Download Imaging in Metastatic Melanoma

Imaging in
Metastatic
Melanoma
Nilanthi Gunawardane
Gillian Lieberman, MD
March 2008
Malignant Melanoma
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Neoplasm of pigment-forming cells,
melanocytes, and nevus cells
Types of melanoma
Superficial spreading
Lentigo maligna
Nodular
Acral lentiginous
www.metrohealth.org
Epidemiology
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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
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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
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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
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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
Recommended
Functions as baseline
Optional periodic CXR q3-6
months
Low sensitivity for detection of
metastasis
Optional periodic CXR q3-6
months
Low sensitivity for detection of
metastasis but higher than stage
I and II
CT
Low yield and high false
positive rate (10-20%)
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
Not indicated
Low sensitivity
Recommended
More sensitive than MRI, CT
PET/CT more accurate than
PET b/c able to correlate
anatomic localization with
physiologic information
MRI
Not indicated
Most sensitive modality to
assess brain mets
Routine imaging in
asymptomatic patients
controversial
Lymphoscintigraphy
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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
 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
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Neoplasm
Infection
Inflammation
Uptake in brain, skeletal muscle, brown fat,
myocardium, bowel
Urinary collecting system
Mr. H: Further Follow-up
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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
Axial T2 GRE
brain MRI
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
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Melanoma
Anaplastic lung carcinoma
Thyroid carcinoma
Choriocarcinoma
Hypernephroma
Companion Patient #1: Melanotic Pattern of
Melanoma
Non-enhanced axial T1 MR
Increased signal intensity on T1
Non-enhanced axial T2 MR
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
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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
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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
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Dr. Lieberman
Dr. Andrew Hines-Peralta
Dr. Kevin Donohoe
Rachel Jimenez
Maria Levantakis
References
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Escott E, A Variety of Appearances of Malignant Melanoma in the Head: A Review.
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