Innovative Surgical Approaches in Palliative Care for Recurrent Sinonasal Melanoma: A Case Study

Sinonasal melanoma is a rare and aggressive cancer that often presents significant treatment challenges, especially when diagnosed late and complicated by local invasion and metastasis. This case study highlights a complex surgical intervention performed by Dr John Chaplin and Dr Joseph Earles on a 78-year-old patient with recurrent left sinonasal mucosal melanoma. The operation involved radical palliative debulking, including left orbital exenteration and extensive sinus removal, followed by reconstruction using a free flap technique. This post explores the clinical background, surgical strategy, and outcomes to provide insight into managing advanced sinonasal melanoma in palliative settings.

Patient Background and Disease Progression

The patient was diagnosed with left sinonasal mucosal melanoma in late 2024. As there was alredy distant metaststatic disease noted on initial imaging including lung, liver and bony mets, initial treatment began with Pembrolizumab in January 2025, which showed an excellent response in both the primary tumor and distant metastatic sites. Despite this, the left sinonasal primary tumor progressed throughout 2025, even as distant metastases remained stable or regressed.

By September 2025, palliative radiotherapy was administered to the left nasal cavity and orbit, delivering 25 Gy in 5 fractions. This treatment provided some initial tumor response but did not halt progression. Between January and April 2026, the sinonasal tumor continued to grow aggressively, invading the left orbit and causing significant symptoms including proptosis, diplopia, chemosis, and discomfort. Pembrolizumab was discontinued in April 2026 due to disease progression.

A PET CT scan in June 2026 revealed stable distant disease except for new metastatic foci in the right cheek and left buttock. The sinonasal tumor had become very large, invading critical structures such as the medial canthal and nasal dorsal skin.

PET CT scan showing large FDG avid left sinonasal mass invading the left orbit and displacing the left globe

Surgical Indications and Goals

The primary goal of surgery was palliative: to reduce tumor burden, relieve symptoms, and improve quality of life. The tumor’s invasion into the orbit and sinuses caused significant discomfort and functional impairment, making radical debulking necessary despite widespread metastatic disease.

Key indications for surgery included:

• Recurrent sinonasal melanoma with local orbital invasion

• Significant proptosis and eye discomfort affecting daily life

• Failure of systemic immunotherapy and radiotherapy to control local disease

• Stable or limited progression of distant metastases allowing focus on local control

  
  

The surgical team planned an extensive resection to remove the tumor mass and involved structures, followed by reconstruction to restore facial contour and function.

Surgical Procedure Details

The operation involved several complex steps:

• Radical palliative debulking of the left sinonasal melanoma: This included removal of the tumor mass from the nasal cavity and sinuses.

• Left orbital exenteration: Complete removal of the left eye and associated orbital contents due to tumor invasion.

• Medial maxillectomy: Resection of the medial maxillary bone to clear tumor margins.

• Exenteration of frontal, ethmoid, and sphenoid sinuses: Removal of these sinuses was necessary to achieve maximal tumor clearance.

• Reconstruction with right anterolateral thigh free flap: A free flap from the right thigh was used to reconstruct the surgical defect, providing soft tissue coverage and restoring facial structure.

  
  

This extensive surgery required careful coordination between surgical oncology, reconstructive surgery, and anesthesiology teams to manage risks and optimize outcomes.

Postoperative Care and Outcomes

Following surgery, the patient was closely monitored for complications such as infection, flap viability, and wound healing. The reconstruction provided adequate soft tissue coverage, improving facial symmetry and protecting exposed areas.

Symptom relief was significant, with reduction in proptosis and eye discomfort. Although the surgery was palliative and not curative, it improved the patient’s quality of life by addressing the most distressing local symptoms.

The patient continued systemic monitoring for metastatic disease progression. The surgical approach demonstrated that even in advanced cases with metastatic spread, aggressive local control can offer meaningful benefits.

Lessons and Implications for Practice

This case illustrates several important points for managing recurrent sinonasal melanoma:

• Multimodal treatment is essential: Combining immunotherapy, radiotherapy, and surgery can help control both local and systemic disease.

• Palliative surgery has a role: Even when cure is not possible, surgery can relieve symptoms and improve quality of life.

• Complex reconstruction techniques are valuable: Free flap reconstruction allows extensive tumor removal while maintaining facial structure.

• Close interdisciplinary collaboration is critical: Successful outcomes depend on teamwork across specialties.

  
  

For clinicians facing similar cases, this example highlights the need to balance aggressive local treatment with overall patient condition and goals of care.

This case underscores the potential for surgical intervention to provide symptom relief in advanced sinonasal melanoma. While systemic therapies remain important, targeted surgery can address local complications that significantly impact patient well-being. Ongoing research and clinical experience will continue to refine these approaches, offering hope for better management of this challenging disease.