Surgical treatment of splenic metastases in patients with melanoma

Incidentally Detected Solitary Metastatic Melanoma of the Spleen Without Known Primary: A Case Report

Splenic masses could be secondary to infection or due to benign and malignant cancers. Due to its anatomy and microenvironment, the spleen is relatively protected from cancer spread. However, melanomas are one of the few cancers that metastasize to the spleen, but only 2% of these metastasize as solitary splenic masses. Among such a small fraction, only a handful have been reported without a known primary. Our patient, an elderly male in his early 60s, was diagnosed with metastatic melanoma of the spleen following a biopsy of the incidentally detected isolated splenic mass. Complete ocular, oral, and dermatological inspections were unremarkable for a probable primary. He responded well to immunotherapy and total splenectomy with no recurrence. Due to advanced imaging modalities in the modern era, the probability of isolated splenic masses as an initial presentation will increase, and a high index of clinical suspicion should be maintained for metastatic cancer as one of the differentials.

Partial splenectomy after preoperative embolization in a patient with metastatic melanoma – A case report

Introduction and importance

There is lack of evidence regarding the best treatment option for metastatic melanoma. In patients with a single splenic metastasis, preoperative superselective embolization followed by partial splenectomy (PS) could be a feasible treatment strategy to preserve splenic function and hopefully reduce the risk of postoperative bleeding. To our knowledge, this two-step procedure has yet not been published in patients with splenic metastasis.

Case presentation

We present the case of a 73-year-old man with stage IV melanoma consisting of a single splenic metastasis located at the lower pole. Four days prior to surgery, the patient underwent percutaneous superselective embolization of the segmental arteries going to the lower splenic pole. Subsequent, PS was performed using an upper midline laparotomy were a clearly visible tumor was found at the devascularized lower third of the spleen. The splenic parenchyma was divided using an energy device and hemostasis was secured with diathermia and a hemostatic patch. The patient had an uncomplicated recovery and was discharged home on postoperative day 8. Histology revealed an 8 mm, partly necrotic metastasis from a melanoma. There were no signs of recurrency at his last control four months postoperative.

Clinical discussion

There are no guidelines on how splenic metastasis from melanoma are to be removed, nor any literature on postoperative splenic function or survival after PS.

Conclusion

Superselective embolization followed by PS for metastatic melanoma could be a feasible treatment approach in highly selective patients where there is a strong desire to preserve splenic function.

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Total splenectomy is associated with an increased risk of infections, thromboembolism and certain malignancies

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Partial splenectomy (PS) may be considered to preserve splenic function in cases where a splenic lesion is to be removed

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Preoperative superselective arterial embolization can be used to devascularize the relevant splenic segment prior to PS

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To our knowledge, superselective splenic embolization followed by PS has not been published in patients with splenic metastasis

Metastatic melanoma of the spleen without known primary

We present the case of a patient who underwent a laparoscopic splenectomy for splenomegaly associated with anemia and thrombocytopenia thought to be secondary to lymphoma and was found to have metastatic melanoma without a primary source. This is a rare entity in that the patient falls into an atypical population group with conflicting opinions about management that has been scarcely reported in the literature.

Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report and Literature Review

Thyroid cancer is the most common endocrine malignancy, presenting with 23 500 new cases per year in the United States. About 7-23% of the patients will present recurrent metastases disease during follow-up. The classic variant of papillary carcinoma is less aggressive compared to its other variants like diffuse sclerosing, tall cell or columnar cell, and insular variants, and the sites to which this metastasizes is already well identified. Metastasis to the spleen is an extremely rare manifestation of papillary thyroid cancer. To date, only 3 cases have been reported in the literature. Herein, we present a 52-year-old male, who developed spleen metastases, 2.4 years after total thyroidectomy and central neck dissection followed by radioactive iodine ablation and seven months after treatment with sorafenib for lung metastases. The splenic lesion was detected in surveillance studies. This case highlights that splenic metastasis, although rare, may occur even in a patient with a locoregional and systemic controlled thyroid cancer and that it can be treated safely with surgical resection.

5-Year survival after splenectomy in a patient with recurrent cutaneous melanoma: a case report

OBJECTIVE

Splenic metastases of melanoma are uncommon and generally part of a disseminated disease with a poor prognosis. In case of solitary visceral metastasis, surgical resection often remains an effective treatment. This case describes a long-term survival after splenectomy for a recurrent melanoma.

METHODS

We present a 55-year-old female with a solitary splenic metastasis. Her medical history revealed a melanoma of the foot in 2007 and an in-transit metastasis in 2011. A PET-CT revealed in 2012 the presence of a small aspecific lesion in the spleen. Close follow-up was chosen. Since PET-CT and MRI showed a progressive lesion, a laparoscopic splenectomy was performed.

RESULTS

Histological report confirmed the diagnosis of a metastatic lesion. Sixty months after the first radiographic evidence of the splenic metastasis, follow-up revealed no signs of residual disease.

CONCLUSIONS

Although current systemic approaches demonstrate to provide clinically important benefit, patients with oligometastatic disease should be evaluated for surgical metastasectomy. A laparoscopic approach for splenic metastasis is shown to be a safe treatment. This disease-free survival of 60 months in a patient with a history of an in-transit metastasis has not been published before. A splenectomy for a solitary metastasis could prolong the survival, even in a recurrent melanoma.

Case report on the role of radiofrequency-assisted spleen-preserving surgery for splenic metastasis in the era of check-point inhibitors

RATIONALE

An isolated splenic metastasis is a rare phenomenon noted in advanced stage melanoma. We report the role of radiofrequency (RF) -based splenic-preserving splenectomy in a patient with a solitary splenic metastasis from advanced stage melanoma that was managed with checkpoint inhibitors.

PATIENT CONCERNS

We report a case of a 60-year-old man who presented with multiple lung metastases and a solitary splenic metastasis with advanced stage melanoma following excision of primary from his trunk 2.3 years back.

DIAGNOSIS

Considering the diagnosis of advanced stage melanoma with multiple lung metastases and a solitary splenic metastasis, and its ongoing progressive nature. This case was discussed in the tumour board meeting.

INTERVENTIONS

A decision was made to commence treatment with immunotherapy in the form of PD-1 inhibitor (programmed cell death 1 receptor) pembrolizumab. Follow-up restaging computer tomography (CT) scan of the abdomen and chest showed a significant reduction in the lung and chest wall lesions, but the splenic lesion remained unchanged. Given the lack of response to treatment in the splenic metastasis and the significant decrease in lung metastases, the multidisciplinary team decided that a partial splenectomy combined with continued immunotherapy treatment would be appropriate as the success of immunotherapy was imminent within the splenic preservation.

OUTCOMES

The postoperative recovery was smooth and the patient was discharged from hospital on the sixth postoperative day with normal platelets and white blood cells. The histopathological analysis of the resected specimen showed a metastatic melanoma with negative margins.At 10-month follow-up after the splenic resection the patient had not experienced further tumour recurrences.

LESSONS

Spleen-preserving resection for an isolated, solitary splenic metastasis of melanoma is a feasible approach as it not only preserves the ongoing efficacy of checkpoint inhibitors by preserving the physiological T cell milieu, but the immunomodulation properties of RF can produce potentially additional therapeutic benefit.

Solitary splenic metastasis from nasopharyngeal carcinoma: a case report and systematic review of the literature

Background

Solitary splenic metastases are a rare occurrence, and the nasopharyngeal carcinoma represents one of the most uncommon primary sources. The present study aimed to describe a rare case of a solitary single splenic metastasis from nasopharyngeal carcinoma and to assess the number of cases of isolated nasopharyngeal carcinoma metastases to the spleen reported in the literature.

Main body

We describe the case of a 56-year-old man with a history of nasopharyngeal carcinoma and complete remission after chemo-radiotherapy. Three months after complete remission, positron emission tomography/computed tomography scan revealed a hypermetabolic splenic lesion without increased metabolic activity in other areas. After laparoscopic splenectomy, the pathology report confirmed a single splenic metastasis from undifferentiated carcinoma of the nasopharyngeal type. The postoperative period was uneventful. We also performed a systematic review of the literature using MEDLINE and Google Scholar databases. All articles reporting cases of splenic metastases from nasopharyngeal carcinoma, with or without histologic confirmation, were evaluated. The literature search yielded 15 relevant articles, which were very heterogeneous in their aims and methods and described only 25 cases of splenic metastases from nasopharyngeal carcinoma.

Conclusion

The present review shows that solitary splenic metastases from nasopharyngeal carcinoma are a rare event, but it should be considered in patients presenting with splenic lesions at imaging and a history of primary or recurrent nasopharyngeal carcinoma. No evidence supports a negative impact of splenectomy in patients with solitary splenic metastasis from nasopharyngeal carcinoma.

Spontaneous splenic rupture in melanoma

Spontaneous rupture of spleen due to malignant melanoma is a rare situation, with only a few case reports in the literature. This study reports a previously healthy, 30-year-old man who came with chief complaint of acute abdominal pain to emergency room. On physical examination, abdominal tenderness and guarding were detected to be coincident with hypotension. Ultrasonography revealed mild splenomegaly with moderate free fluid in abdominopelvic cavity. Considering acute abdominal pain and hemodynamic instability, he underwent splenectomy with splenic rupture as the source of bleeding. Histologic examination showed diffuse infiltration by tumor. Immunohistochemical study (positive for S100, HMB45, and vimentin and negative for CK, CD10, CK20, CK7, CD30, LCA, EMA, and chromogranin) confirmed metastatic malignant melanoma. On further questioning, there was a past history of a nasal dark skin lesion which was removed two years ago with no pathologic examination. Spontaneous (nontraumatic) rupture of spleen is an uncommon situation and it happens very rarely due to neoplastic metastasis. Metastasis of malignant melanoma is one of the rare causes of the spontaneous rupture of spleen.

Postoperative isolated splenic metastasis from gallbladder cancer: report of a case

We present a rare case of metachronous splenic metastasis from gallbladder cancer. A 65-year-old female with gallbladder cancer underwent a partial hepatectomy with en-bloc resection of the gallbladder and extrahepatic bile duct. Ten months later, she presented with isolated splenic metastasis and underwent splenectomy with distal pancreatectomy. The histological diagnosis confirmed metastatic adenocarcinoma from gallbladder cancer. She had no signs of recurrence 4 years after the second surgery. To the best of our knowledge, this is the first report of isolated splenic metastasis from gallbladder cancer.

Laparoscopic approach for isolated splenic metastasis: comprehensive literature review and report of 6 cases

BACKGROUND

Splenic metastases are extremely unusual. The aim of this paper is to review the world experience to date concerning to laparoscopic approach for splenic metastasis, and to report ours at the Hospital de Sant Pau.

METHODS

Literature review was carried out and relevant reports on laparoscopic approach to splenic metastasis were obtained. In addition, we reviewed our patient's database and retrieved the data of those who underwent laparoscopic splenectomy due to splenic involvement.

RESULTS

Electronic search yielded 8 relevant articles on open splenectomy and 7 articles on laparoscopic splenectomy for splenic metastasis. During the study period, 6 patients were operated on laparoscopically. Primary neoplasms were 3 melanomas, 2 colon carcinomas, and 1 malignant fibrous histiocytoma. None of the patients had surgical complications. Outcome ranged from 2-month to 11-year survival.

CONCLUSIONS

The laparoscopic approach for splenic metastasis is feasible. Of course, it must be individualized in each case.

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We report a case of minimally invasive surgery in the management of metastasis to the spleen. A 67-year-old male patient with possible splenic soft tissue melanoma metastasis was referred to our hospital. He had a history of an excised soft tissue melanoma from his back eight months earlier, and the control abdominal computer tomography (CT) scan revealed a hypodense spleen lesion. The patient underwent laparoscopic surgery to diagnose and treat the splenic lesion. The splenectomy was performed and the histological examination revealed a melanoma. The patient had a good postoperative course and was discharged on the second postoperative day. On his 12-month follow-up there was no sign of recurrence. The laparoscopic approach is a safe and effective alternative for treatment of splenic metastases.

Solitary metachronous splenic metastasis from cutaneous melanoma

Melanoma has been found to metastasise to the spleen, usually in cases of disseminated disease. Solitary splenic metastasis from cutaneous melanoma is very rare. Herein we report the case of a 43-year-old man who developed solitary splenic metastasis from cutaneous melanoma. The patient was operated for T(4b) N(1a) Mo superficial spreading melanoma of the anterior thoracic wall. He subsequently underwent left axillary lymph node dissection due to a positive sentinel lymph node. The 33 retrieved lymph nodes were negative for metastasis. The patient received adjuvant therapy with high-dose interferon α-2b. After 27 months and during the follow-up visit an increasing lactate dehydrogenase serum level was observed. Furthermore, CT of the whole body revealed a solitary hypodense tumour of the spleen 9 cm×6 cm. Curative splenectomy was performed and the histopathological report confirmed metastatic melanoma to the spleen.

Debulking surgery in advanced melanoma

In general, patients with stage IV melanoma have poor survival. However, there are subsets of stage IV melanoma patients who are candidates for surgical debulking. There is a growing body of retrospective evidence about clinicians being able to better select patients who may benefit from surgical resection in isolated stage IV disease. In addition, palliative-type resections may improve quality of life in selected cases. In this article, we discuss how recent advances in effective systemic therapies for melanoma may impact the clinical use of debulking surgery in melanoma patients. We also review the available literature about the rationale, risks, benefits and selection of patients for these procedures.

Metastasectomy for stage IV melanoma: for whom and how much?

Although the conventional paradigm for treating metastatic melanoma relies on systemic therapies, a surgical approach should be strongly considered in selected patients. A surgical approach may not be appropriate for all patients, but it can offer a rapid clearance of disease without the toxicity of systemic therapy. Patient selection is of paramount importance for surgery to be effective. The rationale for surgical intervention in the management of metastatic melanoma, selection factors to be considered, published results, and future directions are discussed in this article.

Ultrasound-guided percutaneous microwave ablation of splenic metastasis: report of four cases and literature review

PURPOSE

To investigate the feasibility, safety and efficacy of ultrasound guided percutaneous microwave (MW) ablation for small splenic metastasis.

MATERIALS AND METHODS

A total of four patients with five pathologically proven splenic metastases (from ovarian, pulmonary, gastric adenocarcinoma and hepatocellular carcinoma, respectively) 1.3 to 2.9 cm in diameter were treated with microwave ablation. A cooled-shaft needle antenna was percutaneously inserted into the tumour under ultrasound guidance. One thermocouple was placed about 0.5 cm away from the tumour to monitor temperature in real time during ablation. Microwaves were emitted at 60 W for 600 s routinely and prolonged as necessary to attain temperatures sufficient to ensure tumour killing. Treatment efficacy was assessed by contrast-enhanced imaging at 1, 3 and 6 months, and every 6 months thereafter.

RESULTS

All tumours were completely ablated at a single session and no complications occurred. No local tumour progression was observed at a mean follow up of 22 ± 17.1 months (range 4 to 43 months). The ablation zone was well defined on contrast-enhanced imaging and it gradually shrank with time. One new metastatic lesion was detected in the spleen at 11 months after the ablation and was successfully treated by another MW ablation. The post-ablation survival was mean 22 months. No other complications were observed except for fever and abdominal pain.

CONCLUSIONS

Ultrasound-guided percutaneous MW ablation appears to be a safe and effective minimally invasive technique for management of small splenic metastasis in selected patients.

Isolated splenic metastasis from renal cell carcinoma: case report and review

This report presents the case of a 70-year-old woman with a previous history of a left nephrectomy for renal cell carcinoma (RCC), who developed general malaise and fatigue. Abdominal computed tomography demonstrated an enhancing 6 × 7 cm necrotic lesion in the lower pole of the spleen suggestive of a metastasis. Given the highly suspicious nature of the lesion we proceeded to splenectomy. The tumour did not breach the splenic capsule, and there was no local diaphragmatic involvement. The mass was concluded to be a true metastasis of the original RCC rather than local recurrence of the disease. The causes of isolated solid splenic lesions are wide and varied, however a past or present history of malignancy should lead to a high index of suspicion for a splenic metastasis. We report an extremely unusual case of spread from a RCC.

A report of laryngeal adenocystic carcinoma metastatic to the spleen and the role of splenectomy in the management of metastatic disease: a case report

Introduction

Adenoid cystic carcinoma (ACC) of the larynx is a rare malignancy characterized by an indolent course and late pulmonary metastases. Metastases from the larynx to the spleen are an unusual event. In the present report, we discuss a patient with adenoid cystic carcinoma of the larynx metastatic to the spleen. A review of the literature did not yield any other such incidents. We review the clinical presentation and course of adenoid cystic carcinoma, as well as the role of splenectomy for metastases.

Case presentation

We present a case of laryngeal adenoid cystic carcinoma in a 26-year-old Caucasian man treated with total laryngectomy and ionizing radiation. He initially developed asynchronous pulmonary metastases, which were resected. Our patient subsequently presented with a symptomatic splenic lesion consistent with metastatic disease, for which he underwent laparoscopic splenectomy.

Conclusions

Splenectomy might be indicated for isolated metastases. A splenectomy effectively addresses symptoms and serves as a cytoreduction modality.

Treatment Options for Limited or Symptomatic Metastatic Melanoma

Background

Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis.

Methods

The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma.

Results

A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival.

Conclusions

A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.

Metastatic disease to the pancreas and spleen

Isolated metastases to the pancreas and spleen are a rare occurrence. When they are diagnosed, pancreatic metastases are most often from renal cell carcinoma, lung cancer, and breast cancer. The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian. If extensive staging studies reveal these metastases to be isolated, then curative resection may be warranted. This review will demonstrate that long-term survival may be achieved in patients with isolated metastases and a prolonged disease-free interval.

Splenic metastases: clinicopathologic presentation, differential diagnosis, and pathogenesis

CONTEXT

Splenic metastases from solid tumors, defined as parenchymal lesion, are considered exceptional. Nevertheless, the number of case reports has been increasing due to the improvement of imaging techniques and the long-term follow-up of patients with cancer. Splenic metastases occur in a context of multivisceral disseminated cancer or as a solitary lesion.

OBJECTIVE

To provide a general overview of the clinicopathologic features, differential diagnosis, and pathogenesis of splenic metastases.

DATA SOURCES

Relevant articles indexed in PubMed (National Library of Medicine) database. The search was based on the following terms: (metastasis or metastases) and spleen.

CONCLUSIONS

The most common primary sources of splenic metastasis are breast, lung, colorectal, and ovarian carcinomas and melanoma in cases of multivisceral cancer and colorectal and ovarian carcinomas in cases of solitary splenic lesion. Splenectomy can be replaced by less aggressive methods such as fine-needle aspiration or percutaneous biopsy for establishing the diagnosis of solitary splenic metastasis. The main differential diagnoses are primary lymphoma, vascular tumors, and infectious lesions of the spleen. The relative rarity of splenic metastases could be explained by anatomic factors and the inhibitory effect of the splenic microenvironment on the growth of metastatic cells. The analysis of clinical case reports suggests that solitary splenic metastases may result from the growth of an early blood-borne micrometastasis following a period of clinical latency, often several years after the diagnosis of the primary tumor.

Selected patients with metastatic melanoma may benefit from liver resection

BACKGROUND

In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma.

METHODS

Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities.

RESULTS

Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively.

CONCLUSIONS

Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Surgical treatment of stage IV melanoma

Surgical therapy plays an important role in the management of selected patients with metastatic melanoma. Patients are frequently symptomatic from metastatic lesions, have few effective therapeutic options, and are faced with dismal outcomes. Surgical resection may provide successful palliation of symptomatic lesions with low morbidity and operative mortality. In carefully selected patients, resections performed with curative intent may result in improved survival if a pattern of disease recurrence suggestive of favorable tumor biology is present, and if complete resection of tumor is achieved. Because the majority of post-surgical metastatic patients eventually relapse and succumb to distant disease, adjuvant immunotherapeutic strategies are currently being evaluated.

Role of surgery in patients with stage IV melanoma

PURPOSE OF REVIEW

The purpose of this brief review is to highlight recent advances in the surgical treatment of metastatic melanoma; to review factors important in the decision-making process of selecting the most appropriate patients for resection; and to discuss the current literature in the context of site of recurrence.

RECENT FINDINGS

While there are relatively few new findings on the surgical treatment of metastatic melanoma, recent reports do support prior observations in the field. The recently revised staging system for melanoma groups metastatic disease according to prognostic features. There is currently a great deal of interest in the use of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to more accurately evaluate metastatic disease. The use stereotactic radiosurgery for brain metastases has expanded recently and adds to local treatment options. When procedures are performed with palliative intent, treatment goals must be clearly defined and communicated among the patient, family and surgeon. Improved understanding of the goals of palliative surgery may be facilitated by the concept of a palliative triangle, which helps define the decision making process among the patient, family members, and surgeon.

SUMMARY

Metastatic melanoma is usually associated with a dismal prognosis. When a procedure is performed with palliative intent, appropriately selected patients usually experience reliable relief of symptoms and improved quality of life. Improved survival after a complete resection with curative intent is often predicted by good performance status, longer disease-free interval, limited extent of metastatic disease, and less aggressive tumor biology.