Presentation and Surgical Implications of Brain Melanomas

Osama S. Abdelaziz, M.D, Khaled Abdeen, M.D , Waleed F. El-Saadany, M.D, Alaa I. Issa, M.D, Khaled G. Aref, M.D.

Department of Neurosurgery, Faculty of Medicine, Alexandria

University, Egypt

• Malignant melanomas are uncommon, accounting for 1.5 % of all malignant tumors and for about 12% of brain metastases

• Malignant brain melanomas are mostly metastatic from primary extracranial malignant melanomas of various locations and rarely primary brain melanomas. The present study will correlate the clinical and radiological presentations and will address the role of surgery for brain melanomas.

• Primary melanocytic neoplasms of the brain develop from normally existing leptomenigeal melanocytes with a predilection to the pons, cerebellum, cerebral peduncles, medulla, interpeduncular fossa and the inferior surface of the frontal, temporal and occipital lobes. These neoplasms are generally divided into three main types: diffuse melanosis, meningeal melanocytoma and primary malignant melanoma .

Material and methods

• Eight patients (5 males and 3 females) with an age range of 1.5 to 70 years (median 36 years). Seven patients had metastatic brain melanomas (one of them had xeroderma pigmentosa) and one had primary brain melanoma (in a patient with neurocutaneous melanosis (NCM) syndrome).

• All patients had brain CT scan and only 5 patients had brain MRI. Five patients had metastases confined to the brain, one patient had both brain and lung metastases, and another had metastases to both the brain and the gastrointestinal tract. All patients had surgery for solitary or multiple symptomatic brain lesions.

Demographic characteristic of 8 patients with metastatic brain melanoma

Age:< 40y>40y

35

Gender :male: female 3:5

Location of primary melanomaTrunkHead&neck Upper extermity Lower extermityeye

32111

Histologic type Superficial spreading Acral lentigiousnodular

421

Clinical presentation

Presentation No.of cases

-Focal neurological deficit- Seizures- Mental changes- Deteriorated consciousness- Increased ICP

53333

Types of therapies for 8 patients with brain melanoma

therapy No. of cases

Surgery +WBRTSurgery +chemotherapy Surgery alone WBRT aloneChemotherapy alone

521 [primary melanoma NCM]

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Neurocutaneous melanosis

• Neurocutaneous melanosis is charachterized by : large or multiple congenital naevi associated with malignant melanoma or meningeal melanosis, primarily in children and may be associated with other congenital abnormalities including Dandy –walker and spina bifida.

Hemorrhagic presentation

RESULTS

• At the time of the last follow up, five patients with metastatic brain melanomas [62.5%] had improved neurological signs, two patients [25%] showed stabilization of their neurological status. Conversely, in one patient [12.5%] the neurological symptoms worsened. All 7 patients with metastatic brain melanomas died. Death was attributed in whole or in part to brain metastases in 5 patients while the other two patients succumbed to melanoma outside the brain.

Results

• The overall median survival time for patients with brain metastases was 4 months from the time of surgery and 6 months from the diagnosis of brain tumors. The patient with primary brain melanoma in a neurocutaneous melanosis (NCM) syndrome remained clinically stable until her death, from recurrent disseminated malignant disease within the brain, two months postoperatively.

Conclusion

• Surgery for isolated cerebral metastasis can result in neurological improvement but may not be of value in patients with multiple lesions and extensive extracerebral spread.