Primary melanoma of the spinal cord: a case report, molecular footprint, and review of the literature

Primary leptomeningeal melanocytic neoplasms: A clinicopathologic, immunohistochemical, and molecular study of 12 cases

This study investigated the clinicopathological, immunohistochemical, and molecular features of primary leptomeningeal melanocytic neoplasms (LMNs). Twelve LMN cases were retrospectively reviewed. We performed Fluorescence in-situ hybridization (including a 4-probe FISH assay with CDKN2A and MYC assay) and Next-Generation sequencing analyses on available cases. Histologically, 2 tumours were classified as melanocytomas (MC), 2 as intermediate-grade melanocytomas (IMC), and 8 as leptomeningeal melanomas (LMM). Two rare cases of LMM were associated with large plaque-like blue nevus. One MC case was associated with Ota. Ten cases (83.3%) showed melanocytic cells with benign features diffusely proliferating within the meninges. The Ki-67 in three categories differed (MC 0-1%, IMC 0-3%, LMM 3-10%). 57.1% of LMM cases (4/7) were positive for FISH. Nine of 10 tumours harboured activating hotspot mutations in GNAQ, GNA11, or PLCB4. Additional mutations of EIF1AX, SF3B1, or BAP1 were found in 40%, 30%, and 10% of tumours, respectively. During the follow-up (median = 43 months), 5 LMM patients experienced recurrence and/or metastasis, 3 of them died of the disease and the other 2 are alive with the tumour. Our study is by far the first cohort of LMN cases tested by FISH. In addition to morphological indicators including necrosis and mitotic figures, using a combination of Ki-67 and FISH helps to differentiate between IMC and LMM, especially in LMM cases with less pleomorphic features. SF3B1 mutation is first described in 2 cases of plaque-type blue nevus associated with LMM. Patients with SF3B1 mutation might be related to poor prognosis in LMN.

Primary cervicothoracic melanoma of spinal cord: a case report and literature review

A 53-year-old male patient presented progressive numbness and weakness in the right limbs for a 2-year duration. Magnetic resonance imaging scans revealed an intramedullary lesion crossed over cervical and thoracic levels accompanied by syringomyelia at the proximal end of the lesion. The patient underwent subtotal resection of the neoplasm. The histological findings of the tumor were consistent with primary intramedullary malignant melanoma and not initial ependymoma after careful dermatologic and ophthalmologic re-examination. Primary melanoma of the spinal cord, particularly cervicothoracic localization with syringomyelia, is seldom reported in the literature. We report a case of this uncommon tumor and also discuss the clinical course, diagnosis, and treatment.

Surgical Management of Primary Thoracic Epidural Melanoma

In this study, we reported one of the first cases where a rare robotic-assisted platform with neuronavigation technology and carbon-fiber-polyetheretherketone (CF/PEEK) screws is employed to surgically treat multilevel thoracic primary spinal epidural melanoma. A 67-year-old male presented with left upper thoracic pain. His magnetic resonance imaging (MRI) of the thoracic spine revealed a dumbbell-shaped left epidural mass at the T2-3 level. Partial resection was performed due to tumor growth into the vertebral bodies and patient discretion for minimal surgery. The patient's neurological conditions improved postoperatively, with reduced reported symptoms of pain and numbness. Postoperative imaging showed evidence of appropriate spinal stabilization. Patient underwent stereotactic body radiation therapy (SBRT), and no adverse events were reported. This case reflects one of the first examples of treating thoracic epidural melanoma with the use of robotic-assisted navigation. Further prospective studies are needed to determine the efficacy of robot-assisted navigation for patients with primary spinal malignant melanoma which may open the possibility of surgery to once presumed non-operative patients.

Malignant Melanoma Presenting as Spinal Cord and Pleural Lesions

Primary spinal cord melanoma (PSCM) and primary pleural melanoma (PPM) are extremely rare entities with scarce cases reported in the literature. We present a case of a 54-year-old male diagnosed with possible primary pleural melanoma and primary spinal melanoma, managed with partial surgical resection, postoperative radiotherapy, and chemotherapy consisting of Ipilimumab, nivolumab, and temozolomide. This leads to decreased symptoms and improved quality of life of the patient. In this case report, we review the literature on PSCM and PPM in detail, addressing the pertinent clinical aspects as well as current and upcoming therapeutic options.

An atypical primary malignant melanoma arising from the cervical nerve root: A case report and review of literture

BACKGROUND

Primary melanomas affecting the central nervous system are very rare, and melanomas originating in the spinal canal or origin of the spinal nerve root are even rarer. As a consequence, not much is known about this.

CASE SUMMARY

Here we report a case of primary malignant melanoma originating in the cervical spinal cord nerve root. A 64-year-old woman presented with symptoms of numbness in the right side of the neck, pain, and hypoesthesia in the right upper limb which persisted for 1 year. Neurological examination showed that the superficial sensation in the right upper limb had decreased with muscle strength of grade 4. Magnetic resonance imaging examination revealed a mass (approximately 2.5 cm × 1.4 cm × 1 cm) in the right side of the spinal canal in the C-2 plane. Based on findings obtained during operation, perioperative examination, pathological diagnosis, and the diagnostic criteria of primary central melanoma proposed by Hayward, the mass was confirmed to be a melanoma of intraspinal nerve root origin.

CONCLUSION

This is the first case of primary malignant melanoma originating from cervical spinal cord nerve roots and spread along the inside and outside of the spinal canal. The clinical relevance of this case is discussed to provide new insights into the differential diagnosis of intraspinal tumours. Further studies are needed to better understand the mechanisms driving the growth pattern and development of this type of tumour.

Primary intramedullary malignant melanoma: can imaging lead to the correct diagnosis?

Melanoma is a malignant neoplasm of melanin-producing cells. Melanoma usually occurs in the skin, but can also arise in any anatomical site that contains melanocytes, such as mucous membranes, the eyes, and the central nervous system (CNS). Primary CNS malignant melanoma most often develops in the leptomeninges. We report a case of a rare intramedullary melanoma of the thoracic spinal cord. A 78-year-old man was treated with surgery, radiotherapy, and immunotherapy for leptomeningeal spread. We also discuss the role of imaging methods in diagnosis and follow-up. Medullary melanoma occurs more frequently in adults. The most common presenting symptoms are the insidious onset of lower extremity weakness and paresthesia. Magnetic resonance imaging is the method of choice for evaluation. Although there are no imaging features to accurately distinguish primary malignant melanoma from other melanocytic or hemorrhagic tumors, hyperintensity on T1-weighted magnetic resonance imaging should lead to inclusion of this neoplasm in differential diagnosis of spinal cord tumors. Positron emission tomography-computed tomography is a useful auxiliary examination to evaluate the extent of local and metastatic disease. Surgical resection is the primary treatment for intramedullary melanoma. However, the efficacy of adjunctive radiotherapy and chemotherapy for primary spinal cord malignant melanoma is still controversial.

Primary Spinal Melanoma: Case Report and Systematic Review

INTRODUCTION

Primary malignant melanoma of the spinal cord (PSM) is a rare condition with limited evidence regarding its diagnosis (clinical and radiographic), management, and prognosis. Our aim was to report an extremely rare two cases of primary malignant melanoma of the spine one of them is sacral melanoma which represents the second reported case in the literature and to conduct a systematic review of the relevant literature.

METHODS

The diagnosis and management of these cases were retrospectively reviewed. Using the PRISMA guideline, we conducted a systematic review of the literature to analyze different management strategies and the prognosis of such pathology.

RESULTS

All two patients were operated on, and received gross total removal of their tumors, with extended follow up for tumor recurrences. One of the cases involved a sacral tumor, which was resected without adjuvant therapy. The other one was seen by oncology and received post-operative chemo- and radio- therapy. In addition to the aforementioned cases, we present a comprehensive review of the literature on PSM from 1950 to the present, demonstrating that PSM is a very rare tumor, with a limited counted number of cases reported worldwide.

CONCLUSION

In conclusion, we report an exceedingly rare two cases of primary malignant melanoma of the spine. Early surgical intervention is key to the management of these rare and aggressive tumors. GTR should be attempted if possible.

A Rare Case of Primary Malignant Melanoma Presenting with Lower Extremity Weakness

The authors report a pathologically confirmed case of primary malignant melanoma located in the intradural lumbosacral area, which is extremely rare due to its atypical location and manifestation. However rare, primary malignant melanoma could present as an intradural tumor and cause neurological deficit.

Primary Central Nervous System Malignant Melanoma in Children: A Case Series and Review of the Literature

We describe 2 cases of rapidly progressive primary central nervous system malignant melanoma, and summarize 18 previously reported cases of this extremely rare tumor in children. Both patients presented with focal neurologic symptoms, with no evidence of skin or other organ system involvement. One patient was treated with temozolomide and etoposide, whereas the other was treated with multiple surgical resections, radiation therapy, and a trial of ipilimumab. New molecularly targeted and immune-based therapies used in metastatic melanoma in adults are potential new treatment options, but their efficacy and safety in pediatric patients needs to be established.

Primary Spinal Cord Melanoma: A Case Report and a Systemic Review of Overall Survival

BACKGROUND

The incidence of primary spinal cord melanoma (PSCM) is rare. Several case series and case reports have been published in the literature. However, the predictive factors of PSCM survival and management options are not discussed in detail.

METHODS

We present a case of PSCM; total resection was achieved and chemotherapy was given postoperatively. A comprehensive search was performed on PubMed's electronic database using the words "primary spinal cord melanoma." Survival rates with various gender, location, treatment, and metastasis condition were collected from the published articles and analyzed.

RESULTS

Fifty nine cases were eligible for the survival analysis; 54% were male and 46% were female. Patient sex did not influence overall survival. The most common location was the thorax. Patient sex and tumor location did not influence overall survival. The major presenting symptoms were weakness and paresthesia of the extremities. Metastasis or dissemination was noted in 45.16% of 31 patients. In the Kaplan-Meier survival analysis, patients who had metastasis had the worst prognosis. Extent of resection was not related to mortality. Patients who received surgery and surgery with adjuvant therapy had a better median survival than did those who had adjuvant therapy alone. Prognosis was worst in those patients who underwent only adjuvant therapy without surgery (5 months).

CONCLUSIONS

Surgery is the first treatment of choice in treating PSCM. The goal of tumor resection is to reduce symptoms. Adjuvant therapy after surgery had a beneficial effect on limiting the metastasis.

A rare case of primary spinal cord melanoma

Primary central nervous system melanoma is rare, accounting for approximately 1% of total melanoma cases (1-3). Primary central nervous system melanoma localized to the spinal cord is even rarer. The cervical and thoracic levels are most frequently involved. There are no pathognomonic imaging characteristics and diagnosis must be confirmed immunohistologically. The preferred treatment is gross total resection. Utilization of adjuvant radiotherapy and chemotherapy may improve disease-free survival. The prognosis for primary central nervous system melanoma is generally better than that of metastatic and cutaneous melanoma, although there are relatively few cases from which to draw conclusions. We report a case of a 64-year-old woman diagnosed with primary spinal melanoma of the thoracic spine treated with subtotal surgical resection followed by adjuvant radiation therapy.

Clinical features and long-term outcomes of primary spinal malignant melanoma: a single center experience

Primary malignant melanomas are very rare tumors in the spinal canal. In this study, the authors review their experience in a series of seven patients with histologically proven primary spinal malignant melanoma (PSMM) and discuss the clinical features, treatment strategy, and long-term outcomes. Clinical data of seven patients with PSMM treated at a single institution were retrospectively analyzed. There were three male and four female patients, with a mean age of 44 years. The mean duration of illness was 5.4 months. The tumors showed hyperintensity in six cases on T1-weighted image (WI) and isointensity or hypointensity in five cases on T2WI. Gross total resection (GTR) of the tumor was achieved in two cases, and subtotal resection (STR) was achieved in five cases. Four STR patients underwent postoperative local radiation therapy. Postoperative MRI results showed no tumor recurrence in all four female patients after an average follow-up period of 64.5 months. Three male patients had tumor recurrence and dissemination after postoperative 14.7 months (8-24 months), and all died 16.3 months (10-25 months) after initial diagnosis. PSMM should be considered in the differential diagnosis of a middle-aged patient with spinal lesion if the tumor shows hyperintensity on T1WI and hypointensity or isointensity on T2WI on MRI. STR followed by radiotherapy is not excessively associated with deterioration of the final outcome compared to GTR. Our study suggests that PSMM might have female predominance in favorable outcome. Surgical resection followed by adjuvant radiotherapy and regular follow-up are recommended.

[Primary intramedullary melanoma: Case report and literature review]

A dark pigmented intramedullary mass is very rarely encountered in daily practice, and poses a diagnostic challenge. Several entities have to be considered, including melanin-containing tumours (melanotic ependymoma and melanotic schwannoma) and melanocyte-containing tumours (melanocytoma, primary melanoma and melanoma metastases). The case is presented of a 47 year-old male with a pigmented intramedullary tumour located at T7-T8 level. Magnetic resonance images (MRI) revealed a tumour with hyperintensity on T1 and hypointensity on T2. The tumour was resected partially and treated with adjuvant radiotherapy. The diagnosis of primary intramedullary melanoma (PIM) was established based on histology and the absence of other lesions outside of the CNS. A literature review is presented on the other 26 PIM cases reported. PIM are extremely rare tumours, but are the most frequent cause of pigmented intramedullary tumour. Complete surgical resection is the treatment of choice whenever possible, followed by radiotherapy.

Potential pitfalls of mass spectrometry to uncover mutations in childhood soft tissue sarcoma: A report from the Children's Oncology Group

Mass spectrometry-based methods have been widely applied – often as the sole method – to detect mutations in human cancer specimens. We applied this approach to 52 childhood soft tissue sarcoma specimens in an attempt to identify potentially actionable mutations. This analysis revealed that 25% of the specimens harbored high-confidence calls for mutated alleles, including a mutation encoding FLT3^I836M that was called in four cases. Given the surprisingly high frequency and unusual nature of some of the mutant alleles, we carried out ultra-deep next generation sequencing to confirm them. We confirmed only three mutations, which encoded NRAS^A18T, JAK3^V722I and MET^R970C in three specimens. Beyond highlighting those mutations, our findings demonstrate potential pitfalls of primarily utilizing a mass spectrometry-based approach to broadly screen for DNA sequence variants in archived, clinical-grade tumor specimens. Duplicate mass spectrometric analyses and confirmatory next generation sequencing can help diminish false positive calls, but this does not ameliorate potential false negatives due in part to evaluating a limited panel of sequence variants.

Subcutaneous melanocytoma mimicking a lipoma: a rare presentation of a rare neoplasm with histological, immunohistochemical, cytogenetic and molecular characterization

Melanocytoma are the melanocytic tumors originating from leptomeningeal melanocytes. Melanocytomas are commonly seen in the central nervous system (CNS) and are often associated with neurocutaneous melanosis (NCM). However, simultaneous presentation of intra-axial and extracranial melanocytoma is a very rare event. Here, we report a unique case of 21-year-old male with intermediate-grade subcutaneous (SC) melanocytoma, mimicking lipoma, occurred synchronously with an intracranial melanocytoma, not associated with NCM. A 21-year-old Caucasian male presented to the emergency department (ED) with severe vertigo and vomiting. A magnetic resonance imaging (MRI) of the brain was performed at the ED, which revealed an SC mass in the right occipital scalp and a right cerebellopontine angle (CPA) mass. Excision of the SC mass revealed a well-circumscribed highly pigmented melanocytic tumor. The SC mass tumor cells were positive for melanocytic lineage markers. The histopathological features were between benign melanocytomas and malignant melanomas. The Ki67 and PHH3 IHCs confirm the intermediate grade of the tumors. An array-CGH (comparative genome hybridization) and next-generation sequencing analysis of the tumor DNA extracted from the formalin-fixed paraffin-embedded tissue reveals chromosome 6p gain and p.Q209P mutation in the GNAQ gene, respectively, consistent with the diagnosis of intermediate-grade melanocytoma.

Primary melanocytic tumors of the central nervous system: a review with focus on molecular aspects

Primary melanocytic tumors of the central nervous system (CNS) represent a spectrum of rare tumors. They can be benign or malignant and occur in adults as well as in children, the latter often in the context of neurocutaneous melanosis. Until recently, the genetic alterations in these tumors were largely unknown. This is in contrast with cutaneous and uveal melanomas, which are known to harbor distinct oncogenic mutations that can be used as targets for treatment with small-molecule inhibitors in the advanced setting. Recently, novel insights in the molecular alterations underlying primary melanocytic tumors of the CNS were obtained, including different oncogenic mutations in tumors in adult patients (especially GNAQ, GNA11) vs. children (especially NRAS). In this review, the focus is on molecular characteristics of primary melanocytic tumors of the CNS. We summarize what is known about their genetic alterations and discuss implications for pathogenesis and differential diagnosis with other pigmented tumors in or around the CNS. Finally, new therapeutic options with targeted therapy are discussed.

An uncommon intramedullary tumor: primary spinal cord melanoma

A 47-year-old woman was admitted with complaints of progressive weakness in the lower extremities and pain in the back and left leg. Thoracic magnetic resonance imaging (MRI) revealed a spinal intramedullary tumor between the T9 and L1 levels, which were iso- to hypointense on T2 and slightly hyperintense on T1-weighted images. The tumor was resected as total, and the diagnosis was malignant melanoma confirmed with histopathology. Neurological findings improved at the postoperative period and no residual or recurrence was noted on postoperative MRI at the 9-month follow-up. Primary melanoma of the spinal cord, particularly intramedullar localization, is seldomly reported in the literature. We report a primary malignant melanoma of the spinal cord and emphasize the diagnostic and prognostic challenges.

Is it a primary or metastatic melanocytic neoplasm of the central nervous system?: A molecular based approach

Primary melanocytic neoplasms of the central nervous system (CNS) are uncommon and must be distinguished from metastatic lesions as patients with metastatic disease carry a worse prognosis. Therefore, tools to aid in the diagnosis of a primary CNS melanocytic neoplasm would be of clinical utility. Primary CNS melanocytic neoplasms, including uveal melanomas have frequent mutations in GNAQ and GNA11, but are rare in cutaneous and mucosal melanomas. Additionally, primary uveal melanomas often exhibit monosomy 3 conferring an elevated risk of metastasis. We present a 63 year-old male with a melanocytic neoplasm in the thoracic spinal cord. Molecular studies revealed the tumor contained a GNAQ mutation and four-color fluorescent in situ hybridization (FISH) composed of chromosome enumeration probes for 3, 7, 17 and a locus specific probe for 9p21/CDKN2A yielded a normal result (i.e. two copies per cell), favoring a primary versus metastatic melanocytic neoplasm of the CNS. We report a case in which the combination of mutational analysis and FISH aided in identifying the origin of the neoplasm.

Primary extramedullary spinal melanoma mimicking spinal meningioma: A case report and literature review

Primary spinal melanoma is a rare lesion, which occurs throughout the cranial and spinal regions, however, is primarily observed in the middle or lower thoracic spine. The clinical features of primary spinal melanoma are complex and unspecific, resulting in a high misdiagnosis rate. In the present case report, a rare case of spinal melanoma exhibiting the dural tail sign and mimicking spinal meningioma is reported. The initial diagnosis, using magnetic resonance imaging (MRI), was unclear. Thus, melanin-containing tumors and spinal meningioma should have been considered in the differential diagnosis. The tumor was completely resected using a standard posterior midline approach, which was followed by chemotherapy. Subsequent to the surgery, the patient was discharged with improved motor capacity and a follow-up MRI scan showed no recurrence after six months. The present study demonstrates that it is critical for neurosurgeons to focus on increasing the accuracy of initial diagnoses in order to make informed decisions regarding the requirement for surgical resection. The present case report presents the clinical, radiological and pathological features of primary extramedullary spinal melanoma mimicking spinal meningioma to emphasize the importance of early identification and diagnosis.

Primary melanoma of the cervical spine with cerebral metastases: case report and review of the literature

Primary spinal melanoma is a very rare condition: to date < 60 cases have been reported in the literature. A 48-year-old man presented with a 6-month history of upper- and lower-extremity numbness. Spinal magnetic resonance imaging (MRI) revealed a space-occupying lesion at the C2-C6 level. This was confirmed as a melanoma by immunohistochemistry. Cerebral MRI showed multiple lesions with the same signal characteristics as those seen in the spinal lesion on MRI. Complete skin, mucosal and retinal examination failed to show any primary lesion, therefore a diagnosis of primary cervical melanoma with brain metastases was made. To our knowledge this is the first report of a primary melanoma of the cervical spine with cerebral metastases at the time of diagnosis. This article presents pertinent reported literature and discusses the aetiology, diagnosis, treatment and prognosis of this unusual condition.