Melanoma Case Study #3 Clinical History A 39 year old female with a history of melanoma status post excision now presents with left lower lobe mass. A 39 year old Caucasian female was diagnosed with melanoma seven years ago. More specifically, she had a mole on the right arm/shoulder for which she visited a dermatologist, who performed a biopsy. The results of the biopsy are unknown (the patient says it was Clark level IV, unknown Breslow level). However, she underwent a wide excision and a sentinel lymph node biopsy of the right axilla, which was negative. Of note, she had a satellite mole within 1 inch from the originally excised melanoma. It was decided to treat with interferon therapy three times a week, probably 3 to 5 million units subcutaneously. Her overall treatment lasted for six months. She subsequently stopped because of development of severe side effects (psychosis, depression, energy loss, 17-pound weight loss, bone pain, and recalcitrant flu symptoms). She states that she did not have a proper follow-up. However, she tries to have a whole body CT imaging every year and relevant blood work-up. She recently moved to Pittsburgh, one and a half years ago. The last CT scan was in 2000 and she therefore missed the 2001 follow-up. She has been complaining of right inner lower scapular back pain which may occasionally radiate to the upper ribs or the right iliac area, not specifically associated with movement, questioned whether there was any pleuritic component. This was an alarming symptom for her to seek medical attention. She therefore underwent whole body CT imaging, dated 09/2002, which showed a large mass in the right lower lobe. The liver showed fatty infiltration and otherwise there was no intra-abdominal or pelvic disease. There was also a noted spondylosis defect and spondylolisthesis in the lower lumbar spine. She was referred by her primary care doctor to a pulmonologist, for bronchoscopy. He described an exophytic endobronchial mass arising from the lateral segment of the right lower lobe from which endobronchial biopsies were taken. Pathology report of these lesions from Westmoreland Health System dated 10/2002 reported findings consistent with melanoma composed of small epithelioid cells strongly positive for S100 and focally positive for HMB-45. She was subsequently seen by an oncologist, who referred her for further evaluation and treatment, including PET•CT imaging for more detailed and complete staging. PAST MEDICAL HISTORY:
1. Migraine headaches. 2. Irritable bowel syndrome.
ALLERGIES: No know drug allergies. SOCIAL HISTORY: She is divorced, no children. She smoked one and a half pack of cigarettes per day for approximately 15 years and quit four years ago. Occasional use of alcohol. FAMILY HISTORY: Father died of bladder cancer. Mother died of pancreatic cancer. Grandmother on the mother's side died of colon cancer. Mother's brother died of lung cancer. REVIEW OF SYSTEMS: She denies more headaches than are baseline. She has occasional cough but this is baseline. She does not have any hemoptysis. She denies nausea, vomiting, diarrhea. She denies any belly pain, chest pain. Denies any weight loss or appetite loss. She denies any generalized weakness. PHYSICAL EXAMINATION: Temperature 98.2. Blood pressure 96/64. Pulse is 60. Respiratory rate is 16. Weight is 127 pounds. Comfortable, but burst in to tears when she was notified that her disease is not curable. Pupils equal and reactive to light and accommodation. Extraocular muscles are intact. Moist mucous membranes. Neck without any cervical or supraclavicular adenopathy. There was no JVD. Chest was clear to auscultation. Heart had a rate and rhythm, no murmurs or gallops. Back exam with a right upper back 3-inch scar across the midline and no spine tenderness to pressure, no CVA tenderness. Abdomen is soft, nontender, present bowel sounds, no organomegaly. Extremities with 5-inch linear scar originating from the right upper humerus and all the way down. No evidence of axillary or inguinal lymphadenopathy. ASSESSMENT/PLAN: Metastatic melanoma to the chest:
1. She needs to be accurately staged by having a PET•CT scan. 2. Surgical consideration if disease localized to the right lower lobe lesion. 3. She will also be tissue typed to see in which of the available clinical trials she may be eligible to participate.
NUCLEAR MEDICINE PET•CT PET PORTION SCAN STATED REASON FOR REQUEST: 39 year old female with history of metastatic melanoma. RADIOPHARMACEUTICAL ADMINISTERED: 13.3mCi F18-FDG IV TECHNIQUE: Emission scanning was performed extending from the skull through the pelvis approximately one hour post radiotracer injection. Images were reconstructed with and without attenuation correction using the CT attenuation coefficients. The blood glucose measurement was 73mg/dl. FINDINGS: There are multiple focal abnormal areas of increased FDG uptake of an intense nature involving the soft tissues posterior and closely adjacent to the proximal right humerus, large mass in the right lower lung, and soft tissues of the lower left buttock adjacent to the muscle. IMPRESSION: Abnormal study with findings consistent with widespread metastatic disease as described above involving the soft tissues of the right upper extremity, right lung parenchyma, and soft tissues of the left buttock.
Differential Diagnosis Diffuse metastatic melanoma. Localized metastasis. Pathology TEST 1:
This patient is a 39 year old female with no clinical history
This patient is a 39 year old female with no clinical history
Right lower lobe lung, endobronchial biopsy:
Treatment This patient had Clark level IV melanoma remotely and had been followed with yearly CT scanning. Unfortunately, she missed one follow up scan. After developing pain in the chest wall, she had a CT scan that showed a new right lower lobe mass. A biopsy was performed and was positive for metastatic melanoma. She then was referred for combined PET•CT to restage her disease and to see if she may be a surgical candidate (if she had one lung metastasis). By CT, her disease was localized to the left lower lobe. However, as shown in the figure, she had two unsuspected lesions identified adjacent to the right humerus and in the left gluteal muscle, making her a non-surgical candidate. Discussion This case demonstrates the power of PET•CT to identify lesions that are either not visible on the CT portion of the exam or are very subtle lesions. Both of these lesions were missed prospectively on the CT portion of the exam. In retrospect, there is minimal enhancement of the left gluteal lesion, but this would be a very difficult diagnosis prospectively. Unfortunately, given the multiple unsuspected metastases, she became a non-surgical candidate.
Data courtesy of Dr. Todd Blodgett, University of Pittsburgh Medical Center * Any of the protocols presented herein are for informational purposes and are not meant to substitute for clinician judgment in how best to use any medical devices. It is the clinician that makes all diagnostic determinations based upon education, learning and experience. The Siemens Molecular Imaging University case study on this page is copyright 2009 protected and cannot be used without written consent by Dr. Todd Blodgett.
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