Letter - Clinical
A case of ruptured hepatic metastases during pembrolizumab administration for cutaneous malignant melanoma
Shohei Igari
, Miyuki Yamamoto, Nobuyuki Kikuchi, Mikio Ohtsuka, Toshiyuki Yamamoto
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Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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Clinical</span>" "titulo" => "A case of ruptured hepatic metastases during pembrolizumab administration for cutaneous malignant melanoma" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "450" "paginaFinal" => "451" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Shohei Igari, Miyuki Yamamoto, Nobuyuki Kikuchi, Mikio Ohtsuka, Toshiyuki Yamamoto" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Shohei" "apellidos" => "Igari" "email" => array:1 [ 0 => "shohey19@fmu.ac.jp" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Miyuki" "apellidos" => "Yamamoto" ] 2 => array:2 [ "nombre" => "Nobuyuki" "apellidos" => "Kikuchi" ] 3 => array:2 [ "nombre" => "Mikio" "apellidos" => "Ohtsuka" ] 4 => array:2 [ "nombre" => "Toshiyuki" "apellidos" => "Yamamoto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Fukushima Medical University, Fukushima, Japan" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 1675 "Tamanyo" => 106973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. Multiple pigmentation patches on the heel.</p>" ] ] ] "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 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She was diagnosed with cutaneous acral lentiginous melanoma and underwent resection of the lesions. Histological examination revealed atypical cells infiltrating irregularly from the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These atypical cells were immunoreactive for MART-1 and HMB-45 (Breslow Depth: 3.7 mm, T3bN0M0). Computed Tomography (CT) scan at 18 months of follow-up revealed multiple liver and lung metastases. Pembrolizumab administration was started, and the hepatic metastases were gradually reduced in size. On the day of the 21st dose of pembrolizumab, the patient was pale and complained of nausea and sharp pain in the upper abdomen. The complete blood count showed severe anemia (red blood cells 216×10<span class="elsevierStyleSup">4</span>/µL; hemoglobin 6.6 g/dL). Abdominal CT scan demonstrated a massive hemoperitoneum with arterial bleeding, suggesting a rupture of the metastatic lesions in the left hepatic lobe (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Transcatheter arterial embolization (TAE) of the left hepatic artery with gelatin sponge particles was immediately performed. By the emergency TAE, intraperitoneal bleeding was temporarily stopped, but abdominal CT on the 25th day after TAE indicated that the hematoma in the liver was significantly increased in size. Since arterial rebleeding was not detected, the hematoma growth was considered to be caused by oozing from necrotic metastatic lesions. The patient’s medical condition rapidly deteriorated, and she was transferred to another hospital for palliative care.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">With regard to cutaneous melanoma, only 9 cases of ruptured hepatic metastases have been reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among them, 5 patients received resection of the hepatic lobes with hemorrhaging metastatic lesions, and the remaining four patients and the currently reported patients were treated with TAE.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At present, TAE is widely used as an initial treatment for intraperitoneal bleeding from ruptured hepatic tumors. However, 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.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our patient, TAE was temporarily effective in controlling arterial bleeding from the hepatic metastatic lesions, but extravasation from the tumor might have continued and resulted in the enlargement of the intraperitoneal hematoma and aggravation of the physical condition.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To date, there are few reports of ruptured hepatic metastases in melanoma patients treated with immune checkpoint inhibitors. In our patient, the liver metastases responded well to pembrolizumab therapy and dramatically decreased in size at 13 months after starting pembrolizumab. But at after 3 months, rupture of the hepatic metastases occurred, suggesting the possibility that the hepatic metastases rapidly enlarged during these 3 months. The previously reported in most patients died of melanoma progression or rebleeding within a few months after the onset of rupture.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As rupture of hepatic metastasis of malignant melanoma is very rare, the correct diagnosis may be delayed, resulting in rapid fatal outcomes for affected patients. Therefore, physicians should keep such a rare event in mind when treating patients with hepatic metastases of melanoma showing rapidly progressive anemia and abdominal pain.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Shohei Igari: Designed the study, performed the research and contributed to the analysis and interpretation of data, wrote the initial draft of the manuscript, and read and approved the final version of the manuscript.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto: Designed the study, and assisted in the preparation of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Miyuki Yamamoto: performed the research and contributed to the analysis and interpretation of data, read, and approved the final version of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nobuyuki Kikuchi: Performed the research and contributed to the analysis and interpretation of data, read, and approved the final version of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mikio Ohtsuka: Performed the research and contributed to the analysis and interpretation of data, assisted in the preparation of the manuscript, read, and approved the final version of the manuscript.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-07-01" "fechaAceptado" => "2022-10-03" "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 1675 "Tamanyo" => 106973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. Multiple pigmentation patches on the heel.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1294 "Ancho" => 1675 "Tamanyo" => 561451 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histological feature showing proliferation of atypical melanocytes in the dermis (×100).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1295 "Ancho" => 1675 "Tamanyo" => 117739 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abdominal CT showed a rupture of the liver metastases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured hepatic metastases of cutaneous melanoma during treatment with vemurafenib: an autopsy case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. 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| Ano/Mês | Html | Total | |
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