Liver Metastases from Melanoma Cancer

Stage
Depth
I
Less or equal to 0.75 mm
II
0.75–1.5 mm
III
1.51–2.25 mm
IV
2.26–3.0 mm
V
Greater than 3.0 mm
Table 6.2
Clark’s levels
Level
Depth
I
Melanoma confined to the epidermis
2
Invasion into the papillary dermis
3
Invasion into the junction of the papillary and reticular dermis
4
Invasion into the reticular dermis
5
Invasion into the subcutaneous fat
Table 6.3
AJCC staging
Primary tumor
Tx
Primary cannot be assessed
T0
No evidence of primary tumor
Tis
Melanoma in situ
T1
≤1 mm thick
T2
1.01–2.0 mm thick
T3
2.01–4.0 mm thick
T4
>4.0 mm thick
Regional lymph nodes
Nx
Regional nodes cannot be assessed
N0
No regional metastases detected
N1
Single regional node
a – micrometastasis
b – macrometastasis
N2
2–3 nodes
a – micrometastasis
b – macrometastasis
c – in transit metastasis without lymph nodes
N3
4 or more metastatic nodes or matted nodes or in transit metastasis with metastatic nodes
Distant metastasis
Site of metastasis
LDH
M0
No detectable evidence of distant metastasis
M1a
Skin, subcutaneous, or nodal metastasis
Normal
M1b
Lung
Normal
M1c
All other visceral metastases
Normal
Any distant metastasis
Elevated
Clinical staging
Stage 0
T1s
N0
M0
Stage IA
T1a
N0
M0
Stage IB
T1b
N0
M0
T2a
N0
M0
Stage IIA
T2b
N0
M0
T3a
N0
M0
Stage IIB
T3b
N0
M0
T4a
N0
M0
Stage IIC
T4b
N0
M0
Stage III
Any T
≥N1
M0
Stage IV
Any T
Any N
Any M
a without ulceration, b with ulcerations
Intra-abdominal metastases are common in patients with melanoma. In the vast majority of patients, the disease is disseminated, and of those patients undergoing surgery, two thirds are treatable with intention for complete extirpation of the tumor [3]. The liver is a very common site for metastases from melanoma. Approximately 3 % of all patients have metastases to the liver. Cutaneous melanomas metastasized to the liver in up to 20 % of those patients with metastatic disease. The incidence of hepatic metastases is much more common in patients with ocular melanomas, with up to 40 % of patients having liver metastases at the time of diagnosis [4]. The liver is involved with metastasis from ocular melanoma in over 90 % of cases. Despite the high frequency of metastatic disease, the pattern of disease and associated extrahepatic disease means that only a very small proportion of patients are suitable for surgical treatment [5].

6.3 Surveillance for Metastatic Disease

Follow-up of patients after resection of primary melanomas is related to the depth of invasion of the lesion. For patients with lesions that are less than 1 mm, the risk of recurrence is quite small, and as such if they do not have specific risk factors for the development of a second melanoma, then close follow-up is not necessary. They should have yearly skin checks for 2–3 years, and then review as necessary depending on clinical symptoms. For patients with melanomas thicker than 1 mm, clinical examination of the locoregional lymph nodes, and a complete skin examination, is necessary. As the thickness of the melanoma increases, the frequency of recurrence increases, and more extensive investigations may be required.
In patients with melanomas greater than 4 mm thick serum LDH, staging investigations looking for metastatic disease are required at presentation. There is no evidence that routine surveillance imaging confers a survival benefit, even if metastases are detected earlier, then clinical symptoms arise. In patients where symptoms are present, axial CT scanning and magnetic resonance imaging are appropriate initial investigations. Where there is a high suspicion of recurrence, 18 fluorodeoxyglucose positron emission tomography scan is the most appropriate investigation.

6.4 Staging of Recurrence

When metastatic liver disease is detected, all appropriate clinical and pathological staging investigation should be undertaken. The patients require a serum lactate dehydrogenase level, as well as an axial CT scan of their head, neck, chest, and abdomen. Patients affected by metastases should also undergo an 18 FDG PET scan.

6.5 LDH

Lactate dehydrogenase is secreted when melanoma cells outgrow their vascular supply. It is the strongest independent prognostic factor in metastatic melanoma, and it predicts a poorer survival and a reduction in response to treatment. This is independent of the volume of metastatic disease present. Due to the potential false-positive values for lactate dehydrogenase, it is advised that more than one sample is obtained when using it as a prognostic marker [6].

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Oct 6, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Liver Metastases from Melanoma Cancer

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