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An uncommon presentation of metastatic melanoma: a case report.

Reccia I, Pisanu A, Podda M, Uccheddu A - Medicine (Baltimore) (2015)

Bottom Line: Splenectomy was carried out.Histological report confirmed the peritoneal melanosis and the diagnosis of metastatic spleen lesion from melanoma.Prognosis remains poor, as metachronous disease is indicative of aggressive widespread of the disease.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Surgery, Clinica Chirurgica, University of Cagliari, Policlinico Universitario di Monserrato, Sestu (CA), Italy (IR, AP, MP, AU).

ABSTRACT
Metastases to the spleen are rare and are generally part of a multi-visceral metastatic disease. The most common sources of splenic metastases include breast, lung and colorectal malignancies as well as melanoma and ovarian carcinoma. Solitary splenic metastasis is very uncommon. We present a case of a 44-year-old man who presented at our department for gallstones symptoms. He had a past medical history of neck cutaneous melanoma (T3bN0M0--Stage IIb). He had not attended follow-up schedule for personal reasons. However, abdominal ultrasound revealed the presence of a solitary solid lesion in the spleen. Preoperative workup was completed with CT scan that confirmed the presence of a large splenic lesion with subcapsular fluid collection, also compatible with a post-traumatic lesion.Preoperative findings could not exclude malignancy and patient was therefore submitted to surgery. At laparoscopy, a condition of peritoneal melanosis was present. Splenectomy was carried out. Histological report confirmed the peritoneal melanosis and the diagnosis of metastatic spleen lesion from melanoma. Patient was observed, but died of metastatic disease 14 months after surgery. Splenic metastases are uncommon. Isolated metastases from melanoma are rare and could be found several months after primary diagnosis of melanoma. Surgery remains the most effective treatment, especially for metachronous disease, offering the best chance of long-term survival. Prognosis remains poor, as metachronous disease is indicative of aggressive widespread of the disease.

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(A) Intraoperative findings of focal peritoneal melanosis on the epiploon and on the peritoneal surface of the right diaphragmatic peritoneum; (B) massive amount of peritoneal melanosis around the spleen, on gastrosplenic and phrenicocolic ligaments; (C) Surgical specimen showing a large brownish irregular round mass that protrudes above the surface at the upper pole of the spleen; a cut surface shows the dishomogeneous appearance and the intense dark brown color of the lesion, with soft solid component and areas of colliquation.
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Figure 2: (A) Intraoperative findings of focal peritoneal melanosis on the epiploon and on the peritoneal surface of the right diaphragmatic peritoneum; (B) massive amount of peritoneal melanosis around the spleen, on gastrosplenic and phrenicocolic ligaments; (C) Surgical specimen showing a large brownish irregular round mass that protrudes above the surface at the upper pole of the spleen; a cut surface shows the dishomogeneous appearance and the intense dark brown color of the lesion, with soft solid component and areas of colliquation.

Mentions: A 44-year-old Caucasian man presented to our surgical department after 1 week of epigastric and right upper abdominal pain radiating to the right shoulder. Family history was non-contributory. He had no associated comorbidities. Other complains included bloating and nausea. He had a past medical history of neck cutaneous melanoma (2 years before), with sentinel lymph node biopsy negative (T3bN0M0—Stage IIb), but he did not attend follow-up schedule for personal reasons. Physical examination revealed mild tenderness in the right upper abdominal quadrant. No organomegaly or masses were clinically identified. Laboratory tests showed only a mild leukocytosis and moderate level of lactate dehydrogenase—LDH (488 UI/L, range 208–378). Gallstones were suspected in the view of patient's symptoms. However, admission abdominal ultrasound (US) of the abdomen revealed the presence of a round solid mass at the upper pole of the spleen (9 × 8 cm), with mixed echogenicity and almost no vascularization (Figure 1a). Cholelithiasis was also confirmed by abdominal US. The patient was therefore submitted to Computer Tomography (CT) scan, which showed a round mass (76 × 76 mm) at the upper pole of the spleen, which was dishomogeneous with hypodense and high-density areas, and with a subcapsular fluid collection (Figure 1b). CT scan appearance could also be compatible with a splenic hematoma, but the patient denied any history of trauma and had a past medical history of cancer. Chest X-ray was normal. Because of the US and CT unclear findings and the patient's history, he was referred for surgery for exploratory laparoscopy, cholecystectomy, and splenectomy. The procedure was first attempted laparoscopically with a full lateral right decubitus position, as previously described elsewhere for laparoscopic splenectomy.5 However, on surgical exploration, a diffuse, brown peritoneal pigmentation was found (Figure 2a–b). At frozen section lesions were composed of clusters of pigment-laden macrophages within the peritoneum, compatible with a condition of peritoneal melanosis. No cancer cells were identified. The splenic lesion had a brownish color with bulging into the splenic capsule at the upper pole, without macroscopic evidence of capsular breach. Because the appearance at exploration, the strong suspicion of malignancy, the presence of extensive adhesions and the risk of lesion rupture the procedure was converted to an open approach. Postoperative recovery was uneventful. Pathologic examination showed a parenchymal diffusely necrotic mass rich in melanotic pigment (Figure 2c), with focal capsular invasion and satellite nodules of strongly atypical neoplastic cells (Melan A+, HMB-45+, and S100+). The definitive diagnosis of splenic metastasis from melanoma and peritoneal melanosis was thus made. The patient was evaluated by the oncologists and submitted to brain magnetic resonance imaging (MRI) and positron emission tomography (PET)/CT, which were both negative for metastatic disease. Patient had no evidence of residual disease and was observed. However, at 1 year from surgery patient developed new neurologic symptoms and brain MRI was performed, showing the presence of multiple brain metastases. The patient rapidly developed disseminated disease and died of the disease at 14 months from splenectomy and at 38 months from initial diagnosis of melanoma.


An uncommon presentation of metastatic melanoma: a case report.

Reccia I, Pisanu A, Podda M, Uccheddu A - Medicine (Baltimore) (2015)

(A) Intraoperative findings of focal peritoneal melanosis on the epiploon and on the peritoneal surface of the right diaphragmatic peritoneum; (B) massive amount of peritoneal melanosis around the spleen, on gastrosplenic and phrenicocolic ligaments; (C) Surgical specimen showing a large brownish irregular round mass that protrudes above the surface at the upper pole of the spleen; a cut surface shows the dishomogeneous appearance and the intense dark brown color of the lesion, with soft solid component and areas of colliquation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554175&req=5

Figure 2: (A) Intraoperative findings of focal peritoneal melanosis on the epiploon and on the peritoneal surface of the right diaphragmatic peritoneum; (B) massive amount of peritoneal melanosis around the spleen, on gastrosplenic and phrenicocolic ligaments; (C) Surgical specimen showing a large brownish irregular round mass that protrudes above the surface at the upper pole of the spleen; a cut surface shows the dishomogeneous appearance and the intense dark brown color of the lesion, with soft solid component and areas of colliquation.
Mentions: A 44-year-old Caucasian man presented to our surgical department after 1 week of epigastric and right upper abdominal pain radiating to the right shoulder. Family history was non-contributory. He had no associated comorbidities. Other complains included bloating and nausea. He had a past medical history of neck cutaneous melanoma (2 years before), with sentinel lymph node biopsy negative (T3bN0M0—Stage IIb), but he did not attend follow-up schedule for personal reasons. Physical examination revealed mild tenderness in the right upper abdominal quadrant. No organomegaly or masses were clinically identified. Laboratory tests showed only a mild leukocytosis and moderate level of lactate dehydrogenase—LDH (488 UI/L, range 208–378). Gallstones were suspected in the view of patient's symptoms. However, admission abdominal ultrasound (US) of the abdomen revealed the presence of a round solid mass at the upper pole of the spleen (9 × 8 cm), with mixed echogenicity and almost no vascularization (Figure 1a). Cholelithiasis was also confirmed by abdominal US. The patient was therefore submitted to Computer Tomography (CT) scan, which showed a round mass (76 × 76 mm) at the upper pole of the spleen, which was dishomogeneous with hypodense and high-density areas, and with a subcapsular fluid collection (Figure 1b). CT scan appearance could also be compatible with a splenic hematoma, but the patient denied any history of trauma and had a past medical history of cancer. Chest X-ray was normal. Because of the US and CT unclear findings and the patient's history, he was referred for surgery for exploratory laparoscopy, cholecystectomy, and splenectomy. The procedure was first attempted laparoscopically with a full lateral right decubitus position, as previously described elsewhere for laparoscopic splenectomy.5 However, on surgical exploration, a diffuse, brown peritoneal pigmentation was found (Figure 2a–b). At frozen section lesions were composed of clusters of pigment-laden macrophages within the peritoneum, compatible with a condition of peritoneal melanosis. No cancer cells were identified. The splenic lesion had a brownish color with bulging into the splenic capsule at the upper pole, without macroscopic evidence of capsular breach. Because the appearance at exploration, the strong suspicion of malignancy, the presence of extensive adhesions and the risk of lesion rupture the procedure was converted to an open approach. Postoperative recovery was uneventful. Pathologic examination showed a parenchymal diffusely necrotic mass rich in melanotic pigment (Figure 2c), with focal capsular invasion and satellite nodules of strongly atypical neoplastic cells (Melan A+, HMB-45+, and S100+). The definitive diagnosis of splenic metastasis from melanoma and peritoneal melanosis was thus made. The patient was evaluated by the oncologists and submitted to brain magnetic resonance imaging (MRI) and positron emission tomography (PET)/CT, which were both negative for metastatic disease. Patient had no evidence of residual disease and was observed. However, at 1 year from surgery patient developed new neurologic symptoms and brain MRI was performed, showing the presence of multiple brain metastases. The patient rapidly developed disseminated disease and died of the disease at 14 months from splenectomy and at 38 months from initial diagnosis of melanoma.

Bottom Line: Splenectomy was carried out.Histological report confirmed the peritoneal melanosis and the diagnosis of metastatic spleen lesion from melanoma.Prognosis remains poor, as metachronous disease is indicative of aggressive widespread of the disease.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Surgery, Clinica Chirurgica, University of Cagliari, Policlinico Universitario di Monserrato, Sestu (CA), Italy (IR, AP, MP, AU).

ABSTRACT
Metastases to the spleen are rare and are generally part of a multi-visceral metastatic disease. The most common sources of splenic metastases include breast, lung and colorectal malignancies as well as melanoma and ovarian carcinoma. Solitary splenic metastasis is very uncommon. We present a case of a 44-year-old man who presented at our department for gallstones symptoms. He had a past medical history of neck cutaneous melanoma (T3bN0M0--Stage IIb). He had not attended follow-up schedule for personal reasons. However, abdominal ultrasound revealed the presence of a solitary solid lesion in the spleen. Preoperative workup was completed with CT scan that confirmed the presence of a large splenic lesion with subcapsular fluid collection, also compatible with a post-traumatic lesion.Preoperative findings could not exclude malignancy and patient was therefore submitted to surgery. At laparoscopy, a condition of peritoneal melanosis was present. Splenectomy was carried out. Histological report confirmed the peritoneal melanosis and the diagnosis of metastatic spleen lesion from melanoma. Patient was observed, but died of metastatic disease 14 months after surgery. Splenic metastases are uncommon. Isolated metastases from melanoma are rare and could be found several months after primary diagnosis of melanoma. Surgery remains the most effective treatment, especially for metachronous disease, offering the best chance of long-term survival. Prognosis remains poor, as metachronous disease is indicative of aggressive widespread of the disease.

Show MeSH
Related in: MedlinePlus