Significance of follow-up surveillance in oral malignant melanoma.

Dear Editor,

We read with interest an article entitled “significance of early detection of oral malignant melanoma in improving prognosis”.[1] The effort made by Kaul and Kumar[1] is commendable, as they have tried to draw the attention of researchers and clinicians towards the crucial role of early diagnosis in improving the prognosis of patients with oral malignant melanoma. Sir, in this regard, we would like to highlight the importance of another aspect that has an equally significant role in improving the prognosis of patients with oral malignant melanoma that is the need of a lifelong follow-up to keep vigilance over the recurrence of this aggressive and notorious lesion.

As oral mucosal melanomas are highly malignant tumors with certain typical factors associated with it such as the chameleonic presentation of a mainly asymptomatic condition, the rarity of these lesions, the poor prognosis, the necessity of a highly specialized treatment and high risk of recurrence; every aspect related this disease entity should be seriously considered by the involved health care provider.[2] In most of the cases, the disease is usually advanced at the time of diagnosis with both radial and vertical extensions. Even for patients with presumed early-stage disease, the outcome is generally poor, possibly because of occult metastases at presentation.[3] About 80% of patients with oral melanoma have local disease, and 5-10% of patients present with grossly involved nodes.[4]

As oral melanomas are more aggressive in nature and spread and metastasize more rapidly than other oral cancers or cutaneous melanomas compounded with the anatomic complexity, lymphatic drainage ambiguity, unpredictability of lymphoscintigraphy or intraoperative blue-dye sentinel-node biopsy, unreliable benefit of adjunctive chemo-radiotherapy; so they are associated with significantly higher morbidity and mortality.[45] Local treatment failure is a significant problem for most treated patients and distant metastases are also very common. Local recurrence is usually a harbinger for concurrent or subsequent distant metastases.[3] Even after complete surgical excision, the local-regional relapse rate has been reported to be 10-20%, and 5-year survival rates are clustered around 10-25%. Early recognition, aggressive multimodal therapy, multidisciplinary team management and a strict follow-up regime are essential to improve the disease outcome.

As most of the people do not inspect their oral cavity closely, until significant swelling, tooth mobility, bleeding or other problems arise, so regular dental check-ups are of paramount importance for early recognition of such silent lesions. Simultaneously, the periodic follow-up for oral examination is also necessary to evaluate for disease recurrence. The health care team should encourage the patient to adopt healthy behaviors and to practice self-examination of the oral cavity.[4] They dental personnel must regularly perform thorough oral examinations and imaging studies to rule out recurrence and to recognize and treat other potential problems such as masticatory, swallowing and speech difficulties associated with prostheses. As oral melanoma are known to recur years after the treatment of primary malignancy, hence lifelong scrutinization of the patient through vigilant and regular follow-up is mandatory to improve the prognosis and to enhance the quality of life of the patient.