PMC4532938_01
Preop MRI showing the lesion in the left temporal lobe with no dural attachment.
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fig1
T1 hyperintense and T2 hypointense mass in the left temporal lobe with perilesional oedema with no dural attachment (Figure 1). There was mild heterogeneous enhancement after administration of gadolinium.
H&E stain, x400, sheets of moderately large polygonal cells with round to oval pleomorphic nuclei, dispersed chromatin with mitotic activity (8-10/10 high power field).
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fig2
On immunohistochemistry the tumor cells showed diffuse positivity for human melanin black-45 (HMB-45) antibody and S100 and weak patchy cytoplasmic positivity for antimelanosomal antibody MART-1 (Melan A) which were all suggestive of melanocytic origin (Figures 2 and 3).
S100 staining, x200, cells diffusely positive for S100.
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fig3
On immunohistochemistry the tumor cells showed diffuse positivity for human melanin black-45 (HMB-45) antibody and S100 and weak patchy cytoplasmic positivity for antimelanosomal antibody MART-1 (Melan A) which were all suggestive of melanocytic origin (Figures 2 and 3).
Radiotherapy was administered by 3D conformal technique and the dose wash shown in the figure.
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fig4
He then received adjuvant radiation (Involved Field 3DCRT) along with concurrent Temozolomide to a total dose of 5600 cGy in 28 fractions, 200 cGy per fraction, and five days in week to the postoperative tumor bed using 6 MV linear accelerator (Figure 4).
Post-ChemoRT images showing no recurrent/residual tumor.
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fig5
His MRI brain done four weeks after completion of chemoRT showed no disease recurrence and hence he was started on adjuvant chemotherapy with Temozolomide (Figure 5).
Spine MRI showing drop metastases in the lumbosacral spine.
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fig6
MRI whole spine screening showed multiple tiny T1 hyperintense and T2 hypointense intradural nodular lesions (Figure 6) along the intrathecal nerve roots along with diffuse enhancement of the lower dorsal cord and along the pons.
CSF cytospin smear showing atypical cells in small clusters with intracytoplasmic melanin pigment.
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fig7
His cerebrospinal fluid (CSF) cytospin done now showed melanoma cells (Figure 7) and he was started on Palliative RT to the lumbosacral region (3000 cGy in 10 fractions).