Answer: Melanoma

Histology: A submucosal neoplasm composed of large “pink” cells with large nuclei and single prominent nucleoli. In the background, a number of histiocytes containing pigment are present.

Discussion: Melanomas can be primary to the upper aerodigestive tract. In this patient a careful skin exam including numerous skin biopsies was preformed and a skin primary was not identified. Patients with melanoma of the upper aerodigestive tract often present with symptoms of obstruction, epistaxis or pain. Grossly, these tend to be brown and black as one would expect, and by light microscopy, they are composed of epitheliod to spindle-shaped cells with large nuclei, prominent nucleoli and abundant pink cytoplasm. In some instances, melanin may be seen either in the neoplastic cells or in the associated histiocytes. Immunolabeling for melanoma markers (S-100 protein, HMB-45, etc.), for lymphoid markers (CD45) and for cytokeratins can help distinguish melanomas of the upper aerodigestive tract from lymphomas and sinonasal undifferentiated carcinomas.