The Absent-Minded Professor: An Unusual Complication of Melanoma

SECOND OPINION
Multidisciplinary Consultations on Challenging Cases

The University of Colorado Denver School of Medicine faculty holds weekly second opinion conferences focusing on cancer cases that represent most major cancer sites. Patients seen for second opinions are evaluated by an oncologic specialist. Their history, pathology, and radiographs are reviewed during the multidisciplinary conference, and then specific recommendations are made. These cases are usually challenging, and these conferences provide an outstanding educational opportunity for staff, fellows, and residents in training.

The second opinion conferences include actual cases from genitourinary, lung, melanoma, breast, neurosurgery, gastrointestinal, and medical oncology. On an occasional basis, ONCOLOGY will publish the more interesting case discussions and the resultant recommendations. We would appreciate your feedback; please contact us at

second.opinion@uchsc.edu

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E. David Crawford, MD
Al Barqawi, MD
Guest Editors

University of Colorado Health Sciences Center
and Univeristy of Colorado Cancer Center
Denver, Colorado

The patient is a geology professor who was evaluated in our multidisciplinary cutaneous oncology clinic for a new diagnosis of malignant melanoma with subsequent development of metastatic disease and melanoma-associated retinopathy.

History

The patient initially presented to our clinic in 1998. At that time, he was a 57-year-old geologist with a history of extensive sun exposure who had a pigmented lesion biopsied from his right posterior auricular region. The pathology revealed a Clark’s level IV, 1.28-mm malignant melanoma. He subsequently underwent wide local excision with concurrent sentinel lymph node biopsy. The reexicison specimen revealed no residual melanoma, and three lymph nodes were removed, none of which showed any evidence of metastatic melanoma. After much discussion with the patient, he elected to enroll on an adjuvant clinical trial of interferon with or without tamoxifen. He was randomized to receive interferon alone. He received interferon at 3 million units subcutaneously three times a week for a total of 18 months. The patient tolerated this treatment well, with only fatigue as a complaint. He was then followed with close observation.

He did very well until May of 2002, when he began to complain of trouble with his vision. He reported yellow and white flashing lights and floaters. An optometrist initially evaluated him but found no etiology for these symptoms. Magnetic resonance imaging (MRI) of the brain was performed in June 2002 to further evaluate these symptoms. The scans showed no evidence of metastatic melanoma. Despite this initial negative workup, the patient continued to report worsening vision with persistent flashing lights as well as new symptoms of memory loss. He was therefore evaluated by ophthalmology. Because of his symptoms, there was concern about lymphoma as a possible cause, and therefore a vitreous biopsy was performed. The biopsy was interpreted as vitritis. The pathology revealed inflammatory white cells, no definitive pigment cells, and no lymphoma, and all cultures were negative.

Symptoms particularly worsened in September 2002, with progressive short-term memory loss and difficulty with verbal expression. The patient stated, “I am losing my mind.” A repeat MRI of the brain was performed, revealing a 5×4.4×4 cm left frontal hemorrhagic metastasis. He was admitted to neurosurgery and began therapy with steroids and antiepileptics. A left craniotomy with complete resection was performed, and the pathology was consistent with metastatic melanoma.

Further evaluation with imaging demonstrated mediastinal lymphadenopathy and only postoperative changes on brain MRI. In October 2002 the patient was enrolled on a clinical trial with EPO906A, an experimental epothilone.

FIGURE 1

Patient's Own Drawing of His Visual Symptoms

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