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and she was transferred to another hospital for palliative care&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">With regard to cutaneous melanoma&#44; only 9 cases of ruptured hepatic metastases have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among them&#44; 5 patients received resection of the hepatic lobes with hemorrhaging metastatic lesions&#44; and the remaining four patients and the currently reported patients were treated with TAE&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At present&#44; TAE is widely used as an initial treatment for intraperitoneal bleeding from ruptured hepatic tumors&#46; However&#44; recent reports have shown that rebleeding occurred following TAE and that the long-term outcome of patients treated with TAE was poor compared to those who received hepatic lobectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our patient&#44; TAE was temporarily effective in controlling arterial bleeding from the hepatic metastatic lesions&#44; but extravasation from the tumor might have continued and resulted in the enlargement of the intraperitoneal hematoma and aggravation of the physical condition&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To date&#44; there are few reports of ruptured hepatic metastases in melanoma patients treated with immune checkpoint inhibitors&#46; In our patient&#44; the liver metastases responded well to pembrolizumab therapy and dramatically decreased in size at 13 months after starting pembrolizumab&#46; But at after 3 months&#44; rupture of the hepatic metastases occurred&#44; suggesting the possibility that the hepatic metastases rapidly enlarged during these 3 months&#46; The previously reported in most patients died of melanoma progression or rebleeding within a few months after the onset of rupture&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As rupture of hepatic metastasis of malignant melanoma is very rare&#44; the correct diagnosis may be delayed&#44; resulting in rapid fatal outcomes for affected patients&#46; Therefore&#44; physicians should keep such a rare event in mind when treating patients with hepatic metastases of melanoma showing rapidly progressive anemia and abdominal pain&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Shohei Igari&#58; Designed the study&#44; performed the research and contributed to the analysis and interpretation of data&#44; wrote the initial draft of the manuscript&#44; and read and approved the final version of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Designed the study&#44; and assisted in the preparation of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Miyuki Yamamoto&#58; performed the research and contributed to the analysis and interpretation of data&#44; read&#44; and approved the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nobuyuki Kikuchi&#58; Performed the research and contributed to the analysis and interpretation of data&#44; read&#44; and approved the final version of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mikio Ohtsuka&#58; Performed the research and contributed to the analysis and interpretation of data&#44; assisted in the preparation of the manuscript&#44; read&#44; and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
A case of ruptured hepatic metastases during pembrolizumab administration for cutaneous malignant melanoma
Shohei Igari
Corresponding author
shohey19@fmu.ac.jp

Corresponding author.
, Miyuki Yamamoto, Nobuyuki Kikuchi, Mikio Ohtsuka, Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 76-year-old female visited our department complaining of pigmented lesions on the right heel that had appeared 10 years previously &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; She was diagnosed with cutaneous acral lentiginous melanoma and underwent resection of the lesions&#46; Histological examination revealed atypical cells infiltrating irregularly from the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; These atypical cells were immunoreactive for MART-1 and HMB-45 &#40;Breslow Depth&#58; 3&#46;7&#8239;mm&#44; T3bN0M0&#41;&#46; Computed Tomography &#40;CT&#41; scan at 18 months of follow-up revealed multiple liver and lung metastases&#46; Pembrolizumab administration was started&#44; and the hepatic metastases were gradually reduced in size&#46; On the day of the 21st dose of pembrolizumab&#44; the patient was pale and complained of nausea and sharp pain in the upper abdomen&#46; The complete blood count showed severe anemia &#40;red blood cells 216&#215;10<span class="elsevierStyleSup">4</span>&#47;&#181;L&#59; hemoglobin 6&#46;6&#8239;g&#47;dL&#41;&#46; Abdominal CT scan demonstrated a massive hemoperitoneum with arterial bleeding&#44; suggesting a rupture of the metastatic lesions in the left hepatic lobe &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Transcatheter arterial embolization &#40;TAE&#41; of the left hepatic artery with gelatin sponge particles was immediately performed&#46; By the emergency TAE&#44; intraperitoneal bleeding was temporarily stopped&#44; but abdominal CT on the 25th day after TAE indicated that the hematoma in the liver was significantly increased in size&#46; Since arterial rebleeding was not detected&#44; the hematoma growth was considered to be caused by oozing from necrotic metastatic lesions&#46; The patient&#8217;s medical condition rapidly deteriorated&#44; and she was transferred to another hospital for palliative care&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">With regard to cutaneous melanoma&#44; only 9 cases of ruptured hepatic metastases have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among them&#44; 5 patients received resection of the hepatic lobes with hemorrhaging metastatic lesions&#44; and the remaining four patients and the currently reported patients were treated with TAE&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At present&#44; TAE is widely used as an initial treatment for intraperitoneal bleeding from ruptured hepatic tumors&#46; However&#44; recent reports have shown that rebleeding occurred following TAE and that the long-term outcome of patients treated with TAE was poor compared to those who received hepatic lobectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our patient&#44; TAE was temporarily effective in controlling arterial bleeding from the hepatic metastatic lesions&#44; but extravasation from the tumor might have continued and resulted in the enlargement of the intraperitoneal hematoma and aggravation of the physical condition&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To date&#44; there are few reports of ruptured hepatic metastases in melanoma patients treated with immune checkpoint inhibitors&#46; In our patient&#44; the liver metastases responded well to pembrolizumab therapy and dramatically decreased in size at 13 months after starting pembrolizumab&#46; But at after 3 months&#44; rupture of the hepatic metastases occurred&#44; suggesting the possibility that the hepatic metastases rapidly enlarged during these 3 months&#46; The previously reported in most patients died of melanoma progression or rebleeding within a few months after the onset of rupture&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As rupture of hepatic metastasis of malignant melanoma is very rare&#44; the correct diagnosis may be delayed&#44; resulting in rapid fatal outcomes for affected patients&#46; Therefore&#44; physicians should keep such a rare event in mind when treating patients with hepatic metastases of melanoma showing rapidly progressive anemia and abdominal pain&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Shohei Igari&#58; Designed the study&#44; performed the research and contributed to the analysis and interpretation of data&#44; wrote the initial draft of the manuscript&#44; and read and approved the final version of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Designed the study&#44; and assisted in the preparation of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Miyuki Yamamoto&#58; performed the research and contributed to the analysis and interpretation of data&#44; read&#44; and approved the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nobuyuki Kikuchi&#58; Performed the research and contributed to the analysis and interpretation of data&#44; read&#44; and approved the final version of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mikio Ohtsuka&#58; Performed the research and contributed to the analysis and interpretation of data&#44; assisted in the preparation of the manuscript&#44; read&#44; and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 03650596
Original language: English
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