- Department of Neurological Surgery, University of Virginia, Charlottesville, United States.
- Department of Neurology, University of Virginia, Charlottesville, United States.
- Department of Pathology, University of Virginia, Charlottesville, United States.
- Department of Radiology, University of Virginia, Charlottesville, United States.
Correspondence Address:
Alexandria C. Marino, Department of Neurological Surgery, University of Virginia, Charlottesville, United States.
DOI:10.25259/SNI_285_2022
Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Alexandria C. Marino1, Camilo E. Fadul2, M. Beatriz Lopes3, Sohil Harshad Patel4, Ashok R. Asthagiri1. Melanoma brain metastasis mimicking cortical laminar necrosis. 23-Dec-2022;13:584
How to cite this URL: Alexandria C. Marino1, Camilo E. Fadul2, M. Beatriz Lopes3, Sohil Harshad Patel4, Ashok R. Asthagiri1. Melanoma brain metastasis mimicking cortical laminar necrosis. 23-Dec-2022;13:584. Available from: https://surgicalneurologyint.com/surgicalint-articles/12078/
Abstract
Background: Metastatic lesions to the brain are common in patients with melanoma. Imaging characteristics can support the diagnosis of metastatic melanoma, but alternative diagnoses should be considered.
Case Description: Here, we present a case of a 57-year-old man in whom a metastatic melanoma initially mimicked the imaging characteristics of cortical laminar necrosis.
Conclusion: This comprises the first report of melanoma brain metastasis presenting with these imaging characteristics and emphasizes the importance of maintaining a high index of suspicion for metastatic lesions in patients with known cancer.
Keywords: Brain metastasis, Melanoma, Magnetic resonance imaging
INTRODUCTION
Brain metastases are the most common adult intracranial malignancy. Because of the relatively high incidence of brain metastases in patients with advanced metastatic melanoma, the recommendation is for contrast-enhanced brain magnetic resonance imaging (MRI) screening and surveillance.[
Here, we present the case of a patient with diagnosis of metastatic melanoma without neurologic symptoms, with surveillance MRI revealing the typical appearance of cortical laminar necrosis.
On follow-up MRI, the lesion grew with features suggestive of metastasis that was confirmed on pathology examination. This case emphasizes the necessity of a high index of suspicion for the presence of metastatic disease despite unusual imaging appearance and the need for short-term surveillance when any clinical or radiographic ambiguity or discordance exists.
CASE REPORT
A 57-year-old man was referred to neuro-oncology for brain MRI findings concerning for cortical laminar necrosis in the setting of metastatic melanoma. He was originally diagnosed with Stage IIIB (pT4bN1aM0) BRAF V600E-mutated cutaneous melanoma 6 years before evaluation with positive sentinel lymph node biopsy. Brain MRI at that time was normal. He had received multiple treatments throughout the years but for the past 30 months had been treated only with encorafenib and binimetinib with stable systemic disease. His medical history was otherwise unremarkable and he had no risk factors for vascular disease.
Routine, asymptomatic surveillance brain MRI with contrast was obtained and was notable for gyriform T1 shortening in the right pars opercularis, new from most recent imaging performed 23 months prior [
Figure 1:
Preoperative progression of MRI characteristics. (a) Axial T1 noncontrast, T1 contrast, FLAIR, and sagittal T1 contrast MRI images demonstrate gyral gray matter T1 shortening without contrast enhancement or adjacent edema. No diffusion restriction was present on diffusion-weighted sequences (not shown). (b) Axial T1 noncontrast, T1 contrast, FLAIR, and sagittal T1 contrast MRI images demonstrate interval gyral expansion adjacent to the previously noted T1 shortening, development of surrounding vasogenic edema, and new contrast-enhancing nodule apparent on T1 sagittal postcontrast image.
Repeat MRI obtained 3 months later revealed gyral expansion in the region of the T1 shortening as well as a new contrast-enhancing adjacent nodule with vasogenic edema [
DISCUSSION
We present an unusual case of metastatic melanoma to the brain with MRI imaging characteristics that suggested cortical laminar necrosis consistent with a chronic cortical infarction. The recognition of melanoma brain metastases is important for patient prognostication and treatment. The number of brain metastases is an independent prognostic indicator in melanoma, along with the presence of extracranial metastases, Karnofsky performance score, age, and BRAF status.[
Brain cortical laminar necrosis was the initial diagnostic consideration in this case. This typically occurs following a hypoxic-ischemic event, in which the ischemia is not severe enough to affect less metabolically active white.[
CONCLUSION
The case presented here illustrates a metastatic melanoma that initially mimicked the appearance of cortical laminar necrosis. This emphasizes the role of close surveillance in patients with known primary cancers and unusual imaging findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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