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Journal of Clinical Oncology, Vol 25, No 6 (February 20), 2007: pp. 725-726 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.6230
Cholestasis From Malignant MelanomaDepartment of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland
Department of Medical Radiology/Division of Nuclear Medicine, University Hospital, Zurich, Switzerland
Department of Pathology, University Hospital, Zurich, Switzerland
Department of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland A 40-year-old man presented with postprandial pain in the right upper abdominal quadrant, having suffered 3 months earlier from abdominal pain and cramps without fever. Five years previously the patient had undergone an excision of a malignant melanoma on his back (Breslow 3; Clark IV, pT4 cN0 cM0). Blood analysis showed cholestasis. Abdominal ultrasound revealed no tumor or cause for obstruction. On the axial fused fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) image the focal FDG uptake can be located in the bile duct (Fig 1, arrow). Endoscopic retrograde cholangiopancreatography showed a 1.5 cm filiform common bile duct stenosis, which was stented. A brush cytology revealed metastatic melanoma cells. The patient underwent palliative resection of the tumor obstruction at the bile duct.
The malignant melanoma metastasis obstructed the choledochal duct completely (Fig 2). Histologically, the partially diffuse infiltrating neoplastic cells represent high mitotic activity. The cells are very pleomorphic showing partially hyperchromatinated nuclei with prominent nucleoli. Occasionally pigmentation can be seen (Fig 3).
Melanoma metastasis in the bile duct is uncommon, only a few cases have been reported.1,2 Intra-abdominal metastases are rarely diagnosed clinically, often many years elapse before symptoms appear. Most of malignant melanoma metastases appear occasionally when symptoms like jaundice, hematemesis, or melena occur. Occult visceral metastases are found in 60% of melanoma patients at autopsy while only 5% are diagnosed in lifetime with present imaging techniques.3 Liver metastases are identified with imaging techniques in only 14% to 20% of patients, but in 54% to 77% of patients by means of autopsy.4 Conventional FDG-PET technology already demonstrates high sensitivity (94%) and specificity (83%) especially for soft tissue and is known to be a useful tool for visceral melanoma metastases.5 Rinne et al6 examined 48 melanoma patients with clinical or CT findings suggesting metastatic disease. In this population, a sensitivity, specificity, and accuracy for FDG-PET was found to be 91.8%, 94.4%, and 92.1%, respectively, compared with 57.6%, 45%, and 55.7% for conventional imaging methods.6 The majority of the available literature suggests that FDG-PET is the most accurate imaging modality for identifying distant metastases in patients at high risk for distant metastasis.7 The CT data of integrated PET/CT imaging are very helpful in the precise localization of FDG-active lesions and are also used for attenuation correction of emission PET images. Reinhardt et al8 showed recently that FDG-PET/CT provided high accuracy for noninvasive detection of perihilar cholangiocarcinoma in extra hepatic bile duct strictures. Integrated PET/CT scanners have become more and more clinically available promising better localization of FDG-active lesions compared with PET alone.9 In our case, FDG-PET/CT was a valuable tool for preoperative staging as well as for surgical planning. This may also play a role in follow-up surveillance after treatment of invasive melanoma. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest.
REFERENCES 1. Dasgupta T, Brasfield R: Metastatic melanoma: A clinicopathological study. Cancer 17:1323-1339, 1964[CrossRef][Medline] 2. Garas G, Bramston B, Edmunds SE: Malignant melanoma metastatic to the common bile duct. J Gastroenterol Hepatol 15:1348-1351, 2000[CrossRef][Medline] 3. Patel JK, Didolkar MS, Pickren JW, et al: Metastatic pattern of malignant melanoma: A study of 216 autopsy cases. Am J Surg 135:807-810, 1978[CrossRef][Medline] 4. Bender GN, Maglinte DD, McLarney JH, et al: Malignant melanoma: Patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. Am J Gastroenterol 96:2392-2400, 2001[Medline] 5. Holder WD Jr, White RL Jr, Zuger JH, et al: Effectiveness of positron emission tomography for the detection of melanoma metastases. Ann Surg 227:764-769, 1998[CrossRef][Medline] 6. Rinne D, Baum RP, Hor G, et al: Primary staging and follow-up of high risk melanoma patients with whole-body 18F-fluorodeoxyglucose positron emission tomography: Results of a prospective study of 100 patients. Cancer 82:1664-1671, 1998[CrossRef][Medline] 7. Friedman KP, Wahl RL: Clinical use of positron emission tomography in the management of cutaneous melanoma. Semin Nucl Med 34:242-253, 2004[CrossRef][Medline] 8. Reinhardt MJ, Strunk H, Gerhardt T, et al: Detection of Klatskin's tumor in extrahepatic bile duct strictures using delayed 18F-FDG PET/CT: Preliminary results for 22 patient studies. J Nucl Med 46:1158-1163, 2005 9. Macapinlac HA: FDG PET and PET/CT imaging in lymphoma and melanoma. Cancer J 10:262-270, 2004[Medline]
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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