females and two males, with median age 70.5 years (32–79). Symptoms at presentation were rectal bleeding (8), anal pain (4) and discomfort (3). Tumor location was anal (6), rectal (3) and anorectal transition (2). Seven patients had surgery: abdomino-pelvic resection (5) and local resection (2). Among the two patients who underwent local resection, one was an incidental finding in a hemorrhoidectomy specimen. This patient had further adjuvant chemotherapy (dacarbazine). Three patients had distant metastasis at diagnosis, one had chemotherapy and two had best supportive care. Six of the seven operated patients relapsed in a median time of 5.4 months: distant metastasis (4), local recurrence (1), both (1). The two local relapse patients had surgical widening of resection margins (1) and radiotherapy (2). One-year survival was 30 %; 3-year survival was 20 %. Anorectal melanoma has a poor prognosis due to advanced disease at presentation and aggressive course, with relapse in almost all operated patients. Treatment guidelines have not been established due to the lack of randomized studies. However, recent studies show that sphincter-sparing surgical procedures along with low dose intensity radiotherapy seem to achieve a local control similar to abdomino-pelvic resection. No systemic therapy is considered standard of care for
I. Miguel (&) J. Freire M. J. Passos A. Moreira Servic¸o de Oncologia Me´dica, Instituto Portugueˆs de Oncologia de Lisboa Francisco Gentil, EPE, Rua Prof. Lima Basto, sn, 1077-100 Lisbon, Portugal e-mail: [email protected]
advanced disease, and regimens are extrapolated from cutaneous melanoma experience. Keywords Anorectal melanoma Anal canal Rectum Melanoma Treatment
Introduction Anorectal melanoma (ARM) is an uncommon and aggressive neoplasia [1–4] that was firstly reported by Moore in 1857 [2]. Although it only accounts for 0.4–1.6 % of all melanoma cases, it is the third most common location after skin and choroid [2, 3]. It represents 1 % of all tumors arising in the anal canal [1, 2]. Diagnosis is more common between the age of 50 and 70 years and predominates in females [1–7]. Presentation symptoms often include rectal bleeding, perineal or anal pain, anal discomfort, tenesmus, fecal incontinence or bowel habit change [2–5]. Surgery remains the treatment of choice, but the best procedure is still controversial and can vary from local excision to more radical approaches as in abdomino-perineal resection (APR) [3]. Although APR was considered the best initial treatment for ARM, recent studies do not report a difference in survival between conservative and radical procedures for the treatment of locoregional disease [6, 7]. There is still controversy regarding the benefit of radiation therapy and chemotherapy [2, 8–10].
Materials and methods Retrospective review of the clinical notes of patients treated for malignant ARM at a cancer center in Lisbon between
123
123
1.6 –
Dead
Rectal #, 71
RT radiotherapy, BSC best supportive care, CNS central nervous system
– BSC (2000)
Rectal $, 68
IV (Liver ? lung)
1.6 – – BSC (2006)
Rectal and transition $, 65
IV (CNS)
3.4 – – Dacarbazine (2003)
Anal $, 32
IV (Liver)
7.6 BSC Local ? liver ? peritoneum (5 months) Resection (hemorrhoid surgery) ? dacarbazine (2008)
Anal $, 76
III
Hepatic metastasectomy BSC
BSC
Liver (1 month) Lung (6.5 months) Abdomino-perineal resection (2002)
Anal $, 65
III
Bone (10 months)
11
11.6 RT Regional (5.7 months) Abdomino-perineal resection (2002)
Anal $, 79
III
3.5 BSC Liver (2.8 months) Abdomino-perineal resection (2004)
Anal $, 78
III
137 – – Abdomino-perineal resection (2001)
80
Anorectal transition #, 71
III
BSC
Local resection ? adjuvant RT Local (2.5 months)
Lung (13.6 months) Abdomino-perineal resection (2011)
Local resection (2006) Anal $, 69
III
Initial treatment (year of treatment) Stage at dx (Mx location) Tumor location
ARM is an infrequent neoplasia. ARM is more frequently located on the anal canal or margin in 65 % of cases, and distal rectum in 35 % [1], which is in line with our results. In our case series, the female/male ratio was 4:1 and age at diagnosis was higher than in other series, probably due to a late diagnosis. Clinical manifestations are non-specific and contribute to a delayed recognition. Most frequent complaints are
Patient (gender, age)
Discussion
Table 1 Clinical, treatment and outcome characteristics of ARM patients
Ten patients treated at our center for ARM were analyzed. Patient’s demographics are outlined in Table 1. Eight patients were females (80 %), and median age was 70.5 years (min 32; max 79). Main symptoms at presentation were rectal bleeding (8), anal pain (4), anal discomfort (3) and rectal tenesmus (1). Diagnosis was made based upon endoscopic examination and biopsy in nine patients; one patient was incidentally diagnosed by histopathology examination following a surgical procedure for hemorrhoids. Tumor location was anal canal (6), rectum (3) and anorectal transition (2). Surgical resection was performed as initial treatment in 60 %, APR in five patients and local resection in one case. A young patient was treated with adjuvant dacarbazine after a hemorrhoid surgery. Three patients had distant metastasis at diagnosis, and surgery was not indicated; one case had palliative chemotherapy (dacarbazine). Relapse occurred in six patients, at a median time of 5.4 months. One patient, previously treated with local resection, experienced a local relapse and underwent widening of the surgical resection margin and RT (external beam radiation, 60 Gy cumulative dose) and remains without disease. Another patient had a regional relapse, after having had APR, and was offered palliative radiotherapy (40 Gy) due to comorbidities. Distant metastasis occurred in five patients (liver—3, lung—2, peritoneum—1, bone—1). Cumulative survival is shown in Fig. 1. One-year survival was 30 %, and 3-year survival was 20 %.
Relapse location (time to relapse)
Results
II
Relapse treatment
2000 and 2011. Five patients with incomplete records or transferred to other centers were excluded. Data on clinical presentation, diagnosis, relapse and management were reviewed. One- and 3-year survival was assessed. Statistical analysis was performed using SPSS for Windows v17.0. We used Kaplan–Meier methods to assess survival.
25.7
Med Oncol (2015) 32:445 Survival (months)
445 Page 2 of 4
Med Oncol (2015) 32:445
Fig. 1 Cumulative survival (months) of ARM patients
rectal bleeding and pain. These symptoms can easily be mistaken with other benign diseases such as hemorrhoids, as in one of our patients, which stresses the need to perform a histological evaluation in this situation. ARM remains an aggressive neoplasm, and advanced disease occurred at presentation in 30 % of our cases. This carries a very poor prognosis. Dissemination may occur via hematogenous or lymphatic spread. Anal canal lesions tend to spread to inguinal lymph nodes, and rectum lesions to pelvic nodes [7]. Lymph node involvement is frequently associated with development of distant metastasis. The most common metastatic sites are lungs and liver [7, 11], as observed in 60 % of our patients. Due to its rarity, ARM management is based upon retrospective and small case series reviews. Surgical management is still in discussion [3, 9, 10] and is based on local excision or radical surgery procedures such as APR. Traditionally, APR was considered the best option for ARM due to its alleged superior rate of local control [12]. However, despite the absence of prospective studies, increasing evidence suggests that local excision provides comparable survival outcomes with less perioperative morbidity [3, 4, 6, 7, 13]. Moreover, this sphincter-sparing approach may benefit the patient’s quality of life. Nevertheless, the rates of local recurrence after local excision range are between 26 and 65 % [7, 12], although it does not affect long-term survival [3, 4, 6, 7, 12, 13]. Hypofractionated RT has been proposed as a well-tolerated adjuvant treatment to improve local control rates after local excision in one study, with local recurrence occurring in 17 % and sphincter preservation in 96 %, even though overall survival remained similar to other series [7]. In our case series, one patient with local relapse was treated with a wider margin excision and RT with no further disease after 80 months of follow-up. Adjuvant RT has also
Page 3 of 4 445
been used in patients with lymphatic disease and with very high risk of lymphatic involvement or recurrence [7], and in the palliative setting. Overall survival rates at 5 years for ARM vary between 10 and 30 %, and have remained unchanged in recent decades [1, 7, 14, 15]. Because prognosis of ARM is determined by the presence of distant disease, systemic therapies may have an important role in reducing the risk of distant metastasis. Nowadays, the use of chemotherapy and immunotherapy in ARM is extrapolated from its use in cutaneous melanoma, and no specific regimen has demonstrated a significant survival benefit. In our series, dacarbazine was used in the adjuvant setting for a young patient whose diagnosis was made after a hemorrhoid surgical procedure, and in the palliative setting for a fit patient with liver metastasis, with no success in disease control. New trials involving all mucosal melanomas should provide new insights in this area [1]. In conclusion, ARM is rare and has a poor prognosis due to the fast progression of advanced disease. Standard treatment guidelines have not been established due to the lack of randomized clinical trials. However, sphinctersparing surgical procedures along with low dose intensity RT seem to achieve a comparable local control to APR, carrying less morbidity and with no difference in survival. Future research should focus on molecular mechanisms of progression in order to guide new therapy options. Conflict of interest
The authors declare no conflicts of interest.
References 1. Bello DM, Smythy E, Perez D, Khan S, Temple LK, Ariyan CE, Weiser MR, Carvajal RD. Anal versus rectal melanoma: does site of origin predict outcome? Dis Colon Rectum. 2013;56(2):150–7. 2. Parra RS, Almeida AL, Badiale GB, Moraes MM, Rocha JJ, Fe´res O. Melanoma of the anal canal. Clinics (Sa˜o Paulo). 2010;65(10):1063–5. 3. Belli F, Gallino GF, Lo Vullo S, Mariani L, Poiasina E, Leo E. Melanoma of the anorectal region: the experience of the National Cancer Institute of Milano. Eur J Surg Oncol. 2009;35(2):757–62. 4. Hai-tao Z, Zhi-xiang Z, Hai-zeng Z, Jian-jun B, Ping Z. Wide local excision could be considered as the initial treatment of primary anorectal malignant melanoma. Chin Med J. 2010;123(5):585–8. 5. Coi BM, Kim HR, Yun HR, Choi SH, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK. Treatment outcomes of anorectal melanoma. J Korean Soc Coloproctol. 2011;27(1):27–30. 6. Kiran RP, Rottoli M, Pokala N, Fazio VW. Long-term outcomes after local excision and radical surgery for anal melanoma: data from a population database. Dis Colon Rectum. 2010;53:402–8. 7. Kelly P, Zagars GK, Comier JN, Ross MI, Guadagnolo BA. Shincter-sparing local excision and hypofractioned radiation therapy for anorectal melanoma. Cancer. 2011;117(20):4747–55. 8. Homsi J, Garrett C. Melanoma of the anal canal: a case series. Dis Colon Rectum. 2007;50(7):1004–10.
123
445 Page 4 of 4 9. Meguerditchian AN, Meterissian SH, Dunn KB. Anorectal melanoma: diagnosis and treatment. Dis Colon Rectum. 2011;54(5): 638–44. 10. Nam S, Kim CW, Baek SJ, Hur H, Min BS, Baik SH, Kim NK. The clinical features and optimal treatment of anorectal malignant melanoma. Ann Surg Treat Res. 2014;87(3):113–7. 11. Stoidis CN, Spyropoulos BG, Misiakos EP, Fountzilas CK, Paraskeva PP, Fotiadis AC. Diffuse anorectal melanoma; review of the current diagnostic and treatment aspects based on a case report. World J Surg Oncol. 2009;7:64. doi:10.1186/1477-78197-64. 12. Yeh JJ, Shia J, Hwu WJ, Busam KJ, Paty PB, Guillem JG, Coit DG, Wong WD, Weiser MR. The role of abdominoperineal resection as surgical therapy for anorectal melanoma. Ann Surg. 2006;244(6):1012–7.
123
Med Oncol (2015) 32:445 13. Ling TC, Slater JM, Senthil M, Kazanjian K, Howard F, Gaberoglio CA, Slater JD, Yang GY. Surgical and radiation therapy management of recurrent anal melanoma. J Gastrointest Oncol. 2014;5(1):E7–12. 14. Kohli S, Narang S, Singhal A, Kumar V, Kaur O, Chandoke R. Malignant melanoma of the rectum. J Clin Imaging Sci. 2014;4:4. doi:10.4103/2156-7514.126031. 15. Ragnarsson-Olding BK, Nilsson PJ, Olding LB, Nilsson BR. Primary ano-rectal malignant melanomas within a populationbased national patient series in Sweden during 40 years. Acta Oncol. 2009;48(1):125–31.
SHORT COMMUNICATION
Anorectal malignant melanoma: retrospective analysis of management and outcome in a single Portuguese Institution Isa´lia Miguel • Joa˜o Freire • Maria Jose´ Passos Anto´nio Moreira
•
Received: 6 December 2014 / Accepted: 7 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Anorectal melanoma is an uncommon cancer with a poor prognosis. We aim to describe the clinical presentation, treatment and outcome of patients with anorectal melanoma in our center. Retrospective study of patients with anorectal melanoma treated between 2000 and 2011 at a cancer center in Lisbon. Ten patients were identified, eight females and two males, with median age 70.5 years (32–79). Symptoms at presentation were rectal bleeding (8), anal pain (4) and discomfort (3). Tumor location was anal (6), rectal (3) and anorectal transition (2). Seven patients had surgery: abdomino-pelvic resection (5) and local resection (2). Among the two patients who underwent local resection, one was an incidental finding in a hemorrhoidectomy specimen. This patient had further adjuvant chemotherapy (dacarbazine). Three patients had distant metastasis at diagnosis, one had chemotherapy and two had best supportive care. Six of the seven operated patients relapsed in a median time of 5.4 months: distant metastasis (4), local recurrence (1), both (1). The two local relapse patients had surgical widening of resection margins (1) and radiotherapy (2). One-year survival was 30 %; 3-year survival was 20 %. Anorectal melanoma has a poor prognosis due to advanced disease at presentation and aggressive course, with relapse in almost all operated patients. Treatment guidelines have not been established due to the lack of randomized studies. However, recent studies show that sphincter-sparing surgical procedures along with low dose intensity radiotherapy seem to achieve a local control similar to abdomino-pelvic resection. No systemic therapy is considered standard of care for
I. Miguel (&) J. Freire M. J. Passos A. Moreira Servic¸o de Oncologia Me´dica, Instituto Portugueˆs de Oncologia de Lisboa Francisco Gentil, EPE, Rua Prof. Lima Basto, sn, 1077-100 Lisbon, Portugal e-mail: [email protected]
advanced disease, and regimens are extrapolated from cutaneous melanoma experience. Keywords Anorectal melanoma Anal canal Rectum Melanoma Treatment
Introduction Anorectal melanoma (ARM) is an uncommon and aggressive neoplasia [1–4] that was firstly reported by Moore in 1857 [2]. Although it only accounts for 0.4–1.6 % of all melanoma cases, it is the third most common location after skin and choroid [2, 3]. It represents 1 % of all tumors arising in the anal canal [1, 2]. Diagnosis is more common between the age of 50 and 70 years and predominates in females [1–7]. Presentation symptoms often include rectal bleeding, perineal or anal pain, anal discomfort, tenesmus, fecal incontinence or bowel habit change [2–5]. Surgery remains the treatment of choice, but the best procedure is still controversial and can vary from local excision to more radical approaches as in abdomino-perineal resection (APR) [3]. Although APR was considered the best initial treatment for ARM, recent studies do not report a difference in survival between conservative and radical procedures for the treatment of locoregional disease [6, 7]. There is still controversy regarding the benefit of radiation therapy and chemotherapy [2, 8–10].
Materials and methods Retrospective review of the clinical notes of patients treated for malignant ARM at a cancer center in Lisbon between
123
123
1.6 –
Dead
Rectal #, 71
RT radiotherapy, BSC best supportive care, CNS central nervous system
– BSC (2000)
Rectal $, 68
IV (Liver ? lung)
1.6 – – BSC (2006)
Rectal and transition $, 65
IV (CNS)
3.4 – – Dacarbazine (2003)
Anal $, 32
IV (Liver)
7.6 BSC Local ? liver ? peritoneum (5 months) Resection (hemorrhoid surgery) ? dacarbazine (2008)
Anal $, 76
III
Hepatic metastasectomy BSC
BSC
Liver (1 month) Lung (6.5 months) Abdomino-perineal resection (2002)
Anal $, 65
III
Bone (10 months)
11
11.6 RT Regional (5.7 months) Abdomino-perineal resection (2002)
Anal $, 79
III
3.5 BSC Liver (2.8 months) Abdomino-perineal resection (2004)
Anal $, 78
III
137 – – Abdomino-perineal resection (2001)
80
Anorectal transition #, 71
III
BSC
Local resection ? adjuvant RT Local (2.5 months)
Lung (13.6 months) Abdomino-perineal resection (2011)
Local resection (2006) Anal $, 69
III
Initial treatment (year of treatment) Stage at dx (Mx location) Tumor location
ARM is an infrequent neoplasia. ARM is more frequently located on the anal canal or margin in 65 % of cases, and distal rectum in 35 % [1], which is in line with our results. In our case series, the female/male ratio was 4:1 and age at diagnosis was higher than in other series, probably due to a late diagnosis. Clinical manifestations are non-specific and contribute to a delayed recognition. Most frequent complaints are
Patient (gender, age)
Discussion
Table 1 Clinical, treatment and outcome characteristics of ARM patients
Ten patients treated at our center for ARM were analyzed. Patient’s demographics are outlined in Table 1. Eight patients were females (80 %), and median age was 70.5 years (min 32; max 79). Main symptoms at presentation were rectal bleeding (8), anal pain (4), anal discomfort (3) and rectal tenesmus (1). Diagnosis was made based upon endoscopic examination and biopsy in nine patients; one patient was incidentally diagnosed by histopathology examination following a surgical procedure for hemorrhoids. Tumor location was anal canal (6), rectum (3) and anorectal transition (2). Surgical resection was performed as initial treatment in 60 %, APR in five patients and local resection in one case. A young patient was treated with adjuvant dacarbazine after a hemorrhoid surgery. Three patients had distant metastasis at diagnosis, and surgery was not indicated; one case had palliative chemotherapy (dacarbazine). Relapse occurred in six patients, at a median time of 5.4 months. One patient, previously treated with local resection, experienced a local relapse and underwent widening of the surgical resection margin and RT (external beam radiation, 60 Gy cumulative dose) and remains without disease. Another patient had a regional relapse, after having had APR, and was offered palliative radiotherapy (40 Gy) due to comorbidities. Distant metastasis occurred in five patients (liver—3, lung—2, peritoneum—1, bone—1). Cumulative survival is shown in Fig. 1. One-year survival was 30 %, and 3-year survival was 20 %.
Relapse location (time to relapse)
Results
II
Relapse treatment
2000 and 2011. Five patients with incomplete records or transferred to other centers were excluded. Data on clinical presentation, diagnosis, relapse and management were reviewed. One- and 3-year survival was assessed. Statistical analysis was performed using SPSS for Windows v17.0. We used Kaplan–Meier methods to assess survival.
25.7
Med Oncol (2015) 32:445 Survival (months)
445 Page 2 of 4
Med Oncol (2015) 32:445
Fig. 1 Cumulative survival (months) of ARM patients
rectal bleeding and pain. These symptoms can easily be mistaken with other benign diseases such as hemorrhoids, as in one of our patients, which stresses the need to perform a histological evaluation in this situation. ARM remains an aggressive neoplasm, and advanced disease occurred at presentation in 30 % of our cases. This carries a very poor prognosis. Dissemination may occur via hematogenous or lymphatic spread. Anal canal lesions tend to spread to inguinal lymph nodes, and rectum lesions to pelvic nodes [7]. Lymph node involvement is frequently associated with development of distant metastasis. The most common metastatic sites are lungs and liver [7, 11], as observed in 60 % of our patients. Due to its rarity, ARM management is based upon retrospective and small case series reviews. Surgical management is still in discussion [3, 9, 10] and is based on local excision or radical surgery procedures such as APR. Traditionally, APR was considered the best option for ARM due to its alleged superior rate of local control [12]. However, despite the absence of prospective studies, increasing evidence suggests that local excision provides comparable survival outcomes with less perioperative morbidity [3, 4, 6, 7, 13]. Moreover, this sphincter-sparing approach may benefit the patient’s quality of life. Nevertheless, the rates of local recurrence after local excision range are between 26 and 65 % [7, 12], although it does not affect long-term survival [3, 4, 6, 7, 12, 13]. Hypofractionated RT has been proposed as a well-tolerated adjuvant treatment to improve local control rates after local excision in one study, with local recurrence occurring in 17 % and sphincter preservation in 96 %, even though overall survival remained similar to other series [7]. In our case series, one patient with local relapse was treated with a wider margin excision and RT with no further disease after 80 months of follow-up. Adjuvant RT has also
Page 3 of 4 445
been used in patients with lymphatic disease and with very high risk of lymphatic involvement or recurrence [7], and in the palliative setting. Overall survival rates at 5 years for ARM vary between 10 and 30 %, and have remained unchanged in recent decades [1, 7, 14, 15]. Because prognosis of ARM is determined by the presence of distant disease, systemic therapies may have an important role in reducing the risk of distant metastasis. Nowadays, the use of chemotherapy and immunotherapy in ARM is extrapolated from its use in cutaneous melanoma, and no specific regimen has demonstrated a significant survival benefit. In our series, dacarbazine was used in the adjuvant setting for a young patient whose diagnosis was made after a hemorrhoid surgical procedure, and in the palliative setting for a fit patient with liver metastasis, with no success in disease control. New trials involving all mucosal melanomas should provide new insights in this area [1]. In conclusion, ARM is rare and has a poor prognosis due to the fast progression of advanced disease. Standard treatment guidelines have not been established due to the lack of randomized clinical trials. However, sphinctersparing surgical procedures along with low dose intensity RT seem to achieve a comparable local control to APR, carrying less morbidity and with no difference in survival. Future research should focus on molecular mechanisms of progression in order to guide new therapy options. Conflict of interest
The authors declare no conflicts of interest.
References 1. Bello DM, Smythy E, Perez D, Khan S, Temple LK, Ariyan CE, Weiser MR, Carvajal RD. Anal versus rectal melanoma: does site of origin predict outcome? Dis Colon Rectum. 2013;56(2):150–7. 2. Parra RS, Almeida AL, Badiale GB, Moraes MM, Rocha JJ, Fe´res O. Melanoma of the anal canal. Clinics (Sa˜o Paulo). 2010;65(10):1063–5. 3. Belli F, Gallino GF, Lo Vullo S, Mariani L, Poiasina E, Leo E. Melanoma of the anorectal region: the experience of the National Cancer Institute of Milano. Eur J Surg Oncol. 2009;35(2):757–62. 4. Hai-tao Z, Zhi-xiang Z, Hai-zeng Z, Jian-jun B, Ping Z. Wide local excision could be considered as the initial treatment of primary anorectal malignant melanoma. Chin Med J. 2010;123(5):585–8. 5. Coi BM, Kim HR, Yun HR, Choi SH, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK. Treatment outcomes of anorectal melanoma. J Korean Soc Coloproctol. 2011;27(1):27–30. 6. Kiran RP, Rottoli M, Pokala N, Fazio VW. Long-term outcomes after local excision and radical surgery for anal melanoma: data from a population database. Dis Colon Rectum. 2010;53:402–8. 7. Kelly P, Zagars GK, Comier JN, Ross MI, Guadagnolo BA. Shincter-sparing local excision and hypofractioned radiation therapy for anorectal melanoma. Cancer. 2011;117(20):4747–55. 8. Homsi J, Garrett C. Melanoma of the anal canal: a case series. Dis Colon Rectum. 2007;50(7):1004–10.
123
445 Page 4 of 4 9. Meguerditchian AN, Meterissian SH, Dunn KB. Anorectal melanoma: diagnosis and treatment. Dis Colon Rectum. 2011;54(5): 638–44. 10. Nam S, Kim CW, Baek SJ, Hur H, Min BS, Baik SH, Kim NK. The clinical features and optimal treatment of anorectal malignant melanoma. Ann Surg Treat Res. 2014;87(3):113–7. 11. Stoidis CN, Spyropoulos BG, Misiakos EP, Fountzilas CK, Paraskeva PP, Fotiadis AC. Diffuse anorectal melanoma; review of the current diagnostic and treatment aspects based on a case report. World J Surg Oncol. 2009;7:64. doi:10.1186/1477-78197-64. 12. Yeh JJ, Shia J, Hwu WJ, Busam KJ, Paty PB, Guillem JG, Coit DG, Wong WD, Weiser MR. The role of abdominoperineal resection as surgical therapy for anorectal melanoma. Ann Surg. 2006;244(6):1012–7.
123
Med Oncol (2015) 32:445 13. Ling TC, Slater JM, Senthil M, Kazanjian K, Howard F, Gaberoglio CA, Slater JD, Yang GY. Surgical and radiation therapy management of recurrent anal melanoma. J Gastrointest Oncol. 2014;5(1):E7–12. 14. Kohli S, Narang S, Singhal A, Kumar V, Kaur O, Chandoke R. Malignant melanoma of the rectum. J Clin Imaging Sci. 2014;4:4. doi:10.4103/2156-7514.126031. 15. Ragnarsson-Olding BK, Nilsson PJ, Olding LB, Nilsson BR. Primary ano-rectal malignant melanomas within a populationbased national patient series in Sweden during 40 years. Acta Oncol. 2009;48(1):125–31.
