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Metastatic choroidal melanoma presenting as a solitary pulmonary nodule
Metastatic choroidal melanoma presenting as a solitary pulmonary nodule Vinicius S. Saraiva,* MD; Abelardo A. Rodriguez-Reyes,* MD; Moy F. Chen,† MD; Eun Joo Park Saraiva,‡ MD; Miguel N. Burnier, Jr.,* MD, PhD, FRCSC
U
veal melanoma is the most common primary intraocular tumour in adults. When metastatic dissemination occurs, the liver is the most frequent site of involvement; the lungs are the next most frequent site. When lung metastasis occurs it is usually characterized by numerous nodules. Isolated lung involvement is uncommon, and a solitary pulmonary nodule is an exceedingly rare presentation. To our knowledge, only six cases of metastatic choroidal melanoma presenting as a solitary pulmonary nodule have been previously described, of which four were treated with enucleation1–4 and two with plaque radiotherapy.5
CASE
REPORT
A 48-year-old white man was referred with an asymptomatic peripapillary pigmented choroidal mass in his right eye. Ultrasound examination showed a choroidal tumour measuring 10 mm by 6 mm by 2 mm with medium to low internal reflectivity. Ten months later, follow-up ultrasound examinations revealed tumour growth (10 mm by 8 mm by 3 mm) associated with serous retinal detachment. Systemic evaluation was unremarkable. The patient was treated with proton beam radiotherapy (total dose 60 cobalt-gray equivalent). There was no sign of tumour enlargement for the next 6 years, after which tumour regrowth was diag-
From *the Henry C. Witelson Ophthalmic Pathology Laboratory and Registry and the Departments of †Pathology and ‡Diagnostic Radiology, McGill University, Montreal, Que. Originally received Mar. 26, 2004 Accepted for publication Sept. 3, 2004 Correspondence to: Dr. Vinicius S. Saraiva, Henry C. Witelson Ophthalmic Pathology Laboratory, Room 216, 3775 University St., Montreal QC H3A 2B4; fax (514) 398-5728; vinicius@oftalmo. epm.br This article has been peer-reviewed. Can J Ophthalmol 2005;40:72–4
72
Solitary lung nodule—Saraiva et al
nosed on ultrasonography (13 mm by 12 mm by 3 mm). Uneventful enucleation was performed. Histopathological examination of the enucleated eye showed a mixed-cell-type choroidal melanoma with areas of necrosis and intrascleral and extraocular invasion (Fig. 1, left). Four years later a solitary nodule measuring 15 mm in diameter in the superior lobe of the right lung was incidentally discovered on chest radiography and was confirmed by computed tomography (Fig. 2). The nodule was surgically resected, and the histopathological diagnosis was metastatic melanoma (Fig. 1, right). Immunohistochemical staining of the nodule gave positive results for S-100 protein and HMB-45. No other sites of metastatic disease were found. Despite chemotherapy (first with bryostatin and later with dacarbazine), recurrent metastatic disease developed in the right hemithorax. There was extrinsic compression of the lower esophagus, leading to progressive dysphagia and severe wasting. The patient died 16 months after lung metastasis was initially diagnosed. A complete autopsy was performed. There was no evidence of cutaneous malignant melanoma. The right hemithorax was completely replaced by metastatic uveal melanoma, and the overlying skin and subcutaneous tissue of the lateral chest wall were involved, as were the hilar lymph nodes. There were no other metastatic sites.
COMMENTS In comparison with the previously reported cases,1–5 the distinctive feature of our case is the initial treatment with proton beam irradiation. Furthermore, there was a 6-year interval between radiotherapy and diagnosis of local recurrence, and a 10-year interval between radiotherapy and diagnosis of the metastatic lung nodule. Failure of proton beam radiotherapy is uncommon. However, tumour-specific survival is known to be substantially decreased in patients with recurrent uveal melanoma after proton beam irradiation.6 In any patient with a solitary pulmonary nodule and
Solitary lung nodule—Saraiva et al
Fig. 1—Left: Photomicrograph of choroidal melanoma, showing (from top to bottom) degenerated overlying retina, peripapillary choroidal melanoma, and intrascleral and extraocular invasion (hematoxylin–eosin; magnification ×25). Right: Photomicrograph of solitary pulmonary nodule, showing normal alveoli at top and replacement of lung parenchyma by metastatic choroidal melanoma at bottom (hematoxylin–eosin; magnification ×200).
complete surgical removal of metastatic uveal melanoma in selected patients, including two with a solitary lung nodule. In conclusion, although rare, a solitary pulmonary nodule may be the first clinical manifestation of metastatic choroidal melanoma and may occur after failed proton beam radiotherapy.
REFERENCES 1.
2. Fig. 2—Axial computed tomography scan of chest, showing solitary pulmonary nodule (black arrow). 3.
a previous history of malignant disease, it is of paramount importance to rule out metastasis from the primary site. Therefore, surgical resection should be performed in order to obtain a definitive histopathological diagnosis.7 Surgical removal of tumours metastatic to the lung offers improved palliation and extended survival, particularly in cases in which the pulmonary lesion is solitary and there is no extrathoracic disease.8 Kath and colleagues9 found that the median survival of patients with uveal melanoma who experienced metastasis without liver involvement was better than that of patients with liver involvement (19 versus 7 months). Aoyama and associates5 reported longer survival after
4.
5.
6.
Reed RJ 3rd, Kent EM. Solitary pulmonary melanomas: two case reports. J Thorac Cardiovasc Surg 1964;48:226–31. Harada S, Kuwahara T, Kido M, Kajiki A, Ishikura Y, Koide O. Solitary pulmonary metastasis of choroidal malignant melanoma: report of an unusual case. Endoscopy 1983;15(6):363–4. Tishler M, Greif J, Topilsky M. Solitary pulmonary metastasis of choroidal malignant melanoma simulating primary lung cancer. Eur J Respir Dis 1986; 68(3):215–7. Keller H, Hacker R, Stolte M. [Simultaneous enucleation of a pulmonary melanoma metastasis and myocardial revascularization.] Med Klin (Munich) 1997;92(11):683–5. Aoyama T, Mastrangelo MJ, Berd D, Nathan FE, Shields CL, Shields JA, et al. Protracted survival after resection of metastatic uveal melanoma. Cancer 2000;89(7):1561–8. Egger E, Schalenbourg A, Zografos L, Bercher L, Boehringer T, Chamot L, et al. Maximizing local tumor control and survival after proton beam radiotherapy of uveal melanoma. Int J Radiat Oncol Biol
CAN J OPHTHALMOL—VOL. 40, NO. 1, 2005
73
Solitary lung nodule—Saraiva et al
7.
8.
Phys 2001;51(1):138–47. Ost D, Fein A. Evaluation and management of the solitary pulmonary nodule. Am J Respir Crit Care Med 2000;162(3 Pt 1):782–7. Greelish JP, Friedberg JS. Secondary pulmonary malignancy. Surg Clin North Am 2000;80(2):633–57.
IN THE
NEXT ISSUE
• DANS
9.
Kath R, Hayungs J, Bornfeld N, Sauerwein W, Hoffken K, Seeber S. Prognosis and treatment of disseminated uveal melanoma. Cancer 1993;72(7):2219–23.
Key words: solitary pulmonary nodule, choroidal neoplasm, melanoma
LE PROCHAIN NUMÉRO
IOP control in patients with glaucoma or ocular hypertension receiving treatment Effect of the menstrual cycle on the optic nerve head in women with diabetes mellitus Lymphoproliferative lesions of the lacrimal gland: clinicopathological, immunohistochemical and molecular genetic analysis
74
CAN J OPHTHALMOL—VOL. 40, NO. 1, 2005
U
veal melanoma is the most common primary intraocular tumour in adults. When metastatic dissemination occurs, the liver is the most frequent site of involvement; the lungs are the next most frequent site. When lung metastasis occurs it is usually characterized by numerous nodules. Isolated lung involvement is uncommon, and a solitary pulmonary nodule is an exceedingly rare presentation. To our knowledge, only six cases of metastatic choroidal melanoma presenting as a solitary pulmonary nodule have been previously described, of which four were treated with enucleation1–4 and two with plaque radiotherapy.5
CASE
REPORT
A 48-year-old white man was referred with an asymptomatic peripapillary pigmented choroidal mass in his right eye. Ultrasound examination showed a choroidal tumour measuring 10 mm by 6 mm by 2 mm with medium to low internal reflectivity. Ten months later, follow-up ultrasound examinations revealed tumour growth (10 mm by 8 mm by 3 mm) associated with serous retinal detachment. Systemic evaluation was unremarkable. The patient was treated with proton beam radiotherapy (total dose 60 cobalt-gray equivalent). There was no sign of tumour enlargement for the next 6 years, after which tumour regrowth was diag-
From *the Henry C. Witelson Ophthalmic Pathology Laboratory and Registry and the Departments of †Pathology and ‡Diagnostic Radiology, McGill University, Montreal, Que. Originally received Mar. 26, 2004 Accepted for publication Sept. 3, 2004 Correspondence to: Dr. Vinicius S. Saraiva, Henry C. Witelson Ophthalmic Pathology Laboratory, Room 216, 3775 University St., Montreal QC H3A 2B4; fax (514) 398-5728; vinicius@oftalmo. epm.br This article has been peer-reviewed. Can J Ophthalmol 2005;40:72–4
72
Solitary lung nodule—Saraiva et al
nosed on ultrasonography (13 mm by 12 mm by 3 mm). Uneventful enucleation was performed. Histopathological examination of the enucleated eye showed a mixed-cell-type choroidal melanoma with areas of necrosis and intrascleral and extraocular invasion (Fig. 1, left). Four years later a solitary nodule measuring 15 mm in diameter in the superior lobe of the right lung was incidentally discovered on chest radiography and was confirmed by computed tomography (Fig. 2). The nodule was surgically resected, and the histopathological diagnosis was metastatic melanoma (Fig. 1, right). Immunohistochemical staining of the nodule gave positive results for S-100 protein and HMB-45. No other sites of metastatic disease were found. Despite chemotherapy (first with bryostatin and later with dacarbazine), recurrent metastatic disease developed in the right hemithorax. There was extrinsic compression of the lower esophagus, leading to progressive dysphagia and severe wasting. The patient died 16 months after lung metastasis was initially diagnosed. A complete autopsy was performed. There was no evidence of cutaneous malignant melanoma. The right hemithorax was completely replaced by metastatic uveal melanoma, and the overlying skin and subcutaneous tissue of the lateral chest wall were involved, as were the hilar lymph nodes. There were no other metastatic sites.
COMMENTS In comparison with the previously reported cases,1–5 the distinctive feature of our case is the initial treatment with proton beam irradiation. Furthermore, there was a 6-year interval between radiotherapy and diagnosis of local recurrence, and a 10-year interval between radiotherapy and diagnosis of the metastatic lung nodule. Failure of proton beam radiotherapy is uncommon. However, tumour-specific survival is known to be substantially decreased in patients with recurrent uveal melanoma after proton beam irradiation.6 In any patient with a solitary pulmonary nodule and
Solitary lung nodule—Saraiva et al
Fig. 1—Left: Photomicrograph of choroidal melanoma, showing (from top to bottom) degenerated overlying retina, peripapillary choroidal melanoma, and intrascleral and extraocular invasion (hematoxylin–eosin; magnification ×25). Right: Photomicrograph of solitary pulmonary nodule, showing normal alveoli at top and replacement of lung parenchyma by metastatic choroidal melanoma at bottom (hematoxylin–eosin; magnification ×200).
complete surgical removal of metastatic uveal melanoma in selected patients, including two with a solitary lung nodule. In conclusion, although rare, a solitary pulmonary nodule may be the first clinical manifestation of metastatic choroidal melanoma and may occur after failed proton beam radiotherapy.
REFERENCES 1.
2. Fig. 2—Axial computed tomography scan of chest, showing solitary pulmonary nodule (black arrow). 3.
a previous history of malignant disease, it is of paramount importance to rule out metastasis from the primary site. Therefore, surgical resection should be performed in order to obtain a definitive histopathological diagnosis.7 Surgical removal of tumours metastatic to the lung offers improved palliation and extended survival, particularly in cases in which the pulmonary lesion is solitary and there is no extrathoracic disease.8 Kath and colleagues9 found that the median survival of patients with uveal melanoma who experienced metastasis without liver involvement was better than that of patients with liver involvement (19 versus 7 months). Aoyama and associates5 reported longer survival after
4.
5.
6.
Reed RJ 3rd, Kent EM. Solitary pulmonary melanomas: two case reports. J Thorac Cardiovasc Surg 1964;48:226–31. Harada S, Kuwahara T, Kido M, Kajiki A, Ishikura Y, Koide O. Solitary pulmonary metastasis of choroidal malignant melanoma: report of an unusual case. Endoscopy 1983;15(6):363–4. Tishler M, Greif J, Topilsky M. Solitary pulmonary metastasis of choroidal malignant melanoma simulating primary lung cancer. Eur J Respir Dis 1986; 68(3):215–7. Keller H, Hacker R, Stolte M. [Simultaneous enucleation of a pulmonary melanoma metastasis and myocardial revascularization.] Med Klin (Munich) 1997;92(11):683–5. Aoyama T, Mastrangelo MJ, Berd D, Nathan FE, Shields CL, Shields JA, et al. Protracted survival after resection of metastatic uveal melanoma. Cancer 2000;89(7):1561–8. Egger E, Schalenbourg A, Zografos L, Bercher L, Boehringer T, Chamot L, et al. Maximizing local tumor control and survival after proton beam radiotherapy of uveal melanoma. Int J Radiat Oncol Biol
CAN J OPHTHALMOL—VOL. 40, NO. 1, 2005
73
Solitary lung nodule—Saraiva et al
7.
8.
Phys 2001;51(1):138–47. Ost D, Fein A. Evaluation and management of the solitary pulmonary nodule. Am J Respir Crit Care Med 2000;162(3 Pt 1):782–7. Greelish JP, Friedberg JS. Secondary pulmonary malignancy. Surg Clin North Am 2000;80(2):633–57.
IN THE
NEXT ISSUE
• DANS
9.
Kath R, Hayungs J, Bornfeld N, Sauerwein W, Hoffken K, Seeber S. Prognosis and treatment of disseminated uveal melanoma. Cancer 1993;72(7):2219–23.
Key words: solitary pulmonary nodule, choroidal neoplasm, melanoma
LE PROCHAIN NUMÉRO
IOP control in patients with glaucoma or ocular hypertension receiving treatment Effect of the menstrual cycle on the optic nerve head in women with diabetes mellitus Lymphoproliferative lesions of the lacrimal gland: clinicopathological, immunohistochemical and molecular genetic analysis
74
CAN J OPHTHALMOL—VOL. 40, NO. 1, 2005