| Japanese Journal of Clinical Oncology | Pages |
A Case of a Malignant Melanoma with Late Metastases 16 Years After the Initial Surgery
Introduction
Case report
Discussion
References
A Case of a Malignant Melanoma with Late Metastases 16 Years After the Initial Surgery
Introduction
Recently, late recurrence and second malignancy of malignant neoplasms have been growing topics of discussion, because their curability has been high and patients with them have had a high possibility of a long life. Late recurrences of malignant melanomas are well known but uncommon. We report a case with a late metastasis 16 years after the initial surgery.
Case report
The patient was a 58-year-old Japanese man. He had a past history of tuberculous pleurisy at 11 years old and early gastric cancer at 50 years old. In 1976, he had a pigmented skin lesion with a diameter of 8 mm on the right third finger. He received an amputation of the finger and a dissection of the right axillary. Histological examination of the tumor revealed features of a malignant melanoma with junctional activity and infiltration of the dermis by mixed spindle-epithelioid tumor cells.
The deepest invasion by tumor cells was observed in the papillary layers of the dermis with a thickness of 1.5 mm (Fig. 1). There was no regional lymph node metastasis. Pathological stage was pt2n0m0, stage I, and the histological subtype was considered as an acral lentiginous melanoma. He received no further therapy after the surgery. In December 1991, when he was 73 years old, he was producing bloody sputum. Radiographic examinations, including a chest X-ray, computed tomography and Ga-67 scintigraphy, failed to find any abnormalities. Bronchoscopic examination revealed diffuse reddish bronchial mucosa without malignant lesions. Because Mycobacterium avium complex was detected in the sputum, we gave him anti-tuberculous agents (isoniazid, rifampicin and ethanbutol hydrochloride) for 1 year and checked him through periodic chest radiography. In December 1992, chest radiography showed a round tumor in the left lower lung and computed tomography showed a well demarcated mass in the left lateral basal segment (Fig. 2). No additional abnormalities were observed through radiographic examinations, including brain and abdominal computed tomography and bone and Ga-67 scintigraphy. In February 1993, a left lower lobectomy of the lung and a mediastinal dissection were performed. There was a solitary mass with a black cutting surface 3.0 cm in diameter in the left basal lateral segment. There were no mediastinal lymph nodes metastases. Histological examination of the tumor revealed a malignant melanoma with predominantly epithelioid tumor cells (Fig. 3). This was considered as a metastasis from the initial lesion of the right third finger. In the middle of May, when he had a left hemiparesis, brain computed tomography showed a brain metastasis on the right cerebral hemisphere (Fig. 4). In July, 5 months after the left lower lobectomy of the lung, he died from a hemorrhage of the metastatic brain tumor.
Figure 1. Histological features of the right third finger show a malignant melanoma with junctional activity and infiltration of the dermis by mixed spindle-epithelioid tumor cells. The deepest invasion by tumor cells was observed in the papillary layers of the dermis with a thickness of 1.5 mm. Histological subtype was considered to be an acral lentiginous melanoma. H&E stain; original magnification ×40. Figure 2. Chest computed tomography shows a well demarcated mass in the left lateral basal segment. Figure 3. Histological features of the lung tumor reveal a malignant melanoma with predominantly epithelioid tumor cells, which show mitotic activity. H&E stain; original magnification ×200. Figure 4. Brain computed tomography shows a brain tumor with a hemorrhage on the right cerebral hemisphere. Late recurrences of malignant melanomas are uncommon but they appear to be a growing problem. In previous reports, late recurrence with disease-free intervals of 10 years or more were observed in 0.84-6.83% of cases (1-5). A recent report estimates that 5-10% of those patients who remain disease-free for more than 10 years will eventually relapse (3). On the other hand, a primary melanoma of the lung is very rare and a melanoma involving the respiratory tract is nearly always metastatic in origin (6,7). Our patient had a solitary lung tumor 16 years after the amputation of the right third finger due to a malignant melanoma, and the lung disease was considered to be a metastatic melanoma. It was a controversial hypothesis whether a late recurrence of a malignant melanoma could be predicted at the time of the primary. In the initial lesion of our patient, the deepest invasion was observed in the papillary layers of the dermis with a thickness of 1.5 mm. It was established that both the site and time of the first recurrence from the melanoma depended on the thickness of the primary tumor. Gutman et al. (5), however, explained that the most important prognostic determinant in malignant melanomas, which was tumor thickness, appeared to be of value only in the first 5 years following disease. Also, some investigators reported that none of the factors of prognostic importance, such as tumor thickness, ulcerative state of the primary lesion, anatomical site or initial surgical treatment, proved useful in predicting those patients who would have late recurrences (1,2,4,5,8-10). The grade of atypia or mitotic activity of tumor cells might be responsible for its slow growth and the long-term latency of its subsequent metastasis. In our case, histological features of the primary lesion showed a low grade of atypia and a low mitotic rate in the tumor cells, and that of the metastatic lesion showed greater pleomorphism and higher mitotic activity. Khanna et al. (11) demonstrated the histological features of tumors in the three groups early recurrence, no recurrence and late recurrence. They reported that a higher mitotic rate and greater nuclear pleomorphism were seen in the early recurrence group, but that no difference could be detected between the late recurrence and no recurrence groups. They stated that the histological features of tumors were not of great help in differentiating the three groups. Shaw et al. (1) stated that no host or tumor factors could be identified that could help predict those patients at high risk of having a late recurrence. Investigators have therefore emphasized the lack of predictive factors in late recurrence and the importance of life-long follow-up in treating malignant melanoma. The prognosis after a late recurrence of a malignant melanoma is variable and unpredictable. Whether the lesion is local or distant appears to be the strongest determinant of survival. Some investigators have reported no correlation between the disease-free interval and subsequent survival (3-5,10-12). Tahery et al. (3) reported that survival following a relapse of a malignant melanoma was found to be greater in patients with only a local skin recurrence and that the disease-free interval did not essentially influence the prognosis in patients with regional nodal or soft tissue metastasis. Pearlman et al. (4) reported that they found that the major determinant of survival in most patients with late recurrence was the metastatic site, not the disease-free interval. Gutman et al. (5) reported that a prolonged disease-free interval in malignant melanomas did not imply a better prognosis once metastases occurred and they observed that most of their patients with visceral metastasis died within 2 years. Our patient had a very long disease-free interval of 16 years; however, he underwent a rapid deterioration once visceral metastasis occurred. This might be in keeping with the histological findings that the cells of metastasis showed greater pleomorphism and higher activity than that of the primary tumor. This case indicated the importance of periodic, life-long follow-up in treating malignant melanomas.
Discussion
References
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Last modification: 4 Mar 1999
Copyright© 1999 Foundation for Promotion of Cancer Research, 1999.
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