Ann Thorac Surg 2009;87:1264-1266. doi:10.1016/j.athoracsur.2008.08.052
© 2009 The Society of Thoracic Surgeons
Case Reports
Treatment of Primary Melanoma of the Lung Monitored by 5-S-Cysteinyldopa Levels
Kei Shikuma, MD,
Mitsugu Omasa, MD, PhD*,
Yojiro Yutaka, MD,
Masato Okuda, MD, PhD,
Toshihiko Taki, MD, PhD
Division of Thoracic Surgery, Respiratory Disease Center, The Tazuke Kofukai Medical, Research Institute Kitano Hospital, Kita-ku, Osaka, Japan
Accepted for publication August 20, 2008.
* Address correspondence to Dr Omasa, Division of Thoracic Surgery, Respiratory Disease Center, The Tazuke Kofukai Medical Research Institute Kitano Hospital, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan (Email: m-oomasa{at}kitano-hp.or.jp).
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Abstract
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Malignant melanoma originating outside the skin is very rare, whereas primary malignant melanoma of the lung is extremely rare. 5-S-Cysteinyldopa (5-S-CD), a melanin metabolite, has been reported to be a prognostic marker for cutaneous malignant melanoma. This is the first report in the English language literature dealing with primary malignant melanoma of the lung using serum 5-S-Cysteinyldopa levels to monitor the effects of surgery and chemotherapy.
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Introduction
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Malignant melanoma (MM) is the most common fatal neoplasm of the skin. Approximately 30% of patients with cutaneous melanoma develop metastatic disease, and approximately 40% of metastatic lesions are initially found in the lung [1].
Malignant melanoma usually arises from the skin, but it can sometimes arise from mucosal sites, such as the oral cavity, esophagus, larynx, vagina, and anorectal region [2]. Visceral MM is relatively unusual, and MM originating in the lung is extremely rare. The clinical behavior and prognostic factors of primary MM of the lung are unknown due to the lack of large series.
5-S-Cysteinyldopa (5-S-CD) is a precursor of melanin that is detectable in the urine and serum. The serum 5-S-CD level, widely used by dermatologists, is a useful and well-known tumor marker for cutaneous melanoma that reflects disease progression [3, 4].
A 71-year-old man who was an ex-smoker was admitted to our hospital complaining of cough and dusty sputum. On chest roentgenogram, a round mass was found in the left lower lung field, and a computed tomographic scan showed a 3-cm diameter opacity in the left upper lobe that appeared to extend to the pleura of the lower lobe (Fig 1). On positron emission tomography with fluorodeoxyglucose, the lung tumor had a high uptake (standardized uptake value, 6.7).
The patient underwent a curative left upper lobectomy with wedge resection of the lower lobe. On macroscopic examination, a firm, black, 8-cm tumor was seen (Fig 2).
The histopathologic findings were compatible with MM. The cytoplasm of the tumor cells contained granular, brown pigment, compatible with melanin. The tumor extended to the bronchial epithelium. Immunohistochemical stains were strongly positive for antibodies to S-100 protein and human melanoma black-45, which confirmed the diagnosis of MM. Examination of the surgical specimens showed no lymph node involvement.
To exclude the possibility of metastasis from occult primary MM, an extensive examination was carried out. The patient had no past history of skin tumor, and we could not find any skin, external ear, or ocular lesions. Gastrointestinal fiberscopy, colonoscopy, and endoscopy of the nasal cavity were performed, and no possible primary tumor was detected.
Serum 5-S-CD levels before and after surgery were compared. The serum 5-S-CD level normalized from 24.9 to 6.3 nmol/L (normal range, 1.5 to 8.0 nmol/L, determined by high-performance liquid chromatography) 2 weeks after surgery.
Three months after surgery, the patient had a recurrence develop. On computed tomographic scan, mediastinal nodules and a pericardial effusion were seen, and the serum 5-S-CD level increased to 345 nmol/L. The patient was given chemotherapy, consisting of three cycles of the dacarbazine (DTIC), nimustine hydrochloride (ACNU), and vincristine (VCR) regimen (also known as the DAV regimen). The computed tomographic scan performed after three cycles of chemotherapy confirmed a partial response; there was improvement in the pericardial effusion and in the mediastinal nodules. The patient's serum 5-S-CD level had decreased to 36.7 nmol/L after 1 cycle of chemotherapy. After 2 cycles of chemotherapy, the serum 5-S-CD level had decreased to 12.6 nmol/L.
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Comment
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Primary MM of the lung is an extremely rare disease. Less than 30 cases have been reported in the English language literature. Most reported cases underwent surgical resection (wedge resection, lobectomy, or pneumonectomy), and some received adjuvant chemotherapy/immunochemotherapy. In most cases, patients with primary MM of the lung had a poor prognosis, although in some reports the surgical approach with adjuvant chemotherapy/immunochemotherapy provided long-term survival [2, 5].
Since the pulmonary lesions of MM are almost always metastatic lesions from the primary site, it is important to rule out metastasis before making the diagnosis of primary MM of the lung. The present case fulfilled the strict criteria for diagnosis of primary MM of the lung [2, 6, 7].
Recently, a number of biological markers had reported for MM. Among them, serum 5-S-CD is one of the candidates for cutaneous melanoma marker. It is a melanin metabolite and a specific secretion product of melanocytes. Serum 5-S-CD levels have been reported to be useful as a measurement of disease progression as an early detector of metastasis and for monitoring the effects of therapy [3, 4].
In conclusion, serum 5-S-CD is a very useful marker for monitoring the progression of primary MM of the lung, an extremely rare disease.
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References
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- Petersen RP, Hanish SI, Haney JC, et al. Improved survival with pulmonary metastasectomy: an analysis of 1720 patients with pulmonary metastatic melanoma J Thorac Cardiovasc Surg 2007;133:104-110.[Abstract/Free Full Text]
- Wilson RW, Moran CA. Primary melanoma of the lung: a clinicopathologic and immunohistochemical study of eight cases Am J Pathol 1997;21:1196-1202.
- Li N, Mangini J, Bhawan J. New prognostic factors of cutaneous melanoma: a review of the literature J Cutan Pathol 2002;29:324-340.[Medline]
- Wimmer I, Meyer JC, Seifert B, et al. Prognostic value of serum 5-S-cysteinyldopa for monitoring human metastatic melanoma during immunochemotherapy Cancer Res 1997;57:5073-5076.[Abstract/Free Full Text]
- Ost D, Joseph C, Sogoloff H, et al. Primary pulmonary melanoma: case report and literature review Mayo Clin Proc 1999;74:62-66.[Abstract/Free Full Text]
- Allen MS, Drash EC. Primary melanoma of the lung Cancer 1968;21:154-159.[Medline]
- Jensen OA, Egedorf J. Primary malignant melanoma of the lung Scand J Respir Dis 1967;48:127-135.[Medline]
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Abstract
Introduction
