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Feline melanoma
© S. H. Smith,
M. H. Goldschmidt and P. M. McManus. A
Comparative Review of Melanocytic Neoplasms.
Vet Pathol 39:651-678 (2002).
http://www.vetpathology.org/cgi/content/full/39/6/651
A diagnosis of melanoma in domestic animals
typically carries a grave prognosis. It is generally detected at a
late stage when excision is rarely curative and metastasis is often
already detectable within regional lymph nodes (LN). In dogs it is a
common diagnosis, accounting for 7% of all malignant tumors.50
It is the most common malignant neoplasm of the oral cavity and
the second most frequent subungual neoplasm.148
In cats it is not as common but carries the same poor prognosis. In
gray horses melanoma is so common as to be considered almost
inevitable.150
In humans the cutaneous form of melanoma is expected to reach an
incidence of 1 in 75 among individuals born in the year 2000.2
Although oral melanoma is not common in humans, accounting for only
1–2% of all melanomas, as in domestic animals, it is generally very
advanced when detected and has only a 5% 5-year survival rate.203
Melanoma is uncommon in cats, accounting for less
than 1% of all feline oral neoplasms90,155,220
and approximately 0.5% of feline skin tumors.32,64,86,182
The ocular and cutaneous forms are generally more common than
melanoma of the oral cavity.57,64,73,182
The most common cutaneous sites are head (Fig.
5), tail, distal extremities,144
and lumbar area.57,89,90,243
The prognosis is generally poor because of recurrence and regional
metastasis in up to half the cases.90,243
In a study of 23 cats with non-ocular melanocytic tumours,
approximately half were malignant, including all the three oral
tumours included in the study.144
In another study, four of the six reported cases of oral melanocytic
tumours were malignant, with metastasis to viscera in one case and
local invasion in three.182
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| Melanoma on medial canthus of
eyelid margin in a cat |
Melanoma. Skin of dorsal skull
between ears; feline. Exophytic, crusted, discrete mass elevating the
epidermis. |
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Oral malignant melanoma, cat. Courtesy of Dr. Ben Colmery III |
Oral malignant melanoma, radiographic appearance, cat. Courtesy of Dr. Ben Colmery III |
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Large soft-tissue mass around the left eye of an adult female Balinese cat. The skin incision had been made prior to presentation in an attempt to lance a suspected abscess.
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Spindle-shaped cells with anisokaryosis, anisocytosis, large prominent nucleoli (arrowheads), and scattered dark cytoplasmic granules (Wright-Giemsa stain). The very dark cell with
cytoplasmic vacuoles (thin arrow) is a melanophage. Bar = 20 μm. |
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Computerized tomography (CT) imaging of a Balinese cat with a large periorbital irregularly contrast-enhancing mass (asterisks), compressing and distorting the left eye, and invading
into the left nasal cavity (arrowheads 1) and nasopharynx (arrowhead 2). The round structures in the mouth are the tracheal tube (large) and esophageal stethoscope (small). |
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Ocular melanoma tends to occur in the anterior
uveal tract, originating within the iris, with one study reporting
over 60% of all feline ocular melanocytic tumors at this site.1,57,182
It typically presents as focal to diffuse iris hyperpigmentation
rather than a discrete nodule or mass.65,123
Glaucoma is a common sequela.65
Melanoma originating in the limbus, conjunctiva, and nictitating
membrane have also been reported, although they are very rare.22,49,199
Harris and Dubielzig (1999)107
have observed an atypical form of feline intraocular melanoma that
arises multifocally in parts of the uveal tract other than the
iris and tends to invade both the globe and the sclera. Ocular
melanomas can be locally infiltrative or may metastasize widely.1,18,182
Some authors have documented a slow growth rate, with a long
latent period between detection of primary ocular tumour and
occurrence of metastatic disease.1,57,65
Others suggest that metastasis can occur in earlier stages, although
this may depend on time of diagnosis and method of treatment.18,182
Melanomas with metastatic behaviour have also been described in the
palpebral area,182
in the nictitans,199
and, although normally benign, in the limbus.22,57
In a study of 34 cats with diffuse iris melanoma, the overall
survival time after enucleation for diffuse iris melanoma was
significantly shortened relative to healthy cats and cats with
enucleation for other reasons.123
Cats with disease confined to the iris stroma and trabecular meshwork
(early disease) had survival times comparable with the controls,
but survival times shortened with invasion into the ciliary
body (moderate disease) and were shorter still with advanced disease.
The age-range is comparable in several surveys,
affecting cats from 2 to 18 years of age but peaking at 8 to 12
years.57,84,86,144,182,243
No sex or breed predilection has been demonstrated.
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Fig. 6. Melanoma. Skin;
canine. The dermal neoplastic cells are fusiform and epithelioid.
Melanocytic hyperplasia is evident in the epidermis, but it is
non-neoplastic. HE. Bar = 40 µm.
Fig. 7. Melanoma. Oral; canine. Pagetoid infiltration of oral
mucosa by individual cells and nests of cells (arrows) and neurotization
of submucosal neoplasm. HE. Bar = 40 µm. |
Criteria of malignancy
Melanoma may be one of the few neoplasms in
animals for which location is an important prognostic indicator in
its own right. Melanocytic neoplasias involving the oral cavity,
subungual region, and mucocutaneous junctions are considered
malignant, regardless of any other single feature.7
Interestingly, this also seems to be the case with oral melanoma in
humans. There is no evident relationship between histologic
characteristics, including mitotic index and pigmentation, and
survival rate.70,190
The prognosis for human melanoma at mucocutaneous junctions and
mucosal surfaces is also grave.203
In animal skin and eye melanocytic neoplasms, the
most reliable histologic feature for distinguishing malignant from
benign is the mitotic index.25,26,35,65,158,254
In the World Health Organization's Histologic Classification of
Epithelial and Melanocytic Skin Tumours of Domestic Animals,88
three or more mitotic figures per 10 high-power fields indicate
malignancy. The identification of mitotic figures in sections must be
undertaken with great care to ensure that only true mitoses are
counted. Bleached sections should be used for pigmented neoplasms to
avoid confusing mitoses with pyknotic nuclei and the small
hyperchromatic nuclei of the spindle cells of the supporting stroma.
The mitotic count will vary from area to area within the neoplasm,
and the count should be performed in areas with the greatest
concentration of mitotic figures. Where metastases have been
confirmed, the mitotic rate in intraocular melanoma is usually
greater than four per 10 high-power fields; less than two mitotic
figures per 10 high-power fields is consistent with a melanocytoma.35,254
In cats the value of mitotic activity to prediction of outcome
is less clear, particularly with regard to ocular melanoma.21,22,65
Some authors, however, report a link between high mitotic index
and increased risk of metastatic disease.57,68
Neoplastic cell morphology is also a useful
discriminating feature.25,69,88
Cytologic features of malignancy include the presence of a large
nucleus, variation in nuclear size and shape, hyperchromasia,
abnormal chromatin clumping, one or more nucleoli, and atypical
mitotic figures.65,86
Additional features favouring malignancy are the presence of
neoplastic cells, individually or in nests, within the upper layers
of the epidermis (Fig. 7),65,86,88
although ulceration and necrosis may prevent evaluation of this
feature. The presence or absence of junctional activity is not
specific to melanoma and often occurs in melanocytomas.
The gold standard is, of course, lymphatic or
vascular invasion.88
Pathologists are often asked to evaluate mandibular LN for evidence
of metastatic disease in dogs with oral melanoma. These nodes
may be pigmented because of metastatic melanoma or the accumulation
of melanophages within the medullary sinuses. The latter occurs when
melanophages are transported to the regional LN after inflammation of
the oral mucosa, particularly in dogs with pigmented oral epithelium.
The cytologic features described above, when used to evaluate
bleached sections, usually suffice to distinguish melanophages from
melanoma.
In cats the following histologic features have
been proposed to be of significance in identifying cutaneous
melanoma: nuclear atypia (neoplasms with more extensive atypia are
more likely to be malignant), mitotic activity (a trend of greater
malignancy with increased numbers of mitoses), and tumour cell type
(with epithelioid more likely to be malignant).89
The relationship with cell type is not firmly established in the
literature, in that two studies indicate a less precise relationship
between cell type and malignant potential.144,155
Furthermore, histologic determination of malignancy does not
consistently correlate with clinical behavior.144
The Callender system has been used historically
to determine malignant potential in canine anterior uveal melanocytic
neoplasms.158,254
This system was designed to predict the behaviour of ocular melanoma
in humans,37
which led to criticisms of its use in the veterinary literature for
two main reasons. Firstly, it was designed for malignant tumours in
humans, and most canine intraocular melanocytic tumours are benign.234,254
Secondly, the morphology of the canine neoplastic melanocytes does
not match the cell descriptions in the Callender classification.35,158,254
Several authors favour a simpler system, dividing intraocular
melanocytic tumours into benign and malignant using well-recognized
cytologic features of malignancy as a basis for this classification.158,254
Despite these controversies, some useful morphologic features can be
used to ascribe malignancy, especially with canine anterior
uveal melanoma. A greater risk of metastasis tends to occur in mixed
and epithelioid cell types.206
Melanocytic neoplasms containing narrow spindle-shaped cells with
small nuclei and no mitotic figures, or plump cells with large
amounts of melanin and small round nuclei, are more likely to be
benign.81
This is in contrast to the cat where cellular pleomorphism, degree
of pigmentation, nuclear to cytoplasmic ratio, and number of
nucleoli bear no relationship to the metastatic behaviour of uveal
melanocytic tumors.68
Tumor size,26,80,105,200
degree of pigmentation, intensity of proliferating cell nuclear
antigen (PCNA)–staining,200
the presence of necrosis, ulceration, or inflammation,26,80,254
and p53 expression201
are of limited prognostic value in animals. Depth of tumour invasion
into the skin is an important criterion in human medicine but is felt
to be too impractical in animals.69
More sophisticated techniques, such as flow cytometry to detect
chromosomal anomalies, offer no real advantage over histology in
predicting tumor behavior.25,112
The value of determination of a proliferative index using MIB-1, a
monoclonal antibody to Ki-67, which identifies proliferating cells,
has been investigated. One study examined 27 canine and feline
melanocytic tumours, eight benign and 19 malignant, to correlate
Ki-67 and PCNA activity with 6-month survival.200
Ki-67 activity correlated very well with poor survival but so did the
presence of invasive growth and classification based on cytologic
criteria. PCNA was significantly higher in malignant neoplasms, but
levels did not demonstrate a strong correlation with poor survival.
In a separate study, MIB-1 was applied to 68 cutaneous canine
melanocytic neoplasms to determine if the level of immunoreactivity
would correlate with 2-year survival. Eighteen of 68 tumours were
classed as malignant histologically. The predictive value of the
Ki-67 index for 2-year survival was 97%, which was only slightly
higher than the predictive value associated with histologic
evaluation (91%).133
Differential diagnosis
Other tumours can look clinically very similar to
melanoma, particularly those arising from the skin. These include
melanocytoma as well as pigmented lesions of the epidermis and
adnexa, e.g., feline basal cell tumours and carcinomas,
trichoblastoma, trichoepithelioma, pilomatricoma, sebaceous, and
apocrine neoplasms. Ceruminous cysts in the feline may be mistaken
for multicentric melanoma of the pinna. Melanocytic hyperplasia
(lentigo simplex) on the lips, eyelids, nose, and gingiva of orange,
cream, and silver cats appear as pigmented macules at these sites.
Hyperpigmented macular lesions clinically resembling melanoma may
occur in the skin in dogs, primarily the abdomen and nipple.
Similarly, epidermal hamartomas (pigmented epidermal nevi, canine
seborrheic keratosis), and dermal hemangioma and hemangiosarcoma can
appear as pigmented cutaneous tumors.87,88
Non-melanocytic neoplasms that commonly arise in
the oral cavity and eye seldom present clinically as pigmented
tumours; therefore, pigmentation is not a distraction.
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