Jamie Lee S. Pastor

1
Melanoma with First Presentation in a CSF

• By
• Jamie Lee S. Pastor
• SUNY Upstate Medical University

2
Clinical History

• 49-yr-old man
• Presented with TIA?
• History of anemia, 2 strokes, pacemaker in place
• Did not carry Factor V Leiden mutation
• Symptoms seizures, severe headaches, difficulty
  recalling events and episodes
• No cancer history

3
Clinical Information

• CT scan and MRI revealed a mass of left occipital
  region
• No mass affect or midline shift
• No evidence of hemorrhage
• Cerebral angiogram and CT scan of thorax, pelvis,
  and abdomen were unremarkable

4
Clinical Information

• CSF tests for infection
• Lyme disease not detected
• India ink prep negative for Cryptococcus
• Herpes Simplex Virus negative
• Body fluid culture negative

5
Clinical Information

• Diagnoses
• Left occipital lesion
• Multiple brain lesions
• Leptomeningeal disease

6
Cytology Specimen

• CSF specimen 7.0 ml slightly hazy
• 1 slide for Pap stain
• 1 slide for Wright-Giemsa stain
• 1 slide for melanin

7
Cytological Findings

• Low cellularity
• Large malignant cells with macronucleoli
  eccentric nuclei
• Cells occur singly, pairs, or in tight groups
• Hyperchromatic nuclei (round or oval)
• Vacuolated and pigmented cytoplasm
• Elongated spindly cells
• Mitotic figures
• Melanin stain positive for melanoma

8
Cytology smear Pap stain

• 10X

• 40X

9
Cytology Smear Pap stain

• 10X

• 40X

10
Cytology smear Pap stain 40X
11
Cytology smear Wright Giemsa 40X
12
Cytology smear Wright Giemsa 40X
13
Cytology smear Melanin stain 40X
14
Cytology smear Melanin stain 60X
15
Immunostains for Melanoma

• HMB-45
• S-100

16
Cytological Diagnosis

• CSF cytology positive for malignant melanoma
• Melanin stain positive supporting diagnosis of
  metastatic melanoma

17
Differential Diagnoses

• Basal cell carcinoma
• Large cell lymphoma
• Metastatic carcinoma

18
Treatments for advanced melanoma

• Chemotherapy
• Dacarbazine (DTIC)
• Temozolomide
• Immunotherapy
• Interleukin-2 (IL-2)
• Interferon alpha (IFNA)
• Surgery
• Whole brain radiation therapy (WBRT)
• Stereotactic radiosurgery (SRS)
• Other treatments melanoma vaccines, gene
  therapy, etc.
• Palliative care (patients choice)

19
Discussion

• 55,100 new cases annually in US
• 14 diagnosed with late met. Melanoma
• 160,000 diagnosed annually worldwide
• 60,000 die from melanoma each year
• Melanoma 3rd most common tumor to metastasize
  to CNS (after lung and breast)
• Survival 2-4 months with 1 yr. survival rate of
  lt 13

20
References

• Case from files of SUNY Upstate Medical
  University Hospital
• Koss LG. Diagnostic Cytology and its
  Histopathologic Bases. 5th edition.
• DeMay RM. The Practical Principles of
  Cytopathology.
• Cibas Edmund. Cytology. 2nd edition.
• Press Release Archive. http//www.medarex.com/cgi
  -local/item.pl/20041005-623388

21
Thank You

• Susan B. Stowell, M.A., SCT(ASCP)CMIAC
• Beth G. Walsh, B.S., SCT(ASCP)CMIAC
• Cindy A. Steele, B.S., SCT(ASCP)CMIAC
• Roberta Demoski, CT(ASCP)
• Cheryl Schmidt, CT(ASCP)
• Dr. Luminita Marinescu
• My classmates