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Metastatic Melanoma

Scott Hession Smith

Harvard Medical School IVGillian Lieberman, MD

Scott H. Smith

Gillian Lieberman, MD

September 2001

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Agenda for Presentation

Brief overview ofdisease & preferredsites of metastasis

Discussion ofdifferent imaging

modalities formetastatic melanoma

Patient presentation

Scott H. Smith

Gillian Lieberman, MD

Melanoma, back

Color irregularity

Asymmetry

Border

irregularityImage from J. L. Melton, MD,

Loyola Univ. Chicago

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Epidemiology

Scott H. Smith

Gillian Lieberman, MD

1999 47,000 new primary melanomas

7300 deaths

~1 in 90 Americans will develop

3% of all USA cancers

3rd most common cause of brain metastases (mets)

Affects all ages

Men 30-49: 2nd

most common CA

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Risk factors

Scott H. Smith

Gillian Lieberman, MD

RISK FACTOR RELATIVE RISKAge >15 88

Pigmented lesion 7-64;148

Caucasian 12

Previous cutaneous Melanoma 5-9

Melanoma in 1st degree relative 2-8

Immunosuppression 2-8

Excessive sun (UVB) 3-5Sun sensitivity 2-3

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Numerous classifications

Scott H. Smith

Gillian Lieberman, MD

Cutaneous melanoma Malignant melanocytes

Subtypes exist

Noncutaneous

Mucosal epithelia

Retina

Leptomeninges

Melanoma, trunk

Image from J. L. Melton, MD,

Loyola Univ. Chicago

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Skin: fundamentals

Scott H. Smith

Gillian Lieberman, MD

Image: Edward Buckingham, MD, Combined Plastics Conference, 2000

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5-yr Survival and Tumor Depth

Newer staging system

I, II- localized IA= 4.00 mm

III- limited nodal met, 30-35%

IV- advanced met,~6months

Scott H. Smith

Gillian Lieberman, MD

Clarks

Levels1 2 3 4 5

Image: Edward Buckingham, MD, Combined Plastics Conference, 2000

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Clinical symptoms & signs

Scott H. Smith

Gillian Lieberman, MD

Early: size, change in shape or color,pruritis

ABCDEFs (asymmetry, irregular border,

color variation, diameter >5mm, elevation,

enlarging, Family History)

Late: tenderness, bleeding, ulceration

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Unfavorable Prognosis

Scott H. Smith

Gillian Lieberman, MD

Histologic features Ulceration

High mitotic activity

Tumor micro-satellites Vertical growth

Consider metastatic

potential!Image: Edward Buckingham, MD, Combined Plastics Conference, 2000

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Common sites for metastasis

Skin

Lungs (70%)

Lymph nodes (23-75%)

Liver (58%)

Central nervous (50%)

Kidney (35%)Bone (11-17%)

Bowel & mesentary(8%)

Spleen (1-5%)

Diagnostic dilemma:How to detect?

1. Before known mets

2. With known mets

3. While monitoringtreatment of mets

Average latentperiod of mets:

2-5 years

Scott H. Smith

Gillian Lieberman, MD

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Before known metastasis

Patients who are asymptomatic

Initial screen with PA chest x-ray

Other imaging studies rarely reveal mets whenpatients are symptom-free

Sentinel lymph node (SLN) biopsy

First node to receive tumor drainage

Other screening: Palpate regional nodes, liver, spleen

Neuro exam

Bone pain? Liver function tests

Scott H. Smith

Gillian Lieberman, MD

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Screening chest x-ray

Hematogenousspread: favors bases

Rounded opacities

Bilateral

No cavitation

No gas-fluid levels+/- hilar adenopathy

+/- pleural effusions

Scott H. Smith

Gillian Lieberman, MD

Lung mets

Image: Robert Dunn, MD, Canberra Hospital

S H S i h

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Scott H. Smith

Gillian Lieberman, MD PA chest x-ray: looking for lung, bone mets

Image: Robert Dunn, MD, Canberra Hospital

Lung mets

S tt H S ith

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Lymph nodes

Scott H. Smith

Gillian Lieberman, MD

Melanoma

Other nodes

Possible SLN

Melanoma

Possible LN spread

Diagram from Melanoma.netDiagram from Melanoma.net

S tt H S ith

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Lymphoscintography

Tumors >1mm thick

Technetium-99 injected in or around tumor

Drainage patterns visualized with gammaprobe- mark site

Inject blue dye to identify lymphatic tracks

& sentinel node

Scott H. Smith

Gillian Lieberman, MD

Scott H Smith

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Lymphoscintography

Scott H. Smith

Gillian Lieberman, MD

SLN

(L)

Technetium-99 gamma probe blue dye identification

Diagram from Melanoma.net Diagram from Melanoma.net

Scott H Smith

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Beth Israel Deaconess Patient

33 year old man with known metastaticmelanoma, multiple risk factors

Metastases to:

Brain

Kidneys

Lungs

Scott H. Smith

Gillian Lieberman, MD

Scott H Smith

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CNS mets: MRI

Often symptomatic

Magnetic resonance imaging (MRI) best

Gadolinium-enhanced MRI- most sensitive

Most mets are T2 bright and enhance Edema common

CT+ may miss small mets & leptomeningeal spread

Ddx of primary tumor: Bronchogenic carcinoma (ca) (50%)

Breast ca (20%)

Colon, rectal ca (15%) Melanoma, Renal ca (10%)

Scott H. Smith

Gillian Lieberman, MD

Scott H Smith

T2 i h d MRI

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Scott H. Smith

Gillian Lieberman, MD T2-weighted MRI

Large right frontal met:

heterogeneous hyper-intensity

Large left occipital met:heterogeneous hyperintensity

BIDMC PACS system, courtesy of Dr. M. Spencer

CSF bright

(T2)

Generalized edema wit

slight shift ofseptum

Scott H Smith

T1 i h d MRI f d li i

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Scott H. Smith

Gillian Lieberman, MD T1-weighted MRI after gadolinium

Large right frontal met

hypointense with ringenhancement

Large left occipital met:

hypointense with ring enhancement BIDMC PACS system, courtesy of Dr. M. Spencer

CSF dark

(T1)

Enhancement of

choroid plexus

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Computed Tomography (CT)

Best for abdominal viscera and peritoneumLiver: mets will enhance with contrast, best

during portal-venous phase

Kidneys: may see hemorrhage, parenchyma willenhance- can follow ureters to bladder

Abdominal cavity: +/- malignant ascites,

hemoperitoneum

Stomach: see target lesion with oral contrast

Bowel: see irregularities of lumen

Scott H. Smith

Gillian Lieberman, MD

Scott H. Smith

CT ith l t t ith t IV t t

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Scott H. Smith

Gillian Lieberman, MD CT with oral contrast, without IV contrast

BIDMC PACS system, courtesy of Dr. M. Spencer

Bilateral renal mets with massive hemorrhage

Low density lesion with hemorrhage

Scott H. Smith

CT ith l t t ith t IV t t

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Gillian Lieberman, MD CT with oral contrast, without IV contrast

BIDMC PACS system, courtesy of Dr. M. Spencer

Extravasation of left renal hemorrhage

Left iliopsoas muscle

Scott H. Smith

CT ith l t t IV t t

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Gillian Lieberman, MD CT with oral contrast, + IV contrast

Lower attenuation lesion, compressingthe renal (enhancing) parenchyma

BIDMC PACS system, courtesy of Dr. M. Spencer

Enhancing renal parenchyma

Scott H. Smith

CT ith l t t ith IV t t

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Gillian Lieberman, MD CT with oral contrast, with IV contrast

BIDMC PACS system, courtesy of Dr. M. Spencer

Scott H. Smith

CT ith oral contrast itho t IV contrast

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Gillian Lieberman, MD CT with oral contrast, without IV contrast

Courtesy of Dr. M. Spencer

Stomach with mets projecting into lumen

Scott H. Smith

CT with oral contrast without IV contrast

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Gillian Lieberman, MD CT with oral contrast, without IV contrast

Duodenum with mets projecting into lumen

Courtesy of Dr. M. Spencer

Scott H. Smith

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Gillian Lieberman, MD

Positron Emission Tomography (PET)

Future of imaging metastatic

melanoma?

Use of glucose analog (FDG-glucose)

Advantages: melanoma has high FDG uptake= high

sensitivity in detecting mets early

Able to distinguish between recurrent

disease & radiation necrosis Single test for entire body

Limitations:

CT is better for small pulmonarylesions

Image from Kiran Mehta, MD

Increased

uptake by

mets

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Gillian Lieberman, MD

Positron Emission Tomography (PET)

Malignant melanomaof the right shoulder(bright white spotsnear crossed yellow

lines)

Mets involving theright upper lobeperipherally as well asthe right hilum andmediastinum

Image from Lyndon Gritters, Univ. of Iowa

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Gillian Lieberman, MD

References

Allan, R. Sentinel node localization: do or dye alone? The British Journal of

Radiology, 74 (2001), 475-77. Buckingham, Edward.Melanoma. Combined Plastics Conference, September 6, 2000.

Carvahlo, Paulo.Metastatic Melanoma. Atlas of Brain Perfusion SPECT, case 2, June

1998.

Gritters, Lyndon S., Francis, Isaac R., Zasadny and Wahl, Richard L., "Initial

Assessment of Positron Emission Tomography Using 2-Flourine-18-Fluoro-2Deoxy-

D-Glucose in the Imaging of Malignant Melanoma" The Journal of Nuclear Medicine

(Sept 1993) 1420-1427.

Mehta, Kiran.Melanoma and lymphomas: PET scan applications. SFJM Vol. 4, no. 2:

1-5. Mehta, Sheila. CNS Melanoma. eMedicine Journal, August 20, 2001; Vol.2, #8:1-11.

Terhune, Margaret H., Swanson, Neil, Johnson, Timothy. Use of Chest Radiography in

the Initial Evaluation of Patients with Localized Melanoma. Archives of Dermatology,

May 1998; Vol 134, no. 5: 569-72.

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Acknowledgements

Special thanks to: Gillian Lieberman, MD

Matthew Spencer, MD

Pamela Lepkowski

Larry Barbaras and Cara Lyn Damour

David Quinlan

Gillian Lieberman, MD