Skeletal muscle and solitary bone metastases from malignant melanoma: multimodality imaging and oncological outcome

Spinal Complications of Melanoma: A Case of Acute Paraplegia

Melanoma is an aggressive cancer with a high potential for metastasis, commonly spreading to organs such as the lungs, brain, liver, and bones. Bone metastases, particularly to the spine, are a frequent complication and can result in severe pain, spinal cord compression, and neurological deficits. Prompt diagnosis and treatment are critical, though managing spinal metastases from melanoma poses significant challenges. We present the case of a 41-year-old man with a history of malignant melanoma who developed acute paraplegia following a pathological fracture of the third thoracic vertebra. The patient reported rapidly worsening back pain and loss of motor function in the lower extremities. Magnetic resonance imaging revealed a metastatic lesion in the third thoracic vertebrae, causing spinal cord compression. An emergency open laminectomy with partial tumor resection and vertebroplasty was performed to decompress the spinal cord and stabilize the spine. Postoperative recovery was remarkable, with significant improvement in motor and sensory function within 48 hours. Histopathological and immunohistochemical analysis confirmed the metastatic melanoma diagnosis. This case highlights the challenges of diagnosing and managing acute paraplegia caused by spinal metastases in melanoma patients. Early recognition of symptoms and timely intervention are crucial to improving neurological outcomes.

Management of intramuscular melanoma metastases to the psoas

We detail a case of a woman in her 40s with isolated melanoma skeletal muscle metastasis (MSMM) to the right psoas muscle. This patient underwent R0 surgical resection through a novel pelvic approach. She received subsequent adjuvant immunotherapy with Braftovi/Mektov along with adjuvant radiation. She is currently disease free at 9 months post surgery. Here, we describe our novel surgical approach including description of the tumour pathology. We explain our multidisciplinary management of MSMM consisting of a multidisciplinary surgical approach by surgical oncology, gynecological oncology and urology as well as multidisciplinary medical management by oncology, radiation oncology and pathology. Finally, we discuss best current options for therapeutic management.

The Impact of Adjunct Medical Therapy on Survival after Spine Metastasis: A Systematic Review and Pooled Data Analysis

Targeted therapy has greatly improved the outlook for patients with spinal metastatic cancers. Scoring systems like the Tokuhashi or Tomita scores are commonly used to predict prognosis and inform surgical decisions, but they are outdated and fail to consider recent advancements. We aimed to investigate the current state of the literature and treatment options pertaining to advancements in targeted therapy compared to other forms of medical management for metastatic spinal tumors. This study represents the first comprehensive systematic review that encompasses the most common primary cancers that metastasize to the spine and evaluates the median overall survival (mOS) across five different medical treatment modalities as well as surgical intervention. Additionally, our study analyzes the tumor receptor status in conjunction with these treatments. A PubMed search was conducted, and according to the PRISMA guidelines, 28 articles out of 1834 met the inclusion criteria. The pooled data analysis highlighted the superior efficacy of targeted therapy, evidenced by a significant improvement in the mOS and lower hazard ratios in patients with lung and breast cancers who received targeted therapy compared to those who did not. Our study provides valuable insights into the recent advancements in the medical management of metastatic spinal tumors. Future indications include incorporating this literature into personalized treatment approaches for metastatic spinal tumors.

Atypical late presentation of muscular metastasis of melanoma in the contralateral limb

A man in his 50s presented to plastic surgery again with a lesion on his left upper arm. He had previously been treated for a malignant melanoma (MM) on his right arm over 5 years earlier. Sentinel lymph node biopsy (SLNB) had been negative, and he had completed the recommended 5 years follow-up period. Imaging was suspicious for an intramuscular soft tissue malignancy within the triceps muscle. After discussion with the regional sarcoma service, a core biopsy was performed. Histopathology suggested a diagnosis of metastatic MM, which was confirmed after surgical excision. This case highlights a rare example of an isolated muscular metastasis of MM, which presented at a distant site, over 5 years from the original treatment. This case highlights the unpredictable nature of MM, reminding clinicians of the need for a low threshold for investigation of soft tissue masses in patients with a history of cutaneous malignancy.

Simultaneous Thoracic Spine Metastatic Melanoma and Pre-existing Prostate Adenocarcinoma: A Unique Case Presentation and Literature Review

In melanoma patients, distant metastases frequently manifest in the skin, lung, brain, liver, bone, and intestine. Notably, bone metastasis predominantly occurs within the axial skeleton, with the lumbar and thoracic spines being the most affected regions. Conversely, prostate cancer often disseminates to the bone, lung, liver, pleura, and adrenal glands. The spinal column, particularly the lumbar region, frequently harbors metastases in prostate cancer cases. Given the proximity of axial lesions to the spinal cord, patients commonly experience pain, weakness, and urinary dysfunction. This article presents a compelling case report of a patient initially diagnosed with metastatic prostate cancer, who later exhibited a metastatic lesion in the thoracic spine, subsequently identified as originating from acral melanoma on the plantar surface of the right foot. Histopathological examination confirmed the presence of acral melanoma in both the spine and the right foot. The patient received comprehensive treatment for advanced melanoma from a multidisciplinary team comprising medical and radiation oncologists. Considering the overlapping pathophysiology of prostate cancer and melanoma, simultaneous screening for both diseases in cases where one is detected could yield significant benefits, including enhanced morbidity and mortality outcomes and the facilitation of early detection for secondary malignancies.

Unusual Canine Cutaneous Melanoma Presenting Parietal Bone Metastasis: A Case Report

Melanocytic tumour anatomic location is considered an important prognostic indicator. The cutaneous forms are generally considered benign and may show various biological behaviours. This work reports a rare case of canine cutaneous melanoma showing parietal bone metastasis. Bone invasion in melanocytic tumours is often described in oral or visceral melanomas, but not in cutaneous forms. The patient (dog, male, mixed breed, 12 years) was initially presented for the surgical removal of a cutaneous tumour located on the skin of the carpal region of the right forelimb. Four months after, the patient returned with enlarged lymph nodes and acute respiratory failure. The patient was euthanized due to a decline in physical condition. The necropsy showed metastases in the affected forelimb, regional lymph node, splanchnic organs, parietal bone and meninges. Histopathological examination of tumour tissue samples revealed a mixture of pigmented and non-pigmented spindle and epithelioid melanocytes, while according to immunohistochemistry, the tumours showed a strong immunopositivity for VEGF and MMP-10, and a moderate positivity for MMP-2 expression. This case shows that cutaneous melanocytic tumours may show an aggressive malignant form with positive immunohistochemical reactions for multiple invasiveness factors.

Melanoma of unknown primary origin with skeletal muscle metastasis: a case report

BACKGROUND

Melanoma is usually discovered from an irregular skin patch or a modification of a preexisting patch. Cutaneous and lymph node metastases are common. Muscle metastases are rare. We report a case of melanoma with infiltration of the gluteus maximus, which had normal dermatological examination.

CASE PRESENTATION

A 43-year-old Malagasy man with no history of skin surgery was admitted with progressively worsening dyspnea. On admission, he presented with superior vena cava syndrome, painless cervical lymphadenopathy, and a painful swelling in the right buttock. Skin and mucous membrane examination did not reveal any abnormal or suspicious lesions. The biology was limited to a C-reactive protein of 40 mg/L, a white blood cell count of 23 G/L, and a lactate dehydrogenase level of 1705 U/L. The computed tomography scan showed several lymphadenopathies, compression of the superior vena cava, and a tissue mass at the expense of the gluteus maximus. Cervical lymph node biopsy and cytopuncture of the gluteus maximus were consistent with a secondary melanoma location. A stage IV melanoma of unknown primary origin, and with stage TxN3M1c associated with lymph node metastases and extension to the right gluteus maximus, was suggested.

CONCLUSIONS

Melanoma of unknown primary origin accounts for 3% of diagnosed melanomas. Diagnosis is difficult in the absence of a skin lesion. Patients are diagnosed with multiple metastases. Muscle involvement is unusual and may suggest a benign pathology. In this context, biopsy remains essential for diagnosis.

The effect of organ-specific tumor microenvironments on response patterns to immunotherapy

Immunotherapy, particularly immune checkpoint inhibitors, have become widely used in various settings across many different cancer types in recent years. Whilst patients are often treated on the basis of the primary cancer type and clinical stage, recent studies have highlighted disparity in response to immune checkpoint inhibitors at different sites of metastasis, and their impact on overall response and survival. Studies exploring the tumor immune microenvironment at different organ sites have provided insights into the immune-related mechanisms behind organ-specific patterns of response to immunotherapy. In this review, we aimed to highlight the key learnings from clinical studies across various cancers including melanoma, lung cancer, renal cell carcinoma, colorectal cancer, breast cancer and others, assessing the association of site of metastasis and response to immune checkpoint inhibitors. We also summarize the key clinical and pre-clinical findings from studies exploring the immune microenvironment of specific sites of metastasis. Ultimately, further characterization of the tumor immune microenvironment at different metastatic sites, and understanding the biological drivers of these differences, may identify organ-specific mechanisms of resistance, which will lead to more personalized treatment approaches for patients with innate or acquired resistance to immunotherapy.

Extra-Axial Skeletal Metastasis of Malignant Melanoma: Case Report and Literature Review

The incidence of malignant melanoma is increasing worldwide and is one of the major causes of skin cancer deaths in the United States. Although melanoma has the potential to metastasize to any organ, the incidence of bone metastasis is low (~25%) compared to liver or lung metastasis. However, when a bone is involved, metastasis occurs to the axial skeleton in most cases (80%-90%), and involvement of the appendicular skeleton is relatively rare. We here describe the case of a patient who presented with a pathological fracture due to extra-axial skeletal metastasis of a widespread malignant melanoma. 

A 45-year-old female with an unremarkable past medical history presented to the ED with acute left hip pain. X-ray demonstrated left intertrochanteric femur fracture with an abnormal, suspicious lesion at the fracture site. Detailed physical examination revealed various skin nodules on the anterior chest wall, right upper back, and left cheek. CT of the chest/abdomen/pelvis (CT C/A/P) showed multiple lytic bone lesions and metastatic lesions in lungs, soft tissue, and mediastinal lymph nodes. She underwent surgical stabilization of the fracture, and a biopsy of the bone lesion revealed metastatic malignant melanoma with BRAF V600E mutation. She was started on localized radiotherapy followed by targeted therapy (dabrafenib and trametinib) and denosumab for her stage IV (cTX, cN2, cM1b(1)) (American Joint Committee on Cancer [AJCC] cancer staging 8th edition) disease. Despite treatment, her disease progressed as evidenced by the presence of new metastatic foci on a positron emission tomography-computed tomography (PET-CT) scan performed at a three-month follow-up. Her clinical course was complicated by hemoperitoneum due to bleeding from metastatic liver lesions and respiratory failure requiring a prolonged stay in the ICU before she was deceased.

In most cases, malignant melanoma presents with skin lesions at an early stage. Very few patients (4%) have metastatic disease at presentation. Although metastasis to bone is known to occur in advanced disease, involvement of the extra-axial skeleton is relatively rare. Malignant melanoma, initially presenting as pathological fracture of the appendicular skeleton, is not commonly encountered. Our case emphasizes the aggressive nature of malignant melanoma with an aim to raise physicians' awareness of this uncommon presentation. A brief review of the literature exploring prognosis and currently available treatment options is discussed.

A Rare Presentation of a Solitary Melanoma Bone Metastasis

A 74-year-old woman presented with sudden onset pain and swelling in her right wrist. Plain radiographs showed a pathological fracture through a lytic lesion. The patient had a past medical history of melanoma on her right thigh, which had been excised two years previously. She was referred to the bone cancer unit to undergo a series of investigations that included a magnetic resonance imaging scan, bone scintigraphy and a computed tomography-guided biopsy. Collectively, all investigations revealed a solitary bone metastasis from her previous melanoma in the right distal radius. The patient was treated symptomatically and underwent internal fixation with cement augmentation for symptom control. With the incidence of melanoma increasing, this case demonstrates the importance of being vigilant of unusual presentations. 

Osseous Tumor Reporting and Data System-Multireader Validation Study

OBJECTIVE

To develop and validate an Osseous Tumor Reporting and Data System (OT-RADS) with the hypothesis that the proposed guideline is reliable and assists in separating benign from malignant osseous tumors with a good area under the curve, and that could assist further patient management.

METHODS

In this multireader cross-sectional validation study, an agreement was reached for OT-RADS categories based on previously described magnetic resonance imaging features and consensus of expert musculoskeletal radiologists. World Health Organization classification was used, and a wide spectrum of benign and malignant osseous tumors was evaluated. Magnetic resonance imaging categories were as follows: OT-RADS 0-incomplete imaging; OT-RADS I-negative; OT-RADS II-definitely benign; OT-RADS III-probably benign; OT-RADS IV-suspicious for malignancy or indeterminate; OT-RADS V-highly suggestive of malignancy; and OT-RADS VI-known biopsy-proven malignancy or recurrent malignancy in the tumor bed. Four blinded readers categorized each tumor according to OT-RADS classification. Intraclass correlation (ICC) and Conger κ were used. Diagnostic performance measures including area under the receiver operating curve were reported. Osseous Tumor Reporting and Data System was dichotomized as benign (I-III) and malignant (IV and V) for calculating sensitivity and specificity.

RESULTS

Interreader agreement for OT-RADS (ICC = 0.78) and binary distinction of benign versus malignant (κ = 0.67) were good to excellent, while agreement for individual tumor feature characteristics were poor to fair (ICC = 0.25-0.36; κ = 0.16-0.39). The sensitivities, specificities, and area under the receiver operating curve of the readers ranged from 0.93-1.0, 0.71-0.86, and 0.92-0.97, respectively.

CONCLUSIONS

Osseous Tumor Reporting and Data System lexicon is reliable and helps stratify tumors into benign and malignant categories. It can be practically used by radiologists to guide patient management, improve multidisciplinary communications, and potentially impact outcomes.

An analysis of clinical values of MRI, CT and X-ray in differentiating benign and malignant bone metastases

OBJECTIVE

To investigate the clinical values of magnetic resonance imaging (MRI), computed tomography (CT) and X-ray in differential diagnosis of benign and malignant bone metastases.

METHODS

A total of 80 patients with bone metastases admitted to our hospital were selected as the study subjects. X-ray, CT and MRI examinations were performed, respectively. The pathological examination results were taken as the gold standard to analyze the lesion sites of metastatic tumors in 80 subjects. The diagnostic sensitivity, specificity and accuracy of X-ray, CT and MRI examinations were calculated and compared.

RESULTS

Among the 80 patients, 71 cases were diagnosed as malignant bone metastases and 9 cases as benign lesions according to pathological examination. The diagnostic sensitivity, specificity and accuracy of X-ray, CT and MRI examinations were 63.38%, 33.33% and 60.00%, 84.51%, 66.67% and 82.50%, and 90.14%, 77.78% and 88.75%, respectively. MRI was superior to X-ray in the sensitivity, specificity and accuracy of differential diagnosis of benign and malignant bone metastases (P < 0.05). MRI was superior to CT, but there was no significant difference between the two groups (P < 0.05). The diagnostic sensitivity, specificity and accuracy of CT + MRI were significantly higher than those of any single detection method (P < 0.05).

CONCLUSION

MRI, CT and X-ray exhibit a good value in differential diagnosis of benign and malignant bone metastases. Overall, MRI is superior to CT and X-ray in the screening effects, and the combined detection methods are more satisfactory. It is recommended that CT should be used for primary screening, and CT + MRI should be implemented for a enhanced diagnosis.

Skeletal muscle metastases of hepatocellular carcinoma: A case report and literature review

BACKGROUND

The metastasis of liver cancer to skeletal muscle is extremely rare compared to other sites. We herein report a case of rapidly developing skeletal metastases following liver transplantation due to primary liver cancer.

CASE SUMMARY

A 70-year-old male with underlying chronic hepatitis B virus infection was diagnosed with hepatocellular carcinoma (HCC), for which he underwent liver transplantation in 2014. Six years after receiving the transplant, pathological examination confirmed the presence of HCC without vascular invasion. He was admitted to the hospital with a rapidly growing mass on his right thigh. Ultrasound examination revealed a mixed echo mass in the lateral soft tissue of the middle part of the right femur. Magnetic resonance imaging showed heterogeneous iso-signal intensity on T1-weighted images and heterogeneous hyper-intensity on T2-weighted images compared to the surrounding muscles. Pathological examination of the ultrasound-guided needle biopsy specimen revealed that it was similar to the previously detected liver cancer; the diagnosis was metastasis of HCC. Surgical excision was performed. There were no other sites of metastasis, and the patient recovered well after surgery.

CONCLUSION

This report presents a rare case of skeletal metastasis following liver transplantation for HCC. The study suggests a possible role for skeletal muscle metastasis mechanisms, which should be the focus of future research.

Clinical pathological characteristics of pelvic bone tumors

Introduction: Bone tumors are rare neoplasms whose therapy depends on the location. Pelvic bones represent a special anatomical entity diagnosis and therapy of pelvic tumors in addition to the pathohistological type largely depends on the anatomical specifics of that region. Aim: The aim of this study was to show the frequency, as well as clinical and pathological characteristics of primary and secondary tumors of the pelvic bones. Material and methods: The research as a descriptive study in the period from January 1, to December 31, 2019 at the Institute of Pathology of the Medical Faculty of the University of Belgrade and includes 33 patients. Demographic, clinical and radiological data were obtained from the Bone Tumor Registry. Statistical processing and analysis were done in the Statistical Package for Social Science SPSS Windows version 22 (IBM Chicago, Ilinois, USA). Results: Out of 33 patients, 55% had secondary pelvic tumors, primarily cancer metastases (37%). In 21% of cases, primary malignant bone tumor as diagnosed, and in 12%, primary benign bone tumor. Hematopoietic neoplasms were verified in 12%. Conclusion: Pelvic bone tumors are not common, but these neoplasms, in orthopedic oncology, represents their malignant biological behavior are of great importance. The most common primary malignant tumor in adults is chondrosarcoma, and in children Ewing sarcoma. Highest frequency for pelvic bone metastases has lung cancer. Plasmacytoma in adults, Langerhans cellular histiocytosis in children are hematological neoplasms seen at this site.

A Rare Case of Osteoinvasive Amelanotic Melanoma of the Nail Unit

Introduction

Amelanotic melanoma is a rare subtype, which may be clinically difficult to diagnose due to lack of pigmentation and variable histopathological features. Osteoinvasion is another rare characteristic of melanoma. There are few reports in the literature of amelanotic melanoma of the nail unit (nail bed, matrix, and nail folds) with invasion of bone.

Case Presentation

We present a case of a 73-year-old Caucasian male with a 13-month history of an ungual lesion on his right hallux. The lesion was initially treated as a chronic diabetic ulceration with failure to resolve with standard of care.

Discussion/Conclusion

A heightened index of suspicion for a malignant process is necessary when standard of care fails to lead to improvement or resolution. In these instances, biopsy should be seriously considered.

Regional lymph node infiltration and thick lesions are associated with poor prognosis in high-risk resected melanomas: A retrospective cohort study

Background

Acral lentiginous and mucosal melanoma that represent lesions without cumulative sun-induced damages account for 65% of melanomas among Asians but constitute only 5% in Caucasians. The distinct clinical manifestations might influence the clinical course, response to treatment, and outcomes. Factors associated with the prognosis of high-risk resected melanoma in Asians are still rarely reported.

Methods

Clinical, histological determinants of non-distant metastatic melanoma patients who underwent complete resection in 2014–9 were analyzed.

Results

Mucosal melanoma, nodular melanoma, and acral lentiginous melanoma accounted for 45.1%, 40.2%, and 14.2% of total melanoma cases (N = 82), respectively. Among cutaneous melanomas, all patients were diagnosed with Breslow's depth more than 4 mm (T4), 51% with ulceration, 95.6% with diameter more than 6 mm, 59% with lympho-vascular invasion, and 74% with regional lymph node infiltration. In mucosal melanomas, 78.3% were diagnosed in advanced stages, 14.5% with regional spread to lymph nodes and 77% with regional infiltration beyond mucosa. Lesions with ulceration were associated with higher risk of distant metastasis (OR 3.003, 95%CI:1.01–9.09). Infiltration into regional lymph node was associated with shorter overall survival (median survivals were 17 vs 23.4 months, Mantel-Cox test P = 0.049). Patients diagnosed at Breslow T4 were also associated with poorer overall survival than T1-3 (median survivals were 23 vs 32 months, Mantel-Cox test P = 0.047).

Conclusion

The majority of melanoma patients in our population were diagnosed in advanced stages with a higher risk for recurrence and progression into distant metastasis. Regional lymph node involvement and thicker tumor (T4) were associated with poor prognosis.

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Most of melanoma patients in Indonesia are diagnosed with high-risk of progression and worse survival.

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Revealing factors-associated with high-risk of disease progression is important to set up surveillance program.

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Refinement of public education and care delivery are required to advance management of melanoma in Indonesia.

Ablation of soft tissue tumours by long needle variable electrode-geometry electrochemotherapy: final report from a single-arm, single-centre phase-2 study

Standard electrochemotherapy (ECT) is effective in many tumour types but is confined to the treatment of small superficial lesions. Variable electrode-geometry ECT (VEG-ECT) may overcome these limitations by using long freely-placeable electrodes. Patients with bulky or deep-seated soft-tissue malignancies not amenable to resection participated in a single-arm phase-2 study (ISRCTN.11667954) and received a single course of VEG-ECT with intravenous bleomycin (15,000 IU/m²) and concomitant electric pulses applied through an adjustable electrode array. The primary outcome was radiologic complete response rate (CRR) per RECIST; secondary endpoints included feasibility, metabolic response, toxicity (CTCAE), local progression-free survival (LPFS) and patient perception (EQ-5D). During 2009–2014, we enrolled 30 patients with trunk/limb sarcomas, melanoma, Merkel-cell carcinoma, and colorectal/lung cancer. Median tumour size was 4.7 cm. Electrode probes were placed under US/TC guidance (28 and 2 patients, respectively). Median procedure duration was 80 minutes. Tumour coverage rate was 97% (29 of 30 patients). Perioperative side-effects were negligible; one patient experienced grade-3 ulceration and infection. One-month ¹⁸F-FDG-SUV decreased by 86%; CRR was 63% (95% CI 44–79%). Local control was durable in 24 of 30 patients (two-year LPFS, 62%). Patients reported an improvement in “usual activities”, “anxiety/depression”, and “overall health” scores. VEG-ECT demonstrated encouraging antitumour activity in soft-tissue malignancies; a single course of treatment produced high and durable responses, with low complications.