SESSION TITLE: Bronchology/Interventional Procedures Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: Metastatic melanoma is an often fatal disease. It can involve central airways and cause obstruction. Primary melanoma of the trachea is rare, but airway metastases are more common. Bronchoscopy is indicated for diagnosis and palliation.
CASE PRESENTATION: A 64 year old nonsmoking woman with a history of metastatic melanoma had an abnormal surveillance positive emission tomography (PET) scan demonstrating FDG avidity in a station 2R lymph node and was scheduled for endobronchial ultrasound transbronchial needle aspiration (figure 1). Corresponding CT imaging also revealed non-FDG avid endotracheal mucosal irregularities. Her melanoma was diagnosed in 1998 and treated with wide local excision. She suffered multiple recurrences, including local failure in 1999, and metastatic disease in the parotid in 2000 and 2006, femur in 2009, and a preauricular node in 2009. Each occurrence was treated with surgery, radiation, chemotherapy, immunotherapy, or combinations thereof. Airway examination revealed diffuse involvement of the trachea with multiple exophytic black nodular lesions and plaques which extended from the 2nd tracheal ring to the secondary carinas bilaterally. These lesions corresponded to the mucosal irregularities on CT scan (figure 2). The degree of obstruction was approximately 30% within the proximal trachea. Endobronchial biopsy confirmed metastatic melanoma. Airway patency was improved with a combination of thermal and mechanical debridement techniques.
DISCUSSION: PET/CT is highly sensitive and specific in the staging and restaging of melanoma1,2. In the majority of cases, melanoma is intensely FDG avid. However, metastatic disease, especially to lungs, may be missed on PET. Detection of metastatic involvement may be increased with the careful analysis of the coregistered CT images3. While identification of parenchymal metastases can be straightforward, airway involvement can be far more subtle. Any endoluminal or mucosal irregularities warrant further investigation.
CONCLUSIONS: Involvement of the central airways by metastatic melanoma is rare. Imaging is frequently directed towards assessment of pulmonary parenchyma or lymph nodes, but particular attention to endobronchial abnormalities may provide early diagnosis prior to airway compromise.
Reference #1: Pleiss C, Risse J, Biersack H, and Bender H. Role of FDG-PET in the assessment of survival prognosis in melanoma. Cancer Biother Radiopharm 2007 Dec;22:740-7
Reference #2: Dinesh S, Suneetha B, and A Sen. A rare case of primary malignant melanoma of clivus with extensive skeletal metastasis demonstrated on 18F-FDG PET/CT. Indian J Nucl Med 2013 Oct;28:234-6
Reference #3: Strobel K, Dummer R, Husarik D, et al. High-risk melanoma: accuracy of FDG PET/CT with added CT morphologic information for detection of metastases. Radiology 2007 Aug;244:566-74
DISCLOSURE: The following authors have nothing to disclose: Jennifer Toth, Joshua Hoffman, Michael Reed, Christopher Gilbert
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