Primary spinal melanoma of extramedullary origin: a report of three cases and systematic review of the literature

Primary Spinal Malignant Melanoma Mimicking a Cervical Nerve Root Schwannoma: Case Report and Literature Review

Primary spinal malignant melanoma (PSMM) is a rare cancer of the central nervous system (CNS), and PSMM of the spinal nerve root is even more extraordinary. PSMM of a nerve root can mimic the radiographic appearance of benign nerve sheath tumors, thus resulting in misdiagnosis until tissue diagnosis can be made. A 53-year-old African American woman presented with pain primarily involving the left aspect of her neck and shoulder for 2 years. Magnetic resonance imaging (MRI) of the cervical spine demonstrated a T1-hyperintense, T2-hypointense, homogenously enhancing, dumbbell-shaped, intradural extramedullary mass extending out through the left C2-3 foramen. A midline incision was used to perform a C2 and C3 laminectomy, and the mass was removed from the cavity. The histopathologic profile was consistent with the diagnosis of malignant melanoma. The present case report adds to the 110 cases of PSMM and the 20 cases of PSMM of the spinal nerve root in the existing body of literature. Radiographic and clinical features resemble that of the much more common schwannoma or neurofibroma requiring immunohistochemical analysis for definitive diagnosis. The optimal treatment for PSMM has not yet been defined due to its rarity and it is therefore important to report such cases in order to share our clinical experiences and provide data to other clinicians treating this uncommon disease.

Primary Spinal Intradural Melanocytoma of the Thoracic Region: A Rare Case

While the presence of metastatic melanocytoma in the central nervous system (CNS) is relatively common, primary spinal melanocytoma (PSM) is an extremely rare entity. Only 70 cases have been reported, and its usual position is the cervical region. We report a case of a 35-year-old male with primary spinal intramedullary melanocytoma with a dorsal exophytic component. The tumor was first opened in the periphery and was closed without being operated upon due to it being an uncommon pathology.

Malignant Melanoma Presenting as Spinal Cord and Pleural Lesions

Primary spinal cord melanoma (PSCM) and primary pleural melanoma (PPM) are extremely rare entities with scarce cases reported in the literature. We present a case of a 54-year-old male diagnosed with possible primary pleural melanoma and primary spinal melanoma, managed with partial surgical resection, postoperative radiotherapy, and chemotherapy consisting of Ipilimumab, nivolumab, and temozolomide. This leads to decreased symptoms and improved quality of life of the patient. In this case report, we review the literature on PSCM and PPM in detail, addressing the pertinent clinical aspects as well as current and upcoming therapeutic options.

Malignant melanotic nerve sheath tumors in the spinal canal of psammomatous and non-psammomatous type: Two case reports

BACKGROUND

A malignant melanotic nerve sheath tumor (MMNST), previously known as a melanotic schwannoma, is a rare variant of a peripheral nerve sheath tumor composed of Schwann cells with melanotic differentiation. Only a few reports of spinal MMNST have been reported.

CASE SUMMARY

In the first case, a 58-year-old woman presented with a history of low back pain and paresthesia. Magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbar spine revealed an intradural extramedullary mass lesion with amorphous linear calcification. Complete tumor resection was performed and histological examination revealed a psammomatous melanotic schwannoma. In the second case, a 72-year-old man presented with low back pain and paresthesia. MRI of the thoracolumbar spine revealed an intramedullary mass lesion at the T11 vertebral body level. The mass lesion was hypointense on T2WI and hyperintense on T1WI. Tumor resection was performed and the histologic result was melanotic schwannoma.

CONCLUSION

MMNST should be considered in the differential diagnosis when calcification or melanin is seen in an intradural spinal tumor.

Primary Spinal Melanoma: Case Report and Systematic Review

INTRODUCTION

Primary malignant melanoma of the spinal cord (PSM) is a rare condition with limited evidence regarding its diagnosis (clinical and radiographic), management, and prognosis. Our aim was to report an extremely rare two cases of primary malignant melanoma of the spine one of them is sacral melanoma which represents the second reported case in the literature and to conduct a systematic review of the relevant literature.

METHODS

The diagnosis and management of these cases were retrospectively reviewed. Using the PRISMA guideline, we conducted a systematic review of the literature to analyze different management strategies and the prognosis of such pathology.

RESULTS

All two patients were operated on, and received gross total removal of their tumors, with extended follow up for tumor recurrences. One of the cases involved a sacral tumor, which was resected without adjuvant therapy. The other one was seen by oncology and received post-operative chemo- and radio- therapy. In addition to the aforementioned cases, we present a comprehensive review of the literature on PSM from 1950 to the present, demonstrating that PSM is a very rare tumor, with a limited counted number of cases reported worldwide.

CONCLUSION

In conclusion, we report an exceedingly rare two cases of primary malignant melanoma of the spine. Early surgical intervention is key to the management of these rare and aggressive tumors. GTR should be attempted if possible.

Primary intramedullary melanoma of lumbar spinal cord: A case report

BACKGROUND

Primary intramedullary melanoma is a very rare tumor, most frequently occurring in the cervical and thoracic spinal cord.

CASE SUMMARY

We present a rare case in which the primary intramedullary melanoma was located in the lumbar spine. A 56-year-old man complained of progressive intermittent pain in the lumbar area. Thoracic magnetic resonance imaging showed a spinal intramedullary tumor between the L3 and S1 levels. The tumor was resected entirely, and the diagnosis of malignant melanoma was confirmed by histopathology.

CONCLUSION

Primary melanoma of the spinal cord, particularly intramedullary localization, has rarely been reported in the previous literature. We describe a primary malignant melanoma of the lumbar spinal cord and discuss the challenges associated with the diagnosis.

Primary Spinal Melanoma With Intra- and Extradural Extensions: A Rare Case

Primary spinal melanoma (PSM) is a rare primary central nervous system melanoma with limited literature. A 30-year-old male presented with one year of progressive bilateral leg weakness and back pain. Physical examination revealed slightly decreased power and deep tendon reflexes of the lower extremities, decreased sensation at the level of T10, and normal anal sphincter and plantar reflexes. Magnetic resonance imaging (MRI) scan of the thoracolumbar spine revealed a hypointense lesion on T2-weighted and a hyperintense lesion on T1-weighted imaging at the level of T10 with mild extensions. The lesion was causing a mass effect on the spinal cord. The patient underwent laminectomy and near-total excision which showed a black, firm-to-hard, scarcely vascular extradural tumor extending from T10 to T11 that adhered to nerve roots. Histopathological examination and immunostaining with S-100 and Melan-A stains confirmed the diagnosis of malignant melanoma. Other imaging studies like brain computed tomography (CT) and positron emission tomography/computed tomography (PET/CT) scans, and chest X-ray were normal. On follow-up, the patient reported improvement in the power of his lower limbs with intact sensory function and sphincters. The first radiotherapy session was scheduled for six weeks postoperatively. There was no recurrence at a two-year follow-up. The possibility of a melanocytic tumor should be considered for a spinal lesion with paramagnetic properties as early surgical intervention is important for diagnosis and improved survival.

Extramedullary malignant melanotic schwannoma of the spine: Case report and an up to date systematic review of the literature

BACKGROUND

Melanotic schwannoma is a rare variant of schwannoma. Extramedullary melanotic schwannoma originates in the vicinity of nerve roots mimicking other intervertebral disc disorders. Therefore, T1 and T2-weighted MRI sequences become an essential tool for diagnosis. Aside from case reports, no large studies exist to provide consensus on the signal intensities in T1 and T2-weighted MR imaging. Moreover, no clear evidence is available to delineate prognosis. Here, a case report is presented together with a subsequent systematic review of the literature regarding this rare entity.

CASE DESCRIPTION

A 45-year old female presented with a one-year history of insidious onset of neck pain and paraesthesia. Magnetic resonance imaging confirmed an extramedullary lesion along the C6 nerve root with T1-weighted hyperintensity and T2-weighted hypointensity. Despite two surgical decompressions and adjuvant immunotherapy, the patient unfortunately passed away due to metastatic progression.

DISCUSSION

According to the systematic review conducted, in over half of the cases of extramedullary melanotic schwannoma, there is local reoccurrence and/or distal metastasis. Moreover, in 64.7% and 70.6% of the cases, the T1-weighted image of the lesion appears hyperintense and hypointense on a T2-weighted image, respectively. It is an aggressive variant of schwannoma, one of the most commonly observed extramedullary tumours presenting to neurosurgical practice.

CONCLUSION

Our results highlight that specific T1 and T2-weighted imaging findings can provide valuable information, enabling early suspicion, influencing the surgical aims and strategy and the timely commencement of relevant immunotherapy. Considering the poor prognosis, early adjuvant therapy with other modalities should be considered.

Primary Spinal Cord Melanoma of Intradural Extramedullary Origin

Primary malignant melanoma is the very rare entity of the central nervous system. It accounts only 1% of all melanoma cases. A 67-year-old patient presented to us with lower back pain radiating to the left lower limb and progressive weakness of both lower limbs. She underwent magnetic resonance imaging scan of lumbosacral region that suggested T1 hyperintense, T2 hypointense, extramedullary altered signal intensity lesion at L1 and L2 vertebral level compressing terminal spinal cord, and cauda equine region. On histopathological examination, findings were suggestive of malignant melanoma that was confirmed with immunohistochemistry examination (positive for S-100, Melan-A, and HMB-45). Here, we are discussing an unusual case of primary malignant melanoma of conus and cauda equine region with comprehensive review regarding management and prognosis of the tumor.

Hydrocephalus Secondary to Intradural Extramedullary Malignant Melanoma of Spinal Cord

BACKGROUND

Hydrocephalus secondary to spinal cord tumors is rare.

CASE DESCRIPTION

We present a 39-year-old male with gradual-onset headache whose initial diagnosis was cerebral aneurysm and communicating hydrocephalus. The correct diagnosis was primary intradural extramedullary malignant melanoma of the spinal cord. Initial brain magnetic resonance imaging demonstrated slight dilation of cerebral ventricles and a 3-mm unruptured anterior communicating artery aneurysm. He was placed under observation therapy. Two months later he was seen again due to severe headache. There was no intracranial hemorrhage on brain computed tomography scans. As we suspected rupture of the aneurysm, we operated on him for surgical clipping; however, there was no aneurysmal rupture. We found no lesions responsible for hydrocephalus, so we placed a ventriculoperitoneal shunt. His headache subsequently resolved. Nine months later he developed gait disturbance; a large volume of ascites was observed. Gadolinium-enhanced lumbar magnetic resonance imaging revealed an intradural extramedullary mass at the L-1 to S-5 level. Cytology and immunohistochemistry of the cerebrospinal fluid and ascites identified a few atypical cells positive for HMB-45, S-100 protein, and Melan-A. Whole-body examinations detected no primary lesions outside the central nervous system. Our final diagnosis was primary intradural extramedullary malignant melanoma of the spinal cord with cerebrospinal fluid dissemination.

CONCLUSIONS

Our findings indicate that communicating hydrocephalus may be due to primary malignant melanoma of the spinal cord.

Primary Spinal Cord Melanoma: A Case Report and a Systemic Review of Overall Survival

BACKGROUND

The incidence of primary spinal cord melanoma (PSCM) is rare. Several case series and case reports have been published in the literature. However, the predictive factors of PSCM survival and management options are not discussed in detail.

METHODS

We present a case of PSCM; total resection was achieved and chemotherapy was given postoperatively. A comprehensive search was performed on PubMed's electronic database using the words "primary spinal cord melanoma." Survival rates with various gender, location, treatment, and metastasis condition were collected from the published articles and analyzed.

RESULTS

Fifty nine cases were eligible for the survival analysis; 54% were male and 46% were female. Patient sex did not influence overall survival. The most common location was the thorax. Patient sex and tumor location did not influence overall survival. The major presenting symptoms were weakness and paresthesia of the extremities. Metastasis or dissemination was noted in 45.16% of 31 patients. In the Kaplan-Meier survival analysis, patients who had metastasis had the worst prognosis. Extent of resection was not related to mortality. Patients who received surgery and surgery with adjuvant therapy had a better median survival than did those who had adjuvant therapy alone. Prognosis was worst in those patients who underwent only adjuvant therapy without surgery (5 months).

CONCLUSIONS

Surgery is the first treatment of choice in treating PSCM. The goal of tumor resection is to reduce symptoms. Adjuvant therapy after surgery had a beneficial effect on limiting the metastasis.

Primary Extradural Melanoma Arising in Cervical Spinal Nerve Root

BACKGROUND

Primary cervical melanoma is rare; this is especially true of extradural melanoma arising in the nerve root. Characterizing these cases can provide a basis for improved melanoma management.

CASE DESCRIPTION

A 42-year-old female patient with numbness and pain in the right shoulder and arm persisting for 5 years was admitted. Preoperative magnetic resonance imaging revealed an epidural ladle-shaped mass shape beyond the C7-T1 intervertebral foramen that resembled a nerve sheath tumor. Histopathologic analysis following complete resection confirmed the lesion as malignant melanoma. Radiotherapy and temozolomide and cisplatin chemotherapy were administered in an accompanying hospital with regular follow-ups at our institution. After 2 months of postoperative adjuvant therapy, hepatic metastatic lesions developed. The chemotherapy regimen was changed to carboplatin, nab-paclitaxel, and recombinant human endostatin injections for a 6-month period. Follow-up 8 months after chemotherapy (16 months post surgery) indicated a good prognosis.

CONCLUSIONS

In the past 10 years only 1 case of primary extradural spinal melanoma in cervical intervertebral foramen has been described, with no reported cases of hepatic metastasis. As radiographic results are not unequivocal, a diagnosis of spinal melanoma must be based on postoperative histologic confirmation. However, to date there is no standard postoperative adjuvant therapy for these patients. The chemotherapy regimen described in this report has broader implications for melanoma treatment.