Melanoma metastases - brain and spine

Case contributed by Dr Bruno Di Muzio

Presentation

The patient presented with left-sided severe hemiparesis, hemineglect and Dejerine-Rousy syndrome.

Patient Data

Age: 65-years
Gender: Male

CT Brain

CT

There is a large nodular hyperdense well-defined right parietal mass surrounded by vasogenic edema and causing a local mass effect with compression of the posterior horn of the right lateral ventricle. The lesion shows a peripheric and irregular enhancement. Other two small similar lesions are identified in the left frontal lobe and in the inferior aspect of the left cerebellar lobe. 

MRI Spine

MRI

MRI images show a sacral mass involving the left foramina at S2 and S3 levels and compressing the respective nerve roots. The mass is T1 hypointense and demonstrates a heterogeneous peripheral contrast enhancement which delineates a probable necrotic center. 

Pathology

MICROSCOPIC DESCRIPTION: Paraffin sections show fragments of a densely hypercellular tumor. Tumor cells have markedly pleomorphic round oval and angulated vesicular nuclei many with conspicuous nucleoli and a variable amount of pale cytoplasm. The cytoplasm of scattered cells contains finely granular and globular black/brown pigment. Frequent mitotic figures are identified and there are several foci of tumor necrosis. Tumor is sharply demarcated from a narrow rim of adjacent included brain parenchyma. Immunohistochemistry shows strong nuclear staining for SOX-10 in >90% of tumor cells. No staining for tyrosinase, melan A, HMB-45, GFAP, TTF-1, BER-Ep4, or cytokeratins (AE1/AE3, CK20, CK7) is seen in tumor cells. The features are of metastatic malignant melanoma. DIAGNOSIS: Parieto-occipital brain tumor: Metastatic malignant melanoma.

Case Discussion

This case illustrates a melanoma presentation due to symptoms related to the metastatic disease. Melanoma is the third most common primary neoplasm that metastasizes to the brain.

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