Imaging in Metastatic Melanoma Nilanthi Gunawardane Gillian Lieberman, MD March 2008
Malignant Melanoma Neoplasm of pigment-forming cells, melanocytes,, and nevus cells Types of melanoma Superficial spreading Lentigo maligna Nodular Acral lentiginous www.metrohealth.org
Epidemiology In 2008, an estimated 62,480 individuals will be diagnosed with melanoma and 8420 will die of this disease Lifetime risk of developing melanoma is increasing dramatically 2001: 1 in 71 1985: 1 in 150 1965: 1 in 600
AJCC 2002 Melanoma Clinical Stage Grouping www.uspharmacist.com
Sites of Metastases Lymph nodes Lungs Liver Subcutaneous tissue GI tract Brain Less common: heart, muscle, spleen, kidneys, adrenal glands, gallbladder, breast
Our Patient Mr. H: Initial Presentation 84 yo M presented to a dermatologist with a dysplastic nevus Hx of extensive sun exposure, no hx of skin cancer No family hx of melanoma Lesion resected Followed conservatively
Imaging modalities for the work up of suspected malignant melanoma Plain films Computed Tomography (CT) Positron Emission Tomography (PET) PET-CT Magnetic Resonance Imaging (MRI) Lymphoscintigraphy Ultrasound
Imaging Modalities Modality Stage I and II Stage III CXR CT Recommended Functions as baseline Optional periodic CXR q3-6 months Low sensitivity for detection of metastasis Low yield and high false positive rate (10-20%) Optional periodic CXR q3-6 months Low sensitivity for detection of metastasis but higher than stage I and II Low yield of brain, torso CT in asymptomatic patients Selective imaging indicated Imaging prior to lymph node dissection or IF therapy
Imaging Modalities Modality Stage I and II Stage III PET & PET/CT MRI Not indicated Low sensitivity Not indicated Recommended More sensitive than MRI, CT PET/CT more accurate than PET b/c able to correlate anatomic localization with physiologic information Most sensitive modality to assess brain mets Routine imaging in asymptomatic patients controversial
Lymphoscintigraphy Staging of patients who are clinically node negative Lymph node involvement most important prognostic factor Method: Radioactive colloid injected intradermally around tumor. Imaged by gamma camera/gamma probe Allows preoperative and intraoperative identification of sentinel lymph nodes for biopsy Courtesy of Dr. Donohoe, BIDMC
Mr. H: Follow-up Two years later: CT chest at OSH showed small right lung lesion Decided to follow-up with repeat CT in 6 months Two years, seven months later: Repeat CT at BIDMC
Mr. H: Mass on Non-contrast Chest CT Rounded opacity in RLL, 3cm in diameter, no calcification, no cavitation From PACS, BIDMC
Mr. H: Multiple Nodules on Non-contrast Chest CT 2mm nodule LUL Subpleural 8mm nodule RUL From PACS, BIDMC
DDx for Multiple Pulmonary Nodules Malignancy: Metastasis, Lymphoma Infectious: Abscesses, Septic emboli, Fungi Infectious: A Non-infectious: Wegener s granuloma AVM Pneumoconioses
Mr. H: Lung Mass on PET Focal area of increased FDG uptake in right lung Courtesy of Dr. Donohoe, BIDMC
Lung Mass on PET-CT Focal area of increased FDG uptake on PET Focal area of increased FDG uptake on PET Lung mass on CT Fusion image: area of increased FDG uptake on PET correlates with lung mass on CT Courtesy of Dr. Donohoe, BIDMC
DDx for PET enhancement Neoplasm Infection Inflammation Uptake in brain, skeletal muscle, brown fat, myocardium, bowel Urinary collecting system
Mr. H: Further Follow-up Bronchoscopy - resection of two nodules Pathology poorly differentiated metastatic melanoma Followed with torso CTs Developed acute low back pain MRI findings suspicious for metastasis L2 biopsy showed melanoma
Mr. H: Vertebral Metastases on Spinal MRI Compression fracture L1 T11 L2 From PACS, BIDMC Sagittal T1 MRI thoracic & lumbar spine: Decreased signal intensity suspicious for metastasis in L2 vertebral body and T11 spinous process
Mr. H : Course of Events One year post-imaging at BIDMC Patient awoke with diplopia MRI at OSH metastatic lesions in brain Whole brain radiation One month later: Transferred to BI for further care
Mr. H: Cerebral Mets on MRI Sagittal T1 weighted noncontrast brain MRI Axial T1 weighted non-contrast brain MRI 2X3 cm area of increased signal intensity in right frontal lobe From PACS, BIDMC
Mr. H: Cerebral Mets on MRI Axial T1 weighted non-contrast brain MRI Two areas of increased signal intensity in right hemisphere From PACS, BIDMC
Mr. H: Hemorrhagic Cerebral Mets on MRI Axial T1 weighted non-contrast brain MRI Axial T2 GRE Increased signal intensity area on T1 corresponds with decreased signal intensity area on T2 GRE, consistent with a hemorrhagic lesion From PACS, BIDMC
DDx for Hemorrhagic Brain Mets Melanoma Anaplastic lung carcinoma Thyroid carcinoma Choriocarcinoma Hypernephroma
Companion Patient #1: Melanotic Pattern of Melanoma Non-enhanced axial T1 MR Non-enhanced axial T2 MR Increased signal intensity on T1 Decreased signal intensity on T2 Companion patient #1: 54 yo with brain metastasis from acral lentiginous melanoma Escott E, Radiographics. 2001;21:625-639
Companion Patient #2: Amelanotic Pattern of Melanoma Non-enhanced axial T1 MR Non-enhanced axial T2 MR Hypo & Isointense on T1 Hyper & Isointense on T2 Companion patient #2: 40 yo M with melanoma brain metastasis Escott E, Radiographics. 2001;21:625-639
Mr.H: : Final Events Patient developed SBO and pneumoperitoneum Patient expired
Companion Patients: Other Sites of Metastases Patient #3: Necrotic hepatic melanoma met Patient #4: Subcutaneous melanoma met Patient #5: CT and US of renal melanoma met Donohoe, Imaging Studies in Melanoma, Up-To-Date 2008
Summary Melanoma can metastasize to any organ Imaging is an essential component of melanoma staging Multitude of imaging modalities are utilized in the staging and follow-up of metastatic melanoma Metastatic melanoma lesions, especially in the brain, can have a variety of appearances on imaging
Acknowledgments Dr. Lieberman Dr. Andrew Hines-Peralta Dr. Kevin Donohoe Rachel Jimenez Maria Levantakis
References American Cancer Society: Cancer Facts & Figures, Statistics for 2007 and 2008 Au Shiela, emedicine: : CNS Melanoma Belhocine TZ, Scott AM, Even-Sapir E, et al., Role of nuclear medicine in the management of cutaneous malignant melanoma. J Nucl Med. 2006 Jun;47(6):957-67. 67. Buzaid AC, Gershenwald JE, Ross MI. Staging work-up for melanoma and follow-up guidelines. UpTo Date 2008 Buzaid AC, Gershenwald JE, Ross MI. American Joint Commission on Cancer staging system and prognostic factors in cutaneous melanoma. Up To Date 2008 Donohoe K. Imaging studies in melanoma. Up To Date 2008. Escott E, A Variety of Appearances of Malignant Melanoma in the Head: A Review. Radiographics.. 2001;21:625-639 639 Greene, FL, Page DL, Fleming ID, et al., (Eds( Eds). Melanoma of the skin. In: AJCC Cancer Staging Manual, Springer, New York, 2002, p.209 Iagaru A, Quon A, Johnson D, et al.,2-deoxy Deoxy-2-[F-18]fluoro-D-glucose positron emission tomography/computed tomography in the management of melanoma. Mol Imaging Biol. 2007 Jan-Feb;9(1):50 Feb;9(1):50-7. Kuvshinoff BW, Kurtz C, Coit DG. Computed tomography in evaluation of patients with stage III melanoma. Ann Surg Oncol.. 1997 Apr-May;4(3):252 May;4(3):252-8. Marks JG, Miller JJ. (Eds( Eds). Principles of Dermatology: Pigmented growths pp 71-82.Fourth edition. Saunders 2006
References Mandel J, Stark P. Differential diagnosis and evaluation of multiple pulmonary nodules. UpTo Date 2008 Reinhardt MJ, Joe AY, Jaeger U, et al.,diagnostic performance of whole body dual modality 18F- FDG PET/CT imaging for N-N and M-staging M of malignant melanoma: experience with 250 consecutive patients. J Clin Oncol.. 2006 Mar 1;24(7):1178-87 87 Shirkhoda A, Albin J. Malignant melanoma: correlating abdominal and pelvic CT with clinical staging. Radiology. 1987 Oct;165(1):75-8. Terhune MH, Swanson N, Johnson TM. Use of chest radiography in the initial ial evaluation of patients with localized melanoma. Arch Dermatol.. 1998 May134(5):569-72. Tyler DS, Onaitis M, Kherani A, Hata A, et al., Positron emission tomography scanning in malignant melanoma. Cancer. 2000 Sep 1;89(5):1019-25. Wagner JD, Schauwecker D, Davidson D, et al., Inefficacy of F-18 F fluorodeoxy-d-glucose glucose- positron emission tomography scans for initial evaluation in early ly-stage cutaneous melanoma. Cancer. 2005 Aug 1;104(3):570-9. Yock DH. Magnetic Resonance Imaging of CNS. Mosby Yearbook, Inc.1995 Yudd AP, Kempf JS, Goydos JS, et al. Use of sentinel node lymphoscintigraphy in malignant melanoma. Radiographics.. 1999 Mar-Apr;19(2):343 Apr;19(2):343-53