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METASTATIC OCULAR MELANOMA TO THE KIDNEY 20 YEARS AFTER INITIAL DIAGNOSIS BRIAN M. LEVIN, FOUAD I. BOULOS, AND S. DUKE HERRELL ABSTRACT Metastatic tumors are the most common malignancies of the kidney. We report a rare case of isolated metastatic ocular melanoma to the kidney occurring 20 years after diagnosis. A 71-year-old man presented with gross hematuria. He had undergone left enucleation 20 years previously for ocular melanoma and had not required adjuvant therapy. A right upper pole mass was identified on computed tomography and was excised laparoscopically. Pathologic examination revealed metastatic melanoma. Metastatic melanoma to the kidney is rare. A high index of suspicion must be maintained in any patient with a renal mass and a history of a nonrenal malignancy. UROLOGY 66: 658.e11–658.e12, 2005. © 2005 Elsevier Inc. M etastatic tumors are the most common malig- nancies of the kidney, far outnumbering pri- mary renal neoplasms. Most renal metastases are multifocal and associated with widespread nonre- nal metastases. 1 To our knowledge, we report the first case of isolated renal metastasis secondary to ocular melanoma occurring 20 years after initial diagnosis and treatment. CASE REPORT A 71-year-old man with a history of prostate can- cer treated with external beam radiotherapy pre- sented with intermittent gross hematuria. His his- tory was notable for having undergone left enucleation in 1984 for confined, ocular mela- noma. He had not required adjuvant therapy and had no evidence of disease recurrence. As a part of his hematuria evaluation, a computed tomography scan was obtained demonstrating a 3.5-cm, right upper pole, enhancing, cystic mass (Fig. 1). His laboratory and metastatic evaluations were other- wise negative. The mass was approached using pure laparo- scopic techniques and appeared to be grossly cystic at intraoperative inspection. Given that the lesion was quite endophytic, the renal hilum was dis- sected out and temporarily clamped with laparo- scopic bulldog clamps. The mass was then resected with a margin of normal tissue. The collecting sys- tem was closed with a running 2.0 Vicryl suture, and a series of capsular sutures were placed to re- approximate the edges of the defect over a Surgicel bolster. The total ischemic time was 32 minutes. No complications occurred, and the patient recov- ered well postoperatively. Rigorous follow-up eval- uations revealed no evidence of disease recurrence. Pathologically, the gross specimen appeared dark purple and well circumscribed, measuring 4.0 cm 3.0 cm 3.5 cm. The microscopic specimen revealed a confined, completely excised mela- noma. Hematoxylin-eosin staining demonstrated From the Departments of Urology and Pathology, Vanderbilt University Medical Center, Nashville, Tennessee Address for correspondence: Brian M. Levin, M.D., Depart- ment of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232-2765. E-mail: [email protected] Submitted: October 29, 2004, accepted (with revisions): March 9, 2005 FIGURE 1. Computed tomography scan demonstrating cystic tumor located in upper pole of right kidney. CASE REPORT © 2005 ELSEVIER INC. 0090-4295/05/$30.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.03.035 658.e11

Metastatic ocular melanoma to the kidney 20 years after initial diagnosis

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CASE REPORT

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METASTATIC OCULAR MELANOMA TO THE KIDNEY 20YEARS AFTER INITIAL DIAGNOSIS

BRIAN M. LEVIN, FOUAD I. BOULOS, AND S. DUKE HERRELL

ABSTRACTetastatic tumors are the most common malignancies of the kidney. We report a rare case of isolatedetastatic ocular melanoma to the kidney occurring 20 years after diagnosis. A 71-year-old man presentedith gross hematuria. He had undergone left enucleation 20 years previously for ocular melanoma and hadot required adjuvant therapy. A right upper pole mass was identified on computed tomography and wasxcised laparoscopically. Pathologic examination revealed metastatic melanoma. Metastatic melanoma tohe kidney is rare. A high index of suspicion must be maintained in any patient with a renal mass and a historyf a nonrenal malignancy. UROLOGY 66: 658.e11–658.e12, 2005. © 2005 Elsevier Inc.

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etastatic tumors are the most common malig-nancies of the kidney, far outnumbering pri-

ary renal neoplasms. Most renal metastases areultifocal and associated with widespread nonre-al metastases.1 To our knowledge, we report therst case of isolated renal metastasis secondary tocular melanoma occurring 20 years after initialiagnosis and treatment.

CASE REPORT

A 71-year-old man with a history of prostate can-er treated with external beam radiotherapy pre-ented with intermittent gross hematuria. His his-ory was notable for having undergone leftnucleation in 1984 for confined, ocular mela-oma. He had not required adjuvant therapy andad no evidence of disease recurrence. As a part ofis hematuria evaluation, a computed tomographycan was obtained demonstrating a 3.5-cm, rightpper pole, enhancing, cystic mass (Fig. 1). His

aboratory and metastatic evaluations were other-ise negative.The mass was approached using pure laparo-

copic techniques and appeared to be grossly cystict intraoperative inspection. Given that the lesion

rom the Departments of Urology and Pathology, Vanderbiltniversity Medical Center, Nashville, TennesseeAddress for correspondence: Brian M. Levin, M.D., Depart-

ent of Urology, Vanderbilt University Medical Center, A-1302edical Center North, Nashville, TN 37232-2765. E-mail:

[email protected]: October 29, 2004, accepted (with revisions): March

n, 2005

2005 ELSEVIER INC.LL RIGHTS RESERVED

as quite endophytic, the renal hilum was dis-ected out and temporarily clamped with laparo-copic bulldog clamps. The mass was then resectedith a margin of normal tissue. The collecting sys-

em was closed with a running 2.0 Vicryl suture,nd a series of capsular sutures were placed to re-pproximate the edges of the defect over a Surgicelolster. The total ischemic time was 32 minutes.o complications occurred, and the patient recov-

red well postoperatively. Rigorous follow-up eval-ations revealed no evidence of disease recurrence.Pathologically, the gross specimen appeared

ark purple and well circumscribed, measuring 4.0m � 3.0 cm � 3.5 cm. The microscopic specimenevealed a confined, completely excised mela-

IGURE 1. Computed tomography scan demonstratingystic tumor located in upper pole of right kidney.

oma. Hematoxylin-eosin staining demonstrated

0090-4295/05/$30.00doi:10.1016/j.urology.2005.03.035 658.e11

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pindled melanoma cells with scattered intracyto-lasmic melanin (Fig. 2). Immunohistochemicaltains were positive for HMB45, S100, and vimen-in, confirming malignant melanoma.

COMMENT

Autopsy series have shown that 7% to 12% ofatients dying of cancer have renal metastases,aking it one of the most common sites of meta-

tatic disease.2–4 The most common primary tu-ors, in decreasing order of frequency, are lung,

reast, and skin (melanoma) and tumors of theenitourinary, gastrointestinal, and gynecologicracts. In patients dying of malignant melanoma,he kidney was involved in 24% to 50% of cases.5 Inreview of a large series of patients with metastaticcular melanoma, the liver was the most commonnitial site of metastasis, with no cases of renal in-olvement.6Similar to renal cell carcinoma, melanoma is an

mmunologically active disease. Various forms of sys-emic immunotherapy, including bacille Calmette-

IGURE 2. Hematoxylin-eosin stain showing cytologi-ally bland, spindled melanoma cells with scatteredntracytoplasmic melanin pigment.

uérin, interferon-alpha, and allogenic tumor vac- 1

58.e12

ines have demonstrated favorable improvementsn overall and disease-free survival rates.6–9 Givenhat this patient’s disease recurred with a singleetastatic deposit and he had no other signs of

isease, he has received no adjuvant immunother-py.Although metastatic melanoma to the kidney

ypically causes multifocal lesions, in this case itresented as a solitary mass.1 Therefore, a highndex of suspicion must be maintained in any pa-ient with a renal mass and a prior history of non-enal malignancy. This is particularly true for ocu-ar melanoma, which may metastasize after arolonged disease-free interval.10

REFERENCES1. Choyke PL, White EM, Zeman RK, et al: Renal metas-

ases: clinicopathologic and radiologic correlation. Radiology62: 359–363, 1987.

2. Pollack HM, Banner MP, and Amendola MA: Other ma-ignant neoplasms of the renal parenchyma. Semin Roentgenol2: 260–274, 1987.

3. Bracken RB, Chica G, Johnson DE, et al: Secondaryenal neoplasms: an autopsy study. South Med J 72: 806 –07, 1979.

4. Klinger ME: Secondary tumors of the genitourinaryract. J Urol 65: 144–153, 1951.

5. Stein BS, and Kendall AR: Malignant melanoma of theenitourinary tract. J Urol 132: 859–868, 1984.

6. Veronesi U, Adamas J, Aubert C, et al: A randomizedrial of adjuvant chemotherapy and immunotherapy in cuta-eous melanoma. N Engl J Med 307: 913–916, 1982.

7. Kirkwood JL, Strawderman MH, Ernstoff MS, et al: In-erferon alfa-2b adjuvant therapy of high-risk resected cutane-us melanoma: the Eastern Cooperative Oncology Group trialST 1684. J Clin Oncol 14: 7–17, 1996.

8. Hsueh EC, Gupta RK, Qi K, et al: Correlation of specificmmune responses with survival in melanoma patients withistant metastases receiving polyvalent melanoma cell vac-ine. J Clin Oncol 16: 2913–2920, 1998.

9. Morton DL, Ollila DW, Hsueh EC, et al: Cytoreductiveurgery and adjuvant immunotherapy: a new managementaradigm for metastatic melanoma. CA Cancer J Clin 49: 101–16, 1999.10. Lorigan JG, Wallace S, and Mavligit GM: The preva-

ence and location of metastases from ocular melanoma: im-ging study in 110 patients. AJR Am J Roentgenol 157: 1279–

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UROLOGY 66 (3), 2005