Metástases cutâneas em melanoma de coróide

Cutaneous metastasis in choroidal melanoma

CASE REPORT

Cutaneous metastasis in choroidal melanoma

Metástases cutâneas em melanoma de coróide

Fabricio Lopes da Fonseca^I; Suzana Matayoshi^II

^IMD, Fellow of Oculoplastic Service, Ophthalmology and Otorhinolaryngology Department,Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP – São Paulo (SP), Brazil

^IIPh.D, Associate Professor and Chief of Oculoplastic Service, Ophthalmology and Otorhinolaryngology Department. Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP – São Paulo (SP), Brazil

^{Correspondence}

ABSTRACT

Metastasis in choroidal melanoma is frequent on advanced diseases, involving mainly the liver, lungs and central nervous system. We report a case of cutaneous metastasis in choroidal melanoma because is an unusual condition, even in advanced disease.

Keywords: Melanoma; Choroid neoplasms; Neoplasm metastasis; Eye neoplasms; Skin neoplasms/secondary; Case reports

RESUMO

A ocorrência de metástases do melanoma de coróide é frequente na doença avançada, acometendo principalmente fígado, pulmões e sistema nervoso central. Relatamos um caso de melanoma de coróide com metástases cutâneas, por se tratar de acometimento raro, mesmo em casos avançados da doença.

Descritores: Melanoma; Neoplasias da coróide; Metastase neoplásica; Neoplasias cutâneas/secundário; Relatos de casos

INTRODUCTION

elanomas are malignant neoplasms that develops from dendritic melanocytes in the skin, eyes, mucous epithelium and leptomeninges. Although the skin is the most common site of development, melanoma can occur in any tissue that contains melanocytes⁽¹⁾.

The uveal melanoma is the more frequent intraocular malignancy in adults,affecting approximately 6 to 7 cases per million people in the United States of America². Although rarer than in cutaneous melanoma, metastasis is frequent and involves the liver, the lungs, the bones, the kidneys and the brain. Cutaneous metastasis is a rare manifestation of advanced disease^(2,3).

Besides primary ocular melanoma, arising from eyelids, conjunctiva and uvea, the eye region may be affected by cutaneous melanoma, most often manifesting in the uvea densely vascularized, particularly the choroid, and orbit⁽³⁾.

This paper aims to report a case of choroidal melanoma with cutaneous metastases, because it is an uncommon finding.

Case report

A 47-year-old female was referred to the HCFMUSP ophthalmology clinic with a history of insidious and painless decrease in visual acuity in the right eye for 8 years, proptosis which was initially noticed 2 years ago and the arising of large and pigmented lesions in the scalp are 3 months. She also reported some weight loss and anorexia for 3 months before diagnosis. She was diagnosed with neovascular glaucoma elsewhere, but lost follow-up.

Ophthalmic examination revealed no light perception and total limitation of eye movements in all gaze positions, severe proptosis and palpable hard mass involving the entire orbital rim, with superior temporal hyperpigmentation (Figure 1). Slit-lamp examination showed intense neovascularization of the anterior segment, cataract and flat anterior chamber (Figure 1).

Medical examination revealed hepatomegaly, with hardened liver surface and irregular edges, signs of asciites and three hyperpigmented and elevated lesions in the scalp (Figure 1).

She underwent computerized tomography (CT SCAN) of the skull, orbits, chest and abdomen and also a skin biopsy of the scalp lesions.

The CT scan of the orbit revealed a mass with heterogeneous pattern and irregular limits, affecting the posterior portion of right eye, with bone erosion and invasion of anterior and middle ethmoidal, maxillary and sphenoid sinus (Figure 1). There was no significant intracranial extension.The abdominal CT scan revealed diffuse hepatic involvement, with heterogeneous areas compatible with necrosis and consistent with metastatic neoplasia (Figure 1).

The result of anatomo-pathological examination of the biopsy showed a lesion characterized by intense cellular pleomorphism, with bizarre nuclei and presence of melanin material (Figure 2). The presence of perilesional inflammatory infiltrate was also observed, as macrophages filled with material melanin (Figure 2). On the contrary seen in primary skin lesions, the epidermis remained intact, indicating metastatic involvement of an uveal primary lesion (Figure 2).

The patient was assessed jointly by the Clinical Oncology Service, and refered to palliative radiotherapy and chemotherapy.

Comments

The differentiation between primary uveal melanoma and primary cutaneous melanoma may be difficult, as observed in this report. Clinical history and examination findings are useful, since they increase the likelihood of metastatic disease, as history of nonocular melanoma metastasis, faster growth, multiple and flat lesions, and pigmented cells in the vitreous⁴. In this report, the history of eye symptoms for a long time, multiple skin lesions and the radiological and pathological features leads to the diagnosis of primary choroidal melanoma with skin metastasis.

Although less frequently, choroidal melanoma may course with metastasis in 75% of patients at time of death, opposite to 96% of cases of cutaneous melanoma². The liver is the main site of metastasis. Skin lesions is a rare manifestation which may can represent metastatic disease of choroidal melanoma, mainly in advanced cases as we reported.

Recebido para publicação em 27/8/2010

Aceito para publicação em 29/3/2011

Study carried out at

Oculoplastic Service - Ophthalmology and Otorhinolaryngology Department;Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- USP – São Paulo(SP),Brazil

Interest conflitct - None

• 1. Hurst EA, Harbour JW, Cornelius LA. Ocular melanoma: a review and the relationship to cutaneous melanoma. Arch Dermatol. 2003;139(8):1067-73. Comment in: Arch Dermatol. 2003;140(7):884-5; author reply 885.
• 2. Bell DJ, Wilson MW. Choroidal melanoma: natural history and management options. Cancer Control. 2004;11(5):296-303.
• 3. Shields CL, Shields JA. Ocular melanoma: relatively rare but requiring respect. Clin Dermatol. 2009;27(1):12233.
• 4. Rosenberg C, Finger PT. Cutaneous malignant melanoma metastatic to the eye, lids, and orbit. Surv Ophthalmol. 2008;53(3):187-202.

Publication Dates

• Publication in this collection
  22 Nov 2011
• Date of issue
  Oct 2011

History

• Received
  27 Aug 2010
• Accepted
  29 Mar 2011