Melanoma metastases

Case contributed by A.Prof Frank Gaillard

Presentation

Right hemiparesis.

Patient Data

Age: 77
Gender: Male
Modality: CT

There is a 2.5 cm intraparenchymal high density abnormality demonstrated within the left parietal lobe superiorly. There is evidence of adjacent oedema. Note is a 12 mm high density abnormality demonstrated within the right temporal lobe inferiorly withsome minimal adjacent oedema. These's appear to enhance.

There are some periventricular white matter changes.

There is no midline shift. The basal cistern is not effaced.

Modality: MRI

Two intra axial enhancing mass lesions are demonstrated, the larger of the two located in the white matter of the left precentral gyrus, measuring 2.5 cm, and the smaller of the two located on the right in the fusiform gyrus of the right temporal lobe, measuring 10 mm in diameter. These demonstrate a pronounced signal loss on echoplanar imaging, and intrinsic high T1 signal, consistent with blood product. They are surrounded by a moderate amount of vasogenic oedema.

The remainder of the brain is unremarkable, with no other lesion is evident, and only a modest amount of chronic small vessel ischaemic white matter change.

Conclusion:

Features are consistent with haemorrhagic metastases. Presence of multiple metastatic deposits are seen on CT, including subcutaneous deposit in the left buttock suggests malignant melanoma as the most likely primary.

Modality: CT

There is a large irregular ill-defined mass lesion centred on the colonic wall of the hepatic flexure in the right upper quadrant measuring 10 x 8.5 x 7 cm in maximum dimensions with surrounding fat stranding. Medially, the mass is in contact with, and is possibly adherent to, loops of non-distended small bowel.

There is para-aortic lymphadenopathy measuring 15 mm in maximal short axis diameter consistent with nodal metastatic disease. There is freefluid in the upper abdomen around the liver and spleen in the pelvis with no freeintraperitoneal gas.

The liver contains no focal lesions. The portal and hepatic veins are opacified. The gall bladder is contracted. The pancreas, spleen, and right adrenal gland are normal.There is an abnormal irregular soft tissue density in the left upper quadrants that appears to communicate with the left adrenal gland and may represent adrenal or nodal metastatic disease. There are cortical cysts in both kidneys measuring up to 35 mm inmaximum diameter.

There is abnormal soft tissue density in the right retroperitoneum inferior to the kidney measuring 19 mm maximal diameter. It may represent nodal or distant metastatic disease. There are bilateral inguinal herniae containing fat, larger on the left. Mild distal colonic diverticulosis noted. No distended loops of bowel to suggest obstruction. There is slight superior endplate deformities in the lumbar spine probably due degenerative change. No destructive skeletal lesion is detected.

A number of subcutaneous deposits are also noted. 

Case Discussion

Sometimes, having access to other studies lets you triangulate into strongly favouring a single diagnosis. In this case the presence of hemorrhagic metastases already raises the possibility of melanoma, however the pattern of abdominal disease, especially the subcutaneous deposits, lets you make a preoperative diagnosis with confidence.  

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Case Information

rID: 35464
Case created: 7th Apr 2015
Last edited: 20th Nov 2015
Inclusion in quiz mode: Included

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