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The <strong>Royal</strong> <strong>Marsden</strong><br />
Challenging cases<br />
in melanoma<br />
Dr James Larkin<br />
Consultant Medical Oncologist<br />
The <strong>Royal</strong> <strong>Marsden</strong> and<br />
The Institute of Cancer Research
The <strong>Royal</strong> <strong>Marsden</strong><br />
Patient 1<br />
– 2002 – cutaneous melanoma left shoulder<br />
– 2007 – lymph node recurrence left neck – excised<br />
(FDG-PET normal)<br />
– 2008 – further lymph node recurrence excised left<br />
neck
The <strong>Royal</strong> <strong>Marsden</strong><br />
May 2008 -new patient to The <strong>Royal</strong> <strong>Marsden</strong><br />
– 27 years old<br />
– All known disease resected<br />
– …and 8 weeks pregnant
The <strong>Royal</strong> <strong>Marsden</strong><br />
Initial advice<br />
– Staging – non contrast CT thorax and USS abdomen<br />
– If metastatic disease – termination of pregnancy<br />
discussed<br />
– If no metastatic disease -
The <strong>Royal</strong> <strong>Marsden</strong><br />
Progress<br />
– Proceeded with pregnancy<br />
– Declined ultrasound surveillance of neck<br />
– Delivered healthy baby boy November 2008<br />
– Placental histology normal
The <strong>Royal</strong> <strong>Marsden</strong><br />
Progress<br />
– May 2009 – CT stable<br />
– Baby checked regularly throughout 2009 – healthy<br />
– Oct 2009 – CT stable
The <strong>Royal</strong> <strong>Marsden</strong><br />
Seen by cardio-thoracic surgeon<br />
– Left upper lobectomy planned<br />
– At surgery – significant growth in LUL mass, invading<br />
pericardium and phrenic nerve<br />
– Left intrapericardial pneumonectomy, cuff of left<br />
atrium removed – clear margins
The <strong>Royal</strong> <strong>Marsden</strong><br />
Current progress<br />
– Good recovery from surgery<br />
– Re-staging planned
The <strong>Royal</strong> <strong>Marsden</strong><br />
Summary<br />
– Young woman with metastatic melanoma in early<br />
pregnancy<br />
– Indolent metastatic disease involving lungs<br />
– Underwent radical surgery
The <strong>Royal</strong> <strong>Marsden</strong><br />
Discussion points<br />
– Management of pregnancy in a patient with<br />
(metastatic) melanoma<br />
– Metastasectomy for oligo-metastatic disease<br />
– When is it ‘safe’<br />
– Should we have performed further imaging prior to<br />
surgery
The <strong>Royal</strong> <strong>Marsden</strong><br />
Patient 2<br />
– 52 year old man<br />
– 2 year history of nasal polyps – repeated polypectomy<br />
– Mucosal melanoma right inferior turbinate<br />
discovered during routine follow up
The <strong>Royal</strong> <strong>Marsden</strong><br />
Initial treatment<br />
– Right medial maxillectomy<br />
– Adjuvant radiotherapy<br />
– 2 weeks later – relapse in right cervical nodes – type<br />
III modified radical neck dissection
The <strong>Royal</strong> <strong>Marsden</strong><br />
Surveillance<br />
– Local recurrence removed four months later<br />
– Slow progression in hilar node<br />
– Continued observation
The <strong>Royal</strong> <strong>Marsden</strong><br />
Current progress<br />
– Recovering well from neurosurgery<br />
– Remains under active surveillance
The <strong>Royal</strong> <strong>Marsden</strong><br />
Summary<br />
– Mucosal melanoma (c-kit wild type) with local and<br />
distant recurrence<br />
– Spontaneous regression of biopsy-proven metastatic<br />
disease<br />
– Differential response in metastatic sites with<br />
development of CNS metastases
The <strong>Royal</strong> <strong>Marsden</strong><br />
Discussion<br />
– Spontaneous regression of metastatic disease – rare<br />
but reported with cutaneous melanomas<br />
– Mechanism – loss of immune tolerance to tumour<br />
antigens<br />
– The brain as an immune-privileged site
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