S2666 Recurrence of Uveal Melanoma Presenting as Hepatic Metastases

Abstract

Introduction: Uveal melanoma is considered a rare cancer with a stable incidence of 5.1 per million for many years. This is contrast to cutaneous melanoma that has had steadily increasing incidence since the 1970s. Due to the lack of lymphatics in the uveal tract, ocular melanomas spread hematogenously with the liver being a commonly affected organ. Case Description/Methods: A 69-year-old man presented to the hospital with progressive right upper quadrant pain over the past 3 weeks. He had a history of uveal melanoma status post enucleation in 2016 without evidence of recurrence on several years of follow up. On arrival to the hospital, the patient was hemodynamically stable with laboratory values significant for a bilirubin of 7.2 mg/dL (direct of 5.7 mg/dL), alkaline phosphatase of 212 IU/L, AST 90 U/L, and ALT 42 U/L. Computerized Tomography (CT) showed multiple hypoattenuating lesions in the liver without biliary obstruction. MRI demonstrated several different types of hepatic lesions. This included an increased T2 signal with heterogeneous enhancement measuring 16.2 x 9.7cm, several foci of arterial phase hyperenhancement with the largest measuring 4.4 x 5.3 cm, and several rim enhancing lesions. The patient received a liver biopsy with tumor cells positive for SOX 10 and Melan A (Figure) consistent with metastatic melanoma. He underwent complete staging, including a brain MRI, with only other findings of a sclerotic L1 lesion. The patient decided to pursue comfort care and was discharged to home. Discussion: We report here a case of recurrent melanoma of uveal origin presenting as hepatic metastases. Uveal melanoma has low incidence but carries a very poor prognosis as median overall survival is 4-15 months. Even if treated, there is a high risk of recurrence with metastatic disease, largely to the liver, with majority appearing within 10 years of initial treatment. Survival is directly related to the presence and progression of liver metastases. There are currently no guidelines for surveillance or standard of care treatment modalities for metastatic uveal melanoma. Our patient was closely monitored by his oncologist, and follow-up was discontinued after several disease-free years. This case demonstrates that patients with a history of uveal melanoma may benefit from continued surveillance with liver enzyme tests and liver imaging, akin to hepatocellular carcinoma screening. Heightened physician vigilance and patient awareness may aid in early diagnosis of recurrence.Figure 1:: A) Hematoxylin and eosin stain, B) SOX-10 immunostaining. The tumor cells are positive for SOX10, Melan A, negative for arginase and HSA. The results support the diagnosis of metastatic melanoma.