Giant adrenal metastasis of malignant melanoma: impact of 18F-FDG PET/CT in early assessment of dramatic response to immunotherapy: case report
Egyptian Journal of Radiology and Nuclear Medicine volume 54, Article number: 158 (2023)
This case represents one of the largest adrenal metastases in the literature and highlights the importance of accurate imaging in clinical management of patients with advanced malignant melanoma.
A 67-year-old female with an ulcerated malignant melanoma presented with an asymptomatic 18-cm left adrenal mass on 18F-FDG PET/CT staging. After two cycles of combined systemic immunotherapy, an impressive shrinkage of the adrenal metastatic tumor was observed on 18F-FDG PET/CT imaging.
The case emphasizes the potential of 18F-FDG PET/CT as a functional imaging modality for accurate staging and precise early assessment of response to immunotherapy. Overall, this report highlights the importance of accurate imaging for the effective management of adrenal metastases in melanoma patients.
Malignant melanoma is one of the most common primary sites for adrenal metastases [1, 2]. Adrenal metastases are often asymptomatic and mostly detected as a part of multiorgan metastases . 18F-FDG PET/CT has demonstrated high overall accuracy in detecting distant metastases and, in combination with cerebral MRI, is the preferred imaging approach for staging metastatic melanoma . Systemic mono- or combined immunotherapy (nivolumab plus ipilimumab) is currently considered an initial treatment option in unresectable, non-isolated adrenal metastases. Nivolumab plus ipilimumab is preferred therapy for aggressive feature disease [5,6,7]. To the best of our knowledge, this case presents one of the largest adrenal metastases based on the literature review up to 2023 [1, 8] with a remarkable response to two cycles of immunotherapy.
A 67-year-old female presented with cachexia and a left arm 5 cm skin ulcer. Two weeks after excision of ulcerated malignant melanoma, 18F-FDG PET/CT was performed for primary staging that revealed an 18F-FDG–avid 18-cm left adrenal mass, ascites, 18F-FDG–avid abdominopelvic lymph nodes and intramuscular right gluteal metastasis (Fig. 1A, D). Concurrent brain MRI showed metastatic lesions, most prominently a lesion in the left frontal lobe with surrounding edema (Fig. 1G). Combined immunotherapy with nivolumab and ipilimumab and stereotactic radiation for the brain were started. Evaluation of response to treatment with 18F-FDG PET/CT and brain MRI after two cycles of immunotherapy showed remarkably impressive shrinkage of the adrenal and brain metastatic lesions and complete resolution of the lymph node and muscular metastases (Fig. 1B, E, H). Subsequent follow-up conducted six months later demonstrated continued tumor shrinkage on 18F-FDG PET/CT and MRI (Fig. 1C, F, I).
Considering costs and immune-related adverse effects of these novel therapies, defining an accurate imaging modality for staging and interim assessment of the response to therapy is of great importance. Although this case shows the potential of 18F-FDG PET/CT for assessment of response to immunotherapy, to determine the role of 18F-FDG PET/CT during the treatment course of advanced melanoma, well-designed studies with standardized scanning protocols, including clinical parameters and comparison with other imaging modalities are needed.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Positron emission tomography/computed tomography
Magnetic resonance imaging
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Kalantari, F., Schweighofer-Zwink, G., Rendl, G. et al. Giant adrenal metastasis of malignant melanoma: impact of 18F-FDG PET/CT in early assessment of dramatic response to immunotherapy: case report. Egypt J Radiol Nucl Med 54, 158 (2023). https://doi.org/10.1186/s43055-023-01107-9