T of patients with malignant melanoma

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1 ~~ RADIOGRAPHIC: EVALUATION OF METASTATIC MELANOMA JACK E. MEYER, MD*+$ Malignant melanoma can potentially involve any organ system in the body once it metastasizes beyond the regional lymph nodes. A survey of the radiographic and associated clinical manifestations of metastatic melanoma is presented. The findings from 74 autopsies of patients who died of metastatic melanoma are included. Cancer 42: E PRE- AND POSTOPERATIVE evaluation T of patients with malignant melanoma requires a knowledge of the potential sites of metastatic spread beyond the regional lymph nodes as well as the accompanying clinical manifestations. In some situati0n.s diffuse involvement of an organ system may not be recognizable by current radiographic: methods. Full knowledge of the potential sites of spread in patients who have melanoma allows for better radiographic and clinical evaluation of both symptoms and x-ray findings. MATERIALS AND METHODS One source of material for this study comeis from 74 autopsies performed on patients who died of metastatic melanoma at Pondville Hospital between 1927 and The results of the first 49 autopsies have been reported7 and this is an extension of that study. The remainder of the patient material is selected from many hundreds of patients evaluated and treated at Pondville Hospital for melanoma. Table 1 demonstrates the postmortem findings in 74 patients who died of metastatic melanoma. The following system reviews will point out the radiographic appearance and common clinical symptoms. From the * University of Massachusetts Medical School, Boston, Massachusetts, t Boston University School of Medicine, Boston, Massachusetts, and $ Pondville Hospital, Walpole, Massachusetts. * Associate Professor of Radiology, t Associate Clinical Professor of Radiology, and $ Chief of Diagnostic Radiology. Address for reprints: Department of Radiology, Pondville Hospital, P.O. Box 1 11, Walpole, MA Accepted for publication October 10, X Respiratory Tract Seventy-six percent of the autopsy cases had pulmonary metastasis, most commonly, multiple round nodular deposits. Most patients were asymptomatic but when deposits were large and numerous, a cough or shortness of breath was present. One patient had hemoptysis secondary to an endobronchial metastatic deposit and a solitary pleural based metastasis was present in another (Fig. 1). Malignant melanoma metastatic to the trachea, larynx or oral cavity is quite rare, with only 4 cases of secondary involvement of the larynx having been previously reported. 1,4 Case One CASE REPORTS A 64-year-old male was admitted to Pondville Hospital several months after the development of hoarseness. One year prior to admission, a malignant melanoma was removed from the left buttock. Physical examination revealed numerous pigmented skin nodules subsequently proven to be TABLE 1. Malignant Melanoma Incidence of Metastasis: 74 Autopsies Most common Lung 76% Liver 54% Adrenal 51% Brain 40% Heart 40% Kidney 38% Bone 35% Small intestine 34% Pancreas 32% Spleen 27% Stomach 26% 0 American Cancer Society Less common Colon Thyroid Gall bladder Urinary bladder Ovary Breast Uterus Testis Ureter Parathyroid Eye 24% 23% 20% 16% 12% 7% 7% 7% 3% 2% 1%

128 CANCER July 1978 Vol. 42 FIG. 1. Pleural based pulmonary metastases. FIG. 3. Typical metastasis to the gastric antrum with a central ulceration. metastatic.

left vocal cord. A laryngogram confirmed these findings (Fig. 2)

2 128 CANCER July 1978 Vol. 42 FIG. 1. Pleural based pulmonary metastases. FIG. 3. Typical metastasis to the gastric antrum with a central ulceration. metastatic. There were pigmented painful nodules on the buccal mucosa and indirect laryngoscopy revealed pigmented nodules in both valleculae, pyriform sinuses and true and false cords with poor mobility of the left vocal cord. A laryngogram confirmed these findings (Fig. 2). Gastrointestinal Tract FIG. 2. Laryngogram showing metastatic nodules in the valleculae (upper arrow), pyriform sinuses and the left true and false cords (lower arrow). Stomach: Abdominal pain, diarrhea, melena and/or hematemesis in a patient with a history of malignant melanoma is strong clinical evidence that gastrointestinal metastatic involvement is present and barium studies of the stomach, small bowel and colon should be performed. Metastasis to the stomach occur in 26% of the patients who succumb to disseminated malignant melanoma. Radiographically these have been described as bull s eye or target lesions. This appearance results from hematogeneous dissemination to the submucosa of the gut and then growth in an exophytic manner causing polypoid filling defects with a tendency for central ulceration or umbilication. A typical target ulcer in the antrum of the stomach is shown in Fig. 3. Small bowel: Metastatic involvement of the small bowel may be found coincidentally in patients with diffuse metastases (Fig. 4) or may be the cause of abdominal pain melena and/or obstruction. Intussusception of polypoid metastasis is a fre-

No. 1 METASTATIC MELANOMA * Meyer 129 FIG. 4. Polypoid submucosal metastases found on a small bowel examination utilizing compression.

Case Two A 57-Year-old female was Placed on DTIC for IVidesPrrad cutaneous melanoma.

A barium enema revealed reflux into the terminal ileum and an intussusception of the distal small bowel caused by a polypoid intraluminal

3 No. 1 METASTATIC MELANOMA * Meyer 129 FIG. 4. Polypoid submucosal metastases found on a small bowel examination utilizing compression. quent Lause of bowel obstruction in patients with melanoma. Case Two A 57-Year-old female was Placed on DTIC for IVidesPrrad cutaneous melanoma. Four months later severe abdominal pain, diarrhea and vomiting developed. A barium enema revealed reflux into the terminal ileum and an intussusception of the distal small bowel caused by a polypoid intraluminal obstructing mass (Fig. 5). At laparotomy multiple polypoid masses were found in the distal ileum, FIG cm in diameter polypoid mass in the distal ileum demonstrated on a barium enema examination as a leading mass of an intussusccption causing small bowel obstruction. FIG. 6, Polypoid intraluminal metastatic deposit in the mid jejunum.

130 CANCER JuZy 1978 Vol. 42 FIG. 9. Metastatic melanoma in the upper pole of the left kidney. FIG. 7.

The patient survived 5 months after surgery. Case Three A 21-year-old female was treated for melanoma of the back by wide excision and groin dissection.

Palliative surgical resection provided symptomatic relief for 7 months when a partial resection of the ileum was performed for the same reason yielding a year and a half additional years of pain

4 130 CANCER JuZy 1978 Vol. 42 FIG. 9. Metastatic melanoma in the upper pole of the left kidney. FIG. 7. Metastatic deposit in the base of the cecum which produced an intussusception 3 days after this examination. the largest of which was causing the obstruction. The patient survived 5 months after surgery. Case Three A 21-year-old female was treated for melanoma of the back by wide excision and groin dissection. One year later, abdominal pain and melena prompted an upper G.I. series and small bowel follow-through which showed a polypoid partially obstructing intraluminal mass in the mid-jejunum (Fig. 6). Palliative surgical resection provided symptomatic relief for 7 months when a partial resection of the ileum was performed for the same reason yielding a year and a half additional years of pain relief. Colon: Most metastatic deposits in the colon are discovered coincidentally at autopsy and are small, submucosal nodules unrecognizable even in retrospect on barium enema examination. Potentially they can grow large enough in size to become symptomatic^ Case Four A 77-year-old female presented with a right lower quadrant mass which on barium enema was shown to be a polypoid intraluminal mass at the base of the cecum. Two days later this mass intussuscepted and at surgery proved to be a metastatic deposit of melanoma (Fig. 7). The occult.primax-y skin lesion was subsequently found in the left axilla. Liver: The spectrum of large or small diffuse deposits is reflected in liver scanning results which FIG. 8. Multiple submucosal metastasis in the gallbladder found at postmortem examination. FIG cm in diameter metastatic deposit in the bladder causing hematuria.

No. 1 METASTATIC MELANOMA * Meyer 131 FIG. 12.2 cm in diameter breast nodule in a 22-year-old female representing a metastasis.

range from discrete areas of decreased activity No premortem diagnosis of adrenal metastases has been made in this series although it was present at autopsy in 51% of the patients.

~ Kidney: Renal involvement was present at autopsy in 38% of the patients and is usually unrecognized prior to death.3 The left upper pole mass in Fig.

5 No. 1 METASTATIC MELANOMA * Meyer 131 FIG cm in diameter breast nodule in a 22-year-old female representing a metastasis. F ~ 11, ~ ~, ~ extradural ~ metastatic i ~ deposit ~ of mela- l noma causing complete obstruction of the subarachnoid space. range from discrete areas of decreased activity No premortem diagnosis of adrenal metastases has been made in this series although it was present at autopsy in 51% of the patients. These usually are manifest as small, tiny, diffuse deposits. There has been a report of a calcified metastasis of the adrenal gland, O and a large palpable metastasis which was surgically rem~ved.~ Kidney: Renal involvement was present at autopsy in 38% of the patients and is usually unrecognized prior to death.3 The left upper pole mass in Fig. 9 was asymptomatic and found on routine follow-up examination in a patient who had surgical resection of a bladder metastasis. Bladder: Bladder metastases present with hematuria and can be visualized on intravenous urography as round, smooth, filling defects either solitary or multiple in the bladder with or without very strongly Suspicious for metastasis to diffuse associated ureteral or renal pelvis lesions.6 Palliation of hematuria can be obtained by transurethral resection. heterogeneous activity without discrete areas. If there is no other evidence of metastatic disease and the liver scanning results are equivocal, it is usually necessary to perform a biopsy for complete evaluation in order to exclude the presence of metastasis. Case Five A 56-year-old male, 2 years after primary surgi- Gallbladder: Radiographic demonstration of cal excision of a melanoma experienced hematuria polypoid filling defects in the gallbladder secondary to metastatic disease has been reported.8 The typical appearance of a gallbladder with metastasis, is shown in Fig. 8. This patient had diffuse metastatic disease and the gallbladder involvement was found on postmortem examination. Pancreas: Premortem diagnosis of pancreatic involvement was not made in this group of patients and in all instances it was part of a diffuse intraabdominal process. A patient has been described in whom extensive pancreatic involvement caused jejunal obstruction.* Genitourinary Tract Adrenal gland: At autopsy, metastatic involvement of the genitourinary tract is quite common, but the clinical diagnosis is seldom made. FIG. 13. Painful metastasis in the middle third phalanx.

132 CANCER Jub 1978 Vol. 42 for 3 months and an IVP showed a 4.0 cm mass in the bladder (Fig. 10). A transurethral resection was performed and metastatic melanoma was present in the bladder.

6 132 CANCER Jub 1978 Vol. 42 for 3 months and an IVP showed a 4.0 cm mass in the bladder (Fig. 10). A transurethral resection was performed and metastatic melanoma was present in the bladder. Brain and Spinal Cord Any clinical symptoms related to the central nervous system should be pursued with brain scanning and if negative, a CAT scan, which can detect small foci below the resolution of radionuclide imaging. Clinical signs and symptoms suggesting extradural spinal cord metastasis can be diagnosed by myelography (Fig. 11). Breast Other than leukemia and lymphoma, malignant melanoma is the most common metastatic neoplasm to the A 2.0 cm nodule with some infiltration into the adjacent tissue representing a metastatic deposit is demonstrated on the mammogram shown in Fig. 12. Skeletal System Thirty-five percent of patients eventually develop bone metastasis most frequently as in other malignancies, involving the axial skeleton. The destructive lesion noted in Fig. 13 in the middle 3rd phalanx was an unusual bony metastasis in a patient with melanoma, who presented with localized pain. DISCUSSION Any patient with a history of a treated skin melanoma, no matter how remote, has a potential to develop metastatic disease. The knowledge that the distribution of these hematogenous metastasis can involve any organ system should be helpful in both clinical and radiographic evaluation of these patients. In almost all instances, routine radiographic examinations directed to the specific organ systems can identify the abnormality if it is large enough in size to cause symptoms and the appropriate treatment may be instituted. REFERENCES 1. Chamberlain, D.: Malignant melanoma metastatic to the larynx. Arch. Otoluryngol. 83: , Das Gupta, T., and Brasfield, R.: Metastatic melanoma, a clinico-pathological study. Cancer 17: , Das Gupta, T., and Grabstald, H.: Melanoma of the genitourinary tract.j. Urol. 93: , Fisher, G. E., and Odess, J. S.: Metastatic malignant melanoma of the larynx. Arch. Otoluryngol. 54: , Jochimsen, P., and Brown, R.: Metastatic melanoma in the breast masquerading as a fibroadenoma. JAMA 236: , Meyer, J.: Metastatic melanoma of the urinary bladder. Cancer 34: , Potchen, E. J., Khung, C. L., and Yatsuhashi, M.: X-ray diagnosis of gastric melanoma. N. Engl. J. Med. 271: , Shimkin, P., Soloway, M., and Jaffe, E.: Metastatic melanoma of the gallbladder. Am. J. Roentgmol. 116: , Silverma, E., and Oberman, H.: Metastatic neoplasms in the breast. Surg. Gynpcol. Obstrt. 138: 26-28, Twersky, J., and Levin, D.: Metastatic melanoma of the adrenal. Radzology 116: , 1975.

Case Report Solitary Osteolytic Skull Metastasis in a Case of Unknown Primary Being latter Diagnosed as Carcinoma of Gall Bladder

Cronicon OPEN ACCESS CANCER Case Report Solitary Osteolytic Skull Metastasis in a Case of Unknown Primary Being latter Diagnosed as Carcinoma of Gall Kartik Mittal 1, Rajaram Sharma 1, Amit Dey 1, Meet