A Nasal Cavity Mucosal Melanoma Connected by Nasolacrimal Duct in a Patient with Multiple Co-morbidities: A Treatment Dilemma.

Nasal cavity is a rare site in melanoma and surgery plays important roles in its treatment. A mucosal melanoma penetrating through the nasolacriminal duct (NLD) into orbit in a patient with multiple co-morbidities poses some difficulties in its management. A 78 year-old man developed epiphora and ocular swelling in recent 1 week in his left eye. He had medical histories of hypertension, diabetes, chronic renal insufficiency and right middle cerebral artery infarction. Physical examination revealed left periorbital swelling, chemosis, lateral gaze impairment and a dark-colored mass in left nasal cavity. Mucosal melanoma was diagnosed by biopsy. Contrast enhanced T1-weighted MRI showed an enlarged hyperdense lesion in left nasal cavity which invades through the NLD and gets into left medial aspect of orbit with involvement of preseptal space and retrobulbar fat. The patient was treated with radiation therapy alone (450 cGY in 13 fractions) with partial response. Lung metastasis occurred 3 months later and the patient was alive with disease for 6 more months.Primary surgical resection has been the treatment of choice for mucosal melanoma. Radiotherapy in our patient was chosen for multiple co-morbidities. Neither local nor regional control was improved by this approach. Palliative chemotherapy in this situation could be the treatment of choice for patient's better quality of life.