Melanoma And The Lung

LUNG AND MELANOMA
History
79 year old white male who came to the ER
after a fall also had one week history of
weakness, dry cough and chest congestion
without any fever or night sweats. He is a
non-smoker and non-alcoholic..
PHYSICAL EXAMINATION:
On physical exam:
he was hemodynamically stable and the only
significant finding on the physical exam was
bronchial breathing on the left lower lobe
DIAGNOSTIC STUDIES:
 WBC 10.4, Hb 8.4,Hct 27.9,MCV 91, plt 196.
 Na133, K 4.4, chloride 102, bicarb of 22, BUN
of 85, creatinine 1.7 , glucose 170, calcium
9.1.
 CXR new lung nodule at the right base and
infiltrate at the left mid lung level
CT Chest
 Diffuse interstitial and alveolar opacities
throughout both lungs, likely a combination
of acute and chronic lung disease with small
pleural effusions.
 Fairly suspicious-appearing nodule right
middle lobe 18 mm in diameter
solitary pulmonary nodule
 Malignant Etiology:
.Adenocarcinoma 50%
.Squamus cell carcinoma 25-20%
.metastatic 25% if Pt already has extrapulm ca
(colon ,breast, kidney, testicular, melanoma)
.large cell carcinoma and other lung Ca,
Malignant lymphoma and carcinoid 5%.
solitary pulmonary nodule
 Benign etiology
.Infectious Granulomas 80%
(Endemic fungi e.g., histoplasmosis, coccidioidomycosis
and mycobacteria are most common)
.Hematoma 10 %
Pathology of the patient
lung nodule
 Revealed poorly differentiated non small cell
lung neoplasm with focal necrosis.
 Results of immunohistochemistry were
consistent with melanoma.
 After this histological diagnosis the patient
was extensively examined to locate the
primary tumor but the attempts were
unsuccessful.
 Patient had a PET scan which showed
metastasis to the liver.
 Patient was classified as stage IV.
Metastatic melanoma
Nodal or visceral metastasis may be the
first presentation of melanoma .
This occurs in less than 2% of all melanoma
cases and less than 5% of all patients with
metastatic melanoma.
These patients should have a thorough skin
examination, including the anal region.
Cont. metastatic melanoma
An eye examination is appropriate if the metastatic
pattern is consistent with ocular melanoma.
upper endoscopy and colonoscopy are not
recommended unless the patient has specific signs
or symptoms suggesting mucosal melanoma as a
primary.
Sometimes patients provide history of an unusual skin
lesion arising and disappearing without biopsy or
treatment .
melanoma
 Melanoma is the most deadly cutaneous
neoplasm.
 Incidence increases by 4.1 % per year which
is faster than any other malignancy.
 Risk of developing invasive melanoma is 1 in
74 American.
 The sixth leading cause of cancer death
Risk factor
 Sun sensitivity
 White skin, fair hair, light eyes.
 Tendency to freckle
 Family Hx
 Dysplastic nevi
 Increase Number of typical nevi
 Large congenital nevi
 immunosuppressant
Prognostic factor affecting
staging
 Tumor thickness
 Ulceration
 Level of invasion
 Lymphatic involvement
 Sentinel lymph node BX,RT-PCR analysis and
no of positive lymph nodes.
 Satellite lesion.
 Local recurrence
Cont.
 Distant metastasis
skin, subcutaneous tissue or LN >LUNG
metastasis>Visceral sites (bone, liver or
brain)
 Serum LDH
Clinical Staging of Melanoma
Stage 0
Melanoma in situ
Stage Ia
≤1 mm
Stage Ib
≤1 mm, with ulceration
1.01–2.0 mm, no ulceration
Stage IIa
1.01–2.0 mm, with ulceration or 2.01–4.0 mm without
ulceration
Stage IIb
2.01–4.0 mm, with ulceration or >4.0 mm without
ulceration
Stage IIc
>4.0 mm with ulceration
Stage III
Any depth with lymph node involvement
Stage IV
Distant metastasis
treatment
 Fortunately, the majority of patients present
with stage I to IIA disease . In these patients,
surgery is curative in 70 to 90 percent of
cases.
 stage IIB disease , IIC disease , and stage III
disease are associated with a 30 to 80 percent
risk of recurrence so adjuvant chemotherapy
is needed e.g. Interferon Alfa.
Adjuvant therapy
 Interferon Alfa (IFNa)
.the standard of care for patients with resected
node-positive melanoma (stage III) and
should be considered for patients with
negative nodes whose risk of recurrence is
estimated to be 30 to 40 percent or more
(stage IIB and IIC).
Cont.
 Sage IV: treatment approaches have included
cytotoxic chemotherapy e.g. Dacarbazine
,and immunotherapy IL-2 or interferon alpha.
 The patient in our case was enrolled in
clinical trial for a new chemotherapy .
Follow up guide lines
 Asymptomatic pt with clinical stage I or II
lesions, most imaging studies are not
indicated since detection of distant
metastases is rare.
 Clinical stage III and local recurrence — has
50% rate of recurrence so CBC LDH and CXR
is mandatory as base line,CT MRI and PET
scan has low yield especially in asymptomatic
pt.
Cont.
 STAGE IV — Patients with known systemic
metastases (stage IV) should be evaluated
more comprehensively because the likelihood
of detecting additional, unsuspected lesions
is higher.
References:
1. Up to date.
2. AJCCSS.
3. American academy of family physician.
4. Conn’s current therapy.
Thank you