Presentation
Abdominal pain, vomiting.
Patient Data
Mass measuring 2.4 x 2.9 cm at the hilum of the right lung at the upper edge of the scan - metastasis.
Very small right pleural effusion. Coarse atheromatous calcification of the LAD and the diagonals.
Moderate-sized hiatal hernia containing the proximal stomach.
Enlarged left hepatic lobe. Target-shaped hypodense metastases with hyperenhancing edges scattered throughout both hepatic lobes; most are large (up to 10.8 x 8.5 cm).
Normal-sized spleen with a round hypodense metastasis similar to those in the liver. Small adjacent lesion, most probably representing another metastasis.
Bulky adrenals, with no discrete lesion.
Several small, round, exophytic uterine lesions showing intense peripheral enhancement - probably fibroids, cannot rule out metastases.
Moderate amount of free intraperitoneal fluid measuring 20-30 HU, mostly perihepatic and pelvic. Hemorrhagic fluid abutting the inferior edge of the liver and gallbladder.
One of the hepatic metastases was biopsied under ultrasound guidance.
Ultrasound-guided biopsy from one of the liver metastases.
Case Discussion
Referred to the ER due to hypotension and vomiting. Complained of epigastric pain and vomiting. Rigid abdomen, diffusely tender, mass palpated in right abdomen. Newly elevated liver function tests.
CT abdomen showed hepatic and splenic metastases, as well as a right hilar metastasis at the very upper edge of the scan. A biopsy was obtained from a hepatic metastasis.
Histopathology report:
Cores of liver parenchyma infiltrated by a malignant neoplasm composed of small and large pleomorphic cells occasionally exhibiting a centrally located prominent nucleolus and occasional binuclation.
On immunostains the tumor cells are positive for HMB45, Melan A and S-100.
They are negative for CD3, CD20, CD138, kappa, lambda, MNF116, CK5/6, CK7 and CK20.
The Ki-67 is approximately 50-60%.
Conclusion:
The morphologic changes are consistent with metastatic melanoma.
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