Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Solitary Melanoma in a Pulmonary Nodule: A Case Report Gabrielle Aluisio, OMS-III 1 , Grace Ralston, OMS-III 1 , Gene Saylors, MD 2

1. Edward Via College of Osteopathic Medicine Carolinas, Spartanburg, South Carolina 2. Bon Secours Roper St. Francis Hospital, Charleston Oncology, Charleston, South Carolina

Introduction

Case

Discussion

Case A 63-year-old female presented with chief complaint of chronic right sided sialadenitis and reports of night sweats, fatigue, shortness of breath, cough, and hip and leg pain. • PMHx: hyperlipidemia, coronary artery disease, non-metastatic cutaneous squamous cell carcinoma, osteoarthritis • CT soft tissue neck demonstrated an incidental 12 x 11 mm nodule in the upper lobe of the left lung ( Figure 1 ). This nodule appeared to be new as evidenced by absence of nodule on previous cardiac CT performed 1 year prior . • Any pulmonary lesion confirmed to be melanoma must be assumed to represent metastatic disease until proven otherwise, since it is much more common than a primary lesion. • Primary lung melanoma is estimated to be 0.01% of all primary lung tumors. [1] • Metastasis to the lung is often the first clinically apparent site of visceral metastasis in melanoma patients. [3] Other common sites of metastasis include skin, brain, liver, bone and intestine. [3,4] • The 5-year survival of stage 4 melanoma metastatic to the lung is 7-9 years. [4,5] • Although there is little data regarding primary melanoma of the lung, it is estimated that the 5-year survival is at least 10%. [5] • The one-year survival rates in melanoma patients with clinically apparent metastasis to one, two, or three different visceral sites is: 36%, 13%, and 1%, respectively. [3,4]

• PET/CTdemonstrated a fluorodeoxyglucose avid 1.4 cm solid left upper lobe nodule with no evidence of regional lymph node involvement or distant metastatic disease, suggestive of a primary pulmonary neoplasm ( Figure 2 ). ​ • CT-guided fine needle biopsy demonstrated cells positive for SOX10, MART1, S100 and negative for cytokeratin, consistent with malignant melanoma. ​ • CARIS testing demonstrated elevated TMB, BRAF wild-type, and mutations in NRAS, NF1, RAC1, and TERT promotor genes. • No evidence of metastatic disease or additional hypermetabolic disease on brain MRI and whole-body PET. Has had extensive dermatological and ocular examination with no identifiable lesion.

• Most popular theories regarding the pathophysiology of primary malignant melanoma of the lung (PMML): [6,7] 1. Migration of melanocytes during embryonic development 2. Proliferation of melanocytes in the larynx or esophagus 3. Primary malignant cutaneous melanocytes that form and disappear after metastasizing • Combination checkpoint inhibitors (nivolumab + relatlimab, nivolumab + ipilimumab) are the preferred first line regimen followed by programmed cell death protein (PD-1) inhibitor monotherapy (nivolumab, pembrolizumab) for stage IV metastatic melanoma. [8,9] o Nivolumab is a PD-1 inhibitor and relatlimab is a lymphocyte activation gene 3 (LAG-3) inhibitor. • Patient's regimen choice was supported by Amaria et al stating this combination resulted in a 57% pathologic complete response rate and 70% overall pathologic response rate with no grade 3-4 immune related adverse events observed. [10] o Those with any pathologic response had a 1- and 2-year recurrence-free survival rate of 100% and 92% compared to 88% and 55% for those without pathologic response. [10] • Once restaging imaging is performed, if disease is stable and/or partially responds then resection can be considered with addition of 10 more infusions. If there is disease progression, then ipilimumab + nivolumab will be considered. Conclusions This case report documents the use of metastatic melanoma treatment guidelines for the treatment of a patient with primary malignant melanoma of the lung, thus contributing to the minimal literature on this diagnosis.

B.

A.

Figure 2. PET/CT with FDG avid solid left upper lobe nodule with no evidence of regional lymph node involvement or distant metastatic disease in a) coronal and b) transverse plane • Tumor board agreed the melanoma of unknown primary site should be treated as metastatic melanoma (cTx cN0 cM1b, Stage IV). ​​ • Treatment with nivolumab-relatlimab 280 mg IV every 28 days was initiated. ​​ • Patient is currently undergoing treatment with a plan to re evaluate candidacy for resection if persistent unifocal disease persists after several infusions and no other sites of metastasis present.

References

B.

A.

Figure 1. CT soft tissue neck showing incidental 12x11 mm nodule in upper lobe of the left lung in a) coronal plane and b) transverse plane

2025 Research Recognition Day

56