Late Metastatic Presentation of Ocular Melanoma

Abstract

Choroidal melanoma is the most common primary intraocular malignant tumor and the second most common type of primary malignant melanoma in the body. The liver is main site of metastasis in more than 80% cases. There is no consensus regarding follow up with patient having ocular melanoma to see any metastatic disease. We present a case admitted with right upper quadrant pain and diagnosed with metastatic melanoma due to right ocular lesion treated 20 years ago. After the diagnosis was made patient survived only for two weeks. That further signifies the unpredictable course of the disease. BackgroundChoroidal melanoma represents 85 %, of all ocular melanomas and up to 50 % of patients develop metastatic disease [3]. Liver is the most common site of metastasis and its associated with a very poor prognosis. Uveal melanoma originates from melanocytes located anywhere in uveal tract. Choroid is involved in almost 85% -90% of cases, iris and ciliary body are involved in remaining cases. Despite the development of most effective therapeutic methods, 50 % of patients still develop metastatic disease [3]. Incidence of melanoma is increasing rapidly in both men and women. Cutaneous melanoma and ocular melanoma are considered different entities in both metastatic latency and metastatic diffusion. Liver is the principal target organ of ocular metastasis. While cutaneous melanoma spreads to lymph nodes and soft tissues with a minor incidence of hepatic diffusion [5]. Case Presentation61-year-old female was admitted with abdominal pain mainly in right upper quadrant of abdomen for last 4 weeks. Pain was constant, moderate and radiating to right upper flank with no known aggravating and relieving factors. Pain was associated with night sweats. According to patient she was trying to pull a chair and noticed pain. She did not seek medical attention thinking about muscle spasm but it did not get better. She has a history of right eye choroidal melanoma treated with enucleation in 7/1997. Since then patient was having regular follow up with an ophthalmologist and was negative for metastatic diffusion or recurrence. Her past medical history was significant for basal cell carcinoma of forehead, squamous cell carcinoma of nose and diabetes mellitus. She was on oral hypoglycemic. Patient denied nausea, vomiting black color stools any recent changes in weight or appetite. Patient was feeling depressed due to recent death of her husband but denied any homicidal or suicidal thoughts. After initial treatment with analgesic she had CT of abdomen and pelvis that showed multiple lesion in liver suggestive of metastatic disease. Interventional radiologist consult was requested and patient has CT guided biopsy that came positive for malignant melanoma and there was no other lesion identified on physical examination suggestive of malignant melanoma. Patient has elevated AST and ALT but normal bilirubin level. Patient was discharged home to follow up with oncology.CT scan showing multiple lesions in liver