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Case History

image A 60-year-old man had a melanoma resected from his back 5 years ago, and had an axillary dissection with 3/16 nodes positive for melanoma 2 years later. On routine follow-up, a chest radiograph shows multiple bilateral coin lesions.

How should this patient be further imaged?

Is a tissue diagnosis necessary, and why?

Assuming no other sites of disease, and that the patient is asymptomatic, what would be the initial management options?

What palliative medical treatments could be considered for this patient?


How should this patient be further imaged?

image Prior to further imaging, the patient should have a physical examination paying particular attention to possible regional recurrence. Blood tests including lactate dehydrogenase, urea and electrolytes, liver function tests, calcium and full blood count should be done.

The most reliable method for evaluating lung metastasis is contrast computed tomography (CT). The accuracy of CT scan was compared with chest radiograph in a study of 42 patients with high-risk melanoma.1 Unequivocal nodules were revealed by CT scan in 20 patients but in only 11 by chest radiograph. CT scan is also superior for assessing mediastinal and hilar adenopathy and the presence of lymphangitis, which is particularly important in assessing a patient with a potentially resectable isolated pulmonary metastasis. If CT scan confirms multiple pulmonary metastases, then the patient can be followed by chest radiograph to assess his progression or his response to systemic treatment.

The liver is a common site of metastatic disease (in as many as 58% of patients with metastatic melanoma2), and can be assessed by ultrasound or CT. Liver metastases are usually multiple, but solitary lesions may be considered for resection, radiofrequency ablation or cryotherapy, in which case further assessment by magnetic resonance imaging (MRI) is advisable. Small-bowel metastasis in melanoma is not uncommon.3 Brain imaging in asymptomatic patients is controversial. Up to 25% of patients with metastatic melanoma have asymptomatic brain metastases, but it is unclear whether these lesions require intervention. Some clinicians therefore advocate imaging to look for central nervous system (CNS) involvement only in symptomatic patients,4 in which case MRI is the study of choice.

Is a tissue diagnosis necessary, and why?

Tissue diagnosis is important when there are doubts about the diagnosis and when the disease is not typically following its natural history. In early melanoma most studies indicate that about 80% of recurrences occur within first 3 years. However, up to 16% of first recurrences have been reported to occur after 5 years.5

Thus, in this patient, distant metastasis occurring 3 years after node dissection is not surprising, and it would be safe to omit a biopsy. However, if the history were less typical, lung biopsy should be considered.


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