Pleural metastases from melanoma

Case contributed by A.Prof Frank Gaillard

Presentation

Shortness of breath and left sided chest pain.

Patient Data

Age: 30 years
Gender: Female
X-ray

A large left sided pleural effusion is present with no fluid seen on the right. No evidence of cardiomegaly or pulmonary venous congestion. No evidence of trauma. 

Multiple surgical clips are seen in the right supraclavicular fossa. 

Left sided ICC noted. Left sided effusion has almost entirely been drained with residual associated left basal atelectasis. The pleura demonstrates multiple soft tissue nodules (especially medially along the mediastinum) with the largest region located abutting the descending aorta and spinal column measuring 12 x 28 x  75 mm. Nodules are also seen in the fissures. A number of enlarged nodes are also present, the largest of which is in the aortopulmonary window measuring 16 x 24 x 12 millimetres. 

No mediastinal haematoma. The heart and the great vessels are unremarkable. No rib, sternal or scapula fractures are seen. No suspicious bone lesions identified. 

A cystic mass is located in the left upper quadrant, probably representing the kidney. 

Annotated image

Annotated images

Surgical clips (red) arrows are seen in the supraclavicular fossa on the right, invisible on CT. 

The pleural effusion having been drained, multiple soft tissue nodules are noted along the vertebral column behind the aorta (green arrows), surrounding the lung (blue arrow) and in the oblique fissure (yellow arrow). 

On further questioning, the patient confirmed a previous history of melanoma excised 9 years earlier from the right supraclavicular fossa with clear margins. No disease in the intervening years. 

The fluid from the chest drain was sent for cytology. 

Cytology

MACROSCOPIC DESCRIPTION: 80ml moderately bloodstained fluid. 

MICROSCOPIC DESCRIPTION: The smears are cellular, containing numerous abnormal epithelioid cells. They have pleomorphic nuclei, bi/multinucleation, coarse chromatin, occasional intranuclear pseudoinclusions and moderate amounts of cytoplasm. No pigment is seen. 

FINAL DIAGNOSIS: Positive for malignancy, in keeping with metastatic melanoma.

Case Discussion

Melanoma is notorious for unexpectedly showing up as nodal or metastatic disease many years after excision. It is all the most frightening a disease for this tendency, coupled with its ability to present in a wide range of locations, often not the typical sites for metastases from other malignancies. 

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Case information

rID: 21736
Case created: 14th Feb 2013
Last edited: 2nd Nov 2015
System: Chest
Tag: pleura
Inclusion in quiz mode: Included

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