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Washington University Experience | NEOPLASMS (METASTASES) | Melanoma | 2A0 Case 2 History
Case 2 History ---- The patient was a 58-year-old man with metastatic melanoma (found to be positive for a BRAF D594N mutation) involving the lungs, liver, and spine with hemorrhagic brain metastases. The patient was originally diagnosed in April 2007 with a malignant melanoma, halo type, with a Breslow depth of 0.9 mm, located on the left neck. Altogether, the lesion was biopsied once and excised/re-excised 3 times to achieve negative margins. The patient then presented in the summer of 2013 with left arm and facial numbness, associated with dizziness, proven to represent multiple brain metastases. He completed whole brain radiation therapy (3750 cGy). He then had progression of disease and underwent Gamma Knife radiosurgery to 4 separate lesions in 02/2014. He again had progression of disease and was treated with Gamma Knife radiosurgery to 7 lesions. MRI showed innumerable T1 hyperintense/hemorrhagic and enhancing supratentorial masses, with most of the lesions demonstrating a mild to moderate increase in size compared to October 2014. These lesions had associated mild local mass effect, but no significant ventricular effacement or midline shift. He presented with worsening confusion over a 2 day period, manifest as inappropriate responses and a decreased level of orientation. At the time of admission, the patient was only able to respond with yes and no to very loud verbal stimuli and sternal chest rub. A head CT scan showed no acute intracranial process, but multiple supratentorial hemorrhagic lesions which appeared stable in size compared to the prior MR from 11/2014. There was a suggestion of a new lesion in the left cerebellum. Finally, there were multiple metastatic lesions in the scalp, which appeared larger in size compared to the prior MRI. The patient was admitted in 12/2014 with worsening confusion and hypoxemia. Oral and intravenous dexamethasone was given, as well as Keppra and Namenda. After discussion with family, the patient's status was made was made comfort measures only and he died in late December 2014.
