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Overview
Melanoma
Background
Brain metastases: Epidemiology, Symptoms, Treatment
Melanoma
Tumor of melanocytes
1A
1B
Melanoma: Metastasis
SITE
Lung
Liver
Brain
Bone
GI tract
CLINICALLY
18-36%
14-20%
12-20%
11-17%
1-7%
AUTOPSY
70-87%
54-77%
36-54%
23-49%
26-58%
Melanoma: Metastasis
3rd most common cause of brain metastases
Highest propensity to metastasize to the brain of all
primary tumors in adults
Clinical features:
Headaches & symptoms from increased pressure
Focal neurologic deficits
Seizures; cognitive impairment
Given the recognized neurotropism of melanoma,
neurological symptoms in a melanoma patient should
prompt diagnostic imaging studies. (Sloan et al., 2009)
Indications
1.
2.
3.
18FDG-PET/CT:
Mohr et al. (2009) Ann Oncol; Delbeke (1999) J Nuc Med; Donohoe (2010) UpToDate
Interim Summary 1
We have:
1) Learned why diagnostic imaging of metastatic melanoma in the
brain is important
2) Reviewed the menu of tests relevant for our discussion
3) Familiarized ourselves with a bit of normal brain anatomy
We are now ready to apply and expand our knowledge
Case Presentation
Patient AC and Her Intractable
Melanoma Brain Mets
Patient AC
42 yo female with history of metastatic melanoma,
presented to ED in 3/07 with headache
2/07: Diagnosed with the first brain mets from melanoma after
experiencing severe headaches; underwent whole brain
radiation; dexamethasone wean to begin TMZ
1d prior to admission: Onset of slight bifrontal headaches
Day of admission: Worse headaches, pain 5-6/10
Neurologic ROS unremarkable
Patient AC
Patient AC
3B
4B
Predominant: T1 , T2
or , enhancing
T2 signal
Key:
= hyperintensity
= hypointensity
= isointensity
T2 signal Time
Hgb
Hyperacute
< 24h
Oxy-Hgb, intracellular
Acute
1-3d
Deoxy-Hgb, intracellular
Early subacute
> 3d
Met-Hgb, intracellular
Late subacute
> 7d
Met-Hgb, extracellular
Chronic
> 14d
Mohr et al. (2009) Ann Oncol; Warakaulle & Anslow (2003) Clin Radiol; Escott (2001) RadioGraphics
6B
7B
T2 signal
T1
signal
T2
signal
Time
Hgb
Hyperacute
< 24h
Oxy-Hgb, intracellular
Acute
1-3d
Deoxy-Hgb, intracellular
Early subacute
> 3d
Met-Hgb, intracellular
Late subacute
> 7d
Met-Hgb, extracellular
Chronic
> 14d
Predominant: T1 , T2 or , enhancing
Suggest melanoma metastasis, predominantly with
melanin OR
blood products (likely early subacute)
surrounded by edema
Hemorrhagic lesions
Infarcts
Infections
Intraparenchymal hematoma
Cortical contusions
Diffuse axonal injuries
Subarachnoid hemorrhage
Vascular malformations and aneurysms
associated with hemorrhage and/or
thrombosis
Hemorrhagic primary tumors
Hemorrhagic metastases
Melanoma
Renal cell carcinoma
Choriocarcinoma
Bronchogenic carcinoma
Thyroid carcinoma
Melanin-containing lesions
Endocrine-metabolic disorders
Calcified neoplasms
Infections
Dural osteomas
Lipoma
Dermoid
Lipomatous meningioma
Calcified/ossified lesions
Protein-containing lesions
Fatty lesions
Melanoma metastases
Leptomeningeal melanosis
Miscellaneous
Ectopic neurohypophysis
Multiple sclerosis (chronic stage)
Neurofibromatosis type I
Cakirer et al. (2003) Curr Probl Diagn Radiol
4/10
45 yo, presents with severe bilateral sharp headaches
Similar to headaches from prior metastatic disease
Associated nausea
8B
8C
9B
Interim Summary 2
As we have learned from the multiple MR
images, beware of atypical and various
appearances of melanoma mets!
1) They can adhere to OR deviate from the typical
melanotic and amelanotic patterns.
2) They can be subtle and small OR easily discernible.
3) They may or may not hemorrhage.
4) They can be stable OR rapidly growing!
10B
Majority = HIGH
attenuation
pre-contrast
Meningioma
Lymphoma
GBM
Ependymoma
Colloid cyst
Craniopharyngioma
Germinoma
Hemorrhage
Metastatic tumors
Melanoma
Renal cell carcinoma
Choriocarcinoma
Thyroid carcinoma
Infection
Inflammation
Neoplasm
Beware of physiologic uptake (brain, myocardium,
exercising muscle, thymus in children and post-chemo
patients, thyroid in patients with thyroid disease, etc)
12B
Summary
1. Radiologic imaging of melanoma metastases to the brain is
clinically important
2. MRI with contrast enhancement is the imaging modality of
choice for brain metastases of melanoma, and we saw
multiple examples in our patient AC
3. Metastatic melanoma lesions in the brain have a variety of
appearances due to hemorrhage and melanin: Beware!
4. While MRI is the preferred test, CT and FDG-PET/CT have
their uses in melanoma imaging in the brain: Remember
when and why these imaging modalities can be useful
Acknowledgements
Gillian Lieberman, MD
Kevin Donohoe, MD
Neel Madan, MD
Johannes Roedl, MD
Maria Levantakis
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