images in haematology
Metastatic melanoma mimicking acute leukaemia
A 71-year-old male who was immunosuppressed following liver transplantation underwent resection of a 31 mm-deep melanoma on his back. At the time of surgery, a positron emission tomography/computed tomography (PET-CT) scan and biopsy of the left sentinel axillary lymph nodes showed no evidence of metastasis. Three months later he presented with back pain. Another PET-CT was performed, which showed uptake in the left axilla and diffuse activity in the bone marrow. Blood counts were normal and lactic dehydrogenase was 20 times normal. A bone marrow aspirate (upper left) and staining with alpha naphthyl acetate esterase (upper right) were suggestive of acute monocytic leukaemia. Flow cytometry identified a population of cells that were CD45 , CD117+, CD61+, CD71+, CD56+ and were negative for myeloid markers. Bone marrow biopsy sections stained with haematoxylin and eosin (bottom left) and HMB45, recognizing a melanocyte antigen (bottom right), confirmed
ª 2013 John Wiley & Sons Ltd British Journal of Haematology, 2014, 165, 1
massive infiltration by melanoma. The axillary lymph nodes were also infiltrated. The tumour was tested for BRAF mutations and was found to harbour c.1801A > G resulting in K601E substitution and 1750C > T resulting in L584F substitution. Little is known about the clinical implication of these mutations. Despite a significant initial response to treatment with vemurafenib, the patient developed numerous brain metastases within 8 weeks and died 2 weeks later. We attribute the atypical pattern of metastasis to the transplantrelated immunosuppression. Rafael A. Kaliks1, Paulo Augusto A. Silveira2, Akemi Osawa3, Paulo V. Campregher4, Nydia S. Bacal2 and Elvira Deolinda R. P. Velloso2 1
Department of Oncology and Haematology, 2Haematology Laboratory,
3
Department of Nuclear Medicine, and 4Molecular Biology Laboratory,
Hospital Israelita Albert Einstein, S~ao Paulo, Brazil E-mail: [email protected]
First published online 25 November 2013 doi:10.1111/bjh.12669
Metastatic melanoma mimicking acute leukaemia
A 71-year-old male who was immunosuppressed following liver transplantation underwent resection of a 31 mm-deep melanoma on his back. At the time of surgery, a positron emission tomography/computed tomography (PET-CT) scan and biopsy of the left sentinel axillary lymph nodes showed no evidence of metastasis. Three months later he presented with back pain. Another PET-CT was performed, which showed uptake in the left axilla and diffuse activity in the bone marrow. Blood counts were normal and lactic dehydrogenase was 20 times normal. A bone marrow aspirate (upper left) and staining with alpha naphthyl acetate esterase (upper right) were suggestive of acute monocytic leukaemia. Flow cytometry identified a population of cells that were CD45 , CD117+, CD61+, CD71+, CD56+ and were negative for myeloid markers. Bone marrow biopsy sections stained with haematoxylin and eosin (bottom left) and HMB45, recognizing a melanocyte antigen (bottom right), confirmed
ª 2013 John Wiley & Sons Ltd British Journal of Haematology, 2014, 165, 1
massive infiltration by melanoma. The axillary lymph nodes were also infiltrated. The tumour was tested for BRAF mutations and was found to harbour c.1801A > G resulting in K601E substitution and 1750C > T resulting in L584F substitution. Little is known about the clinical implication of these mutations. Despite a significant initial response to treatment with vemurafenib, the patient developed numerous brain metastases within 8 weeks and died 2 weeks later. We attribute the atypical pattern of metastasis to the transplantrelated immunosuppression. Rafael A. Kaliks1, Paulo Augusto A. Silveira2, Akemi Osawa3, Paulo V. Campregher4, Nydia S. Bacal2 and Elvira Deolinda R. P. Velloso2 1
Department of Oncology and Haematology, 2Haematology Laboratory,
3
Department of Nuclear Medicine, and 4Molecular Biology Laboratory,
Hospital Israelita Albert Einstein, S~ao Paulo, Brazil E-mail: [email protected]
First published online 25 November 2013 doi:10.1111/bjh.12669
