|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 4 | Page : 150-151
Malignant melanoma metastasizing to bone marrow
Monica Jain MD Pathology 1, Pragya Shukla2
1 Department of Oncopathology, Delhi State Cancer Institute, Delhi, India
2 Department of Clinical Oncology, Delhi State Cancer Institute, Delhi, India
|Date of Web Publication||18-Jan-2017|
Dr. Monica Jain
Assistant Professor, Department of Oncopathology, Delhi State Cancer Institute, Dilshad Garden, Delhi 110095
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain M, Shukla P. Malignant melanoma metastasizing to bone marrow. J Appl Hematol 2016;7:150-1
Bone marrow metastasis in patients with malignant melanoma is a rare phenomenon. A 40-year-old male presented with complaints of pain on walking and persistently low blood counts. The patient was previously diagnosed as a case of malignant melanoma of right-sided chest wall swelling. The biopsy done from the tumor was suggestive of malignant neoplasm with epithelioid phenotype and was positive for HMB-45 and Melan-A and negative for Cytokeratin (CK), Epithelial membrane antigen (EMA), TTF-1, CD-30, and Desmin. The patient had received palliative radiotherapy to the right chest wall with a dose of 20 Gy in 5 fractions. Following this, the patient was given three cycles of cisplatin-, vinblastin-, dacarbazin-, interferon-, and temazolamide-based chemotherapy.
The patient underwent positron emission tomography–computed tomography, which showed an expansile soft tissue density mass lesion involving the right 8th rib with extensive liver and skeletal metastasis. His X-ray pelvis showed multiple lytic lesions in the pelvis. In view of bone metastasis, he was also given zoledronic acid injection and 30 Gy in 10 fractions to the pelvis.
His biochemical investigations revealed elevated alkaline phosphatase (ALP = 700 U/L), elevated lactate dehydrogenase (LDH = 2120 U/L), and high uric acid levels (6.3 mg/dl). The complete blood count (CBC) showed bicytopenia with hemoglobin = 9.7 g/dl, total leukocyte count = 10 × 103/μl and platelet count = 50 × 103/μl. Peripheral smear examination showed a leucoerythroblastic picture. On the basis of his CBC and peripheral blood smear findings, he underwent bone marrow aspiration and biopsy. The bone marrow aspirate smears revealed a diluted marrow with trilineage hematopoeisis and only an occasional melanophage. Bone marrow biopsy of 2 cm length was obtained. It showed 12 marrow spaces out of which 8 marrow spaces consecutively showed trilineage hematopoeisis with scattered melanin like pigment only. Four marrow spaces showed diffuse infiltration by malignant cells having hyperchromatic nuclei and distinct nucleoli along with few pigmented tumor cells and melanophages in a fibromyxoid background. Immunohistochemical staining with HMB-45 and S-100 was positive and negative with Pan-CK [Figure 1]. On the basis of these findings, a diagnosis of bone marrow metastases by malignant melanoma was made. The patient was planned for palliative chemotherapy, but his general condition deteriorated and he expired.
|Figure 1: (a) Bone marrow biopsy (H&E stain) 3×; (b) Bone marrow aspirate (Giemsa stain) 10×; (c) Bone marrow biopsy (H&E stain) 40×; (d) Immunohistochemistry (IHC) on bone marrow biopsy with HMB-45 40×|
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Malignant melanoma is an aggressive and highly metastatic disease. The most frequent metastatic sites are the liver, the bone, and the brain. Bone marrow infiltration is found in nearly 7% during staging and in about 45% on autopsy. In a retrospective review of 293 cases of stage IV melanoma patients during a 15-year period, 28 cases (9.5%) with bone metastases were identified out of which only 7.4% cases had bone marrow infiltration. The majority of the recurrences and metastasis occur within 3 years; therefore, more frequent follow-up in the early period has been recommended. Bone marrow metastasis in the present case occurred after 14 months of initial diagnosis. Bain suggested a minimum trephine biopsy length of 16 mm before processing based on the findings of Bishop et al., in which a plateau was achieved in the rate of detection of metastatic tumor after trephine length exceeded 16 mm. In our case, the bone marrow aspirate showed no abnormal cells, and in the bone marrow biopsy, areas of normal hematopoeisis along with focal areas with malignant cells were seen emphasizing the importance of the bone marrow biopsy length.
The above case reiterates the importance of a close follow-up and adequate biopsy length from the bone marrow.
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