History 79 year old white male who came to the ER after a fall also had one week history of weakness, dry cough and chest congestion without any fever or night sweats. He is a non-smoker and non-alcoholic..

PHYSICAL EXAMINATION: On physical exam: he was hemodynamically stable and the only significant finding on the physical exam was bronchial breathing on the left lower lobe

DIAGNOSTIC STUDIES:  WBC 10.4, Hb 8.4,Hct 27.9,MCV 91, plt 196.  Na133, K 4.4, chloride 102, bicarb of 22, BUN of 85, creatinine 1.7, glucose 170, calcium 9.1.  CXR new lung nodule at the right base and infiltrate at the left mid lung level

CT Chest  Diffuse interstitial and alveolar opacities throughout both lungs, likely a combination of acute and chronic lung disease with small pleural effusions.  Fairly suspicious-appearing nodule right middle lobe 18 mm in diameter

solitary pulmonary nodule  Malignant Etiology:.Adenocarcinoma 50%.Squamus cell carcinoma 25-20%.metastatic 25% if Pt already has extrapulm ca (colon,breast, kidney, testicular, melanoma).large cell carcinoma and other lung Ca, Malignant lymphoma and carcinoid 5%.

solitary pulmonary nodule  Benign etiology.Infectious Granulomas 80% (Endemic fungi e.g., histoplasmosis, coccidioidomycosis and mycobacteria are most common).Hematoma 10 %

Pathology of the patient lung nodule  Revealed poorly differentiated non small cell lung neoplasm with focal necrosis.  Results of immunohistochemistry were consistent with melanoma.

 After this histological diagnosis the patient was extensively examined to locate the primary tumor but the attempts were unsuccessful.  Patient had a PET scan which showed metastasis to the liver.  Patient was classified as stage IV.

Metastatic melanoma  Nodal or visceral metastasis may be the first presentation of melanoma.  This occurs in less than 2% of all melanoma cases and less than 5% of all patients with metastatic melanoma.  These patients should have a thorough skin examination, including the anal region.

Cont. metastatic melanoma  An eye examination is appropriate if the metastatic pattern is consistent with ocular melanoma.  upper endoscopy and colonoscopy are not recommended unless the patient has specific signs or symptoms suggesting mucosal melanoma as a primary.  Sometimes patients provide history of an unusual skin lesion arising and disappearing without biopsy or treatment.

melanoma  Melanoma is the most deadly cutaneous neoplasm.  Incidence increases by 4.1 % per year which is faster than any other malignancy.  Risk of developing invasive melanoma is 1 in 74 American.  The sixth leading cause of cancer death

Risk factor  Sun sensitivity  White skin, fair hair, light eyes.  Tendency to freckle  Family Hx  Dysplastic nevi  Increase Number of typical nevi  Large congenital nevi  immunosuppressant

Prognostic factor affecting staging  Tumor thickness  Ulceration  Level of invasion  Lymphatic involvement  Sentinel lymph node BX,RT-PCR analysis and no of positive lymph nodes.  Satellite lesion.  Local recurrence

Cont.  Distant metastasis skin, subcutaneous tissue or LN >LUNG metastasis>Visceral sites (bone, liver or brain)  Serum LDH

Clinical Staging of Melanoma Stage 0Melanoma in situ Stage Ia≤1 mm Stage Ib≤1 mm, with ulceration 1.01–2.0 mm, no ulceration Stage IIa1.01–2.0 mm, with ulceration or 2.01–4.0 mm without ulceration Stage IIb2.01–4.0 mm, with ulceration or >4.0 mm without ulceration Stage IIc>4.0 mm with ulceration Stage IIIAny depth with lymph node involvement Stage IVDistant metastasis

treatment  Fortunately, the majority of patients present with stage I to IIA disease. In these patients, surgery is curative in 70 to 90 percent of cases.  stage IIB disease, IIC disease, and stage III disease are associated with a 30 to 80 percent risk of recurrence so adjuvant chemotherapy is needed e.g. Interferon Alfa.

Adjuvant therapy  Interferon Alfa (IFNa).the standard of care for patients with resected node-positive melanoma (stage III) and should be considered for patients with negative nodes whose risk of recurrence is estimated to be 30 to 40 percent or more (stage IIB and IIC).

Cont.  Sage IV: treatment approaches have included cytotoxic chemotherapy e.g. Dacarbazine,and immunotherapy IL-2 or interferon alpha.  The patient in our case was enrolled in clinical trial for a new chemotherapy.

Follow up guide lines  Asymptomatic pt with clinical stage I or II lesions, most imaging studies are not indicated since detection of distant metastases is rare.  Clinical stage III and local recurrence — has 50% rate of recurrence so CBC LDH and CXR is mandatory as base line,CT MRI and PET scan has low yield especially in asymptomatic pt.

Cont.  STAGE IV — Patients with known systemic metastases (stage IV) should be evaluated more comprehensively because the likelihood of detecting additional, unsuspected lesions is higher.

References: 1. Up to date. 2. AJCCSS. 3. American academy of family physician. 4. Conn’s current therapy. Thank you