Beware the person with the glass eye and the large liver

Abstract

DESCRIPTIONA 67-year-old woman presented to the emergency department reporting of epigastric fullness, fatigue and weight loss.Physical examination revealed three fingerbreadths of hepatomegaly. Blood tests were unremarkable, save for a moderately raised erythrocyte sedimentation rate.An urgent CT of her abdomen demonstrated two large liver lesions of low attenuation on the non-enhanced scan ( figure 1A), showing heterogeneous enhancement in the arterial phase (figure 1B) with contrast washout after a 5 min delay ( figure 1C), an appearance typical of hypervascular metastasis. Ultrasound-guided biopsy of one of these lesions was performed as a primary tumour was not identified. This revealed metastatic melanoma, however the primary lesion was not apparent on clinical examination.At a follow-up appointment the patient admitted to progressively worsening headaches. Non-contrast CT scan of the brain excluded any space-occupying lesions. A solid hyperdense mass was however identified at the posteroinferior aspect of the left lobe.MRI revealed a well-defined, homogenous, intraorbital mass with intrinsic hyperintensity on T1 and fluid-attenuated inversion recovery ( figure 2A), showing avid enhancement postcontrast ( figure 2B, C). There was no evidence of extraocular extension or associated retinal detachment. Given the advanced stage of the tumour, she was treated conservatively with systemic chemotherapy and symptomatic pain relief and is currently being followed up regularly by the oncology team. The imaging findings described are characteristic of malignant uveal melanoma which is the most common primary intraocular malignancy in adults and the second commonest