A CASE OF SINGLE SITE PROGRESSIVE METASTATIC MELANOMA UTILIZING SURGICAL RESECTION

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Introduction: The management and outcomes for patients with metastatic melanoma have been revolutionized by immunotherapy. This case report highlights the role of surgery as an adjuvant to systemic therapies when there is a single site of progressive metastasis.

Case Presentation: We report a case of a 74-year-old male with metastatic melanoma, which was initially managed with wide local excision and axillary lymph node dissection in 2015. He had negative margins and remained asymptomatic until 2018 when he presented with weight loss and dark tarry stool. Diagnostic workup revealed metastatic melanoma involving the lung and multiple inguinal and retroperitoneal lymph nodes. He was treated with immunotherapy (ipilimumab and nivolumab) and had a complete radiographic response. However, he recurred in the retroperitoneum, and this single site of disease continued to enlarge despite immunotherapy, reaching 10 cm in maximal dimension and encasing the inferior vena cava (IVC, Figure 1). After multidisciplinary discussion, resection of this single site of progressive disease was recommended. At operation, exploration first confirmed there were no other sites of metastasis. A right-sided visceral rotation was required to fully expose the retroperitoneal mass. There was no invasion into the aorta or right kidney, indicating resectability. Therefore, the mass was resected en bloc with a short segment of the IVC. The IVC was reconstructed with a synthetic tube graft. The patient had an uneventful recovery and was discharged home on aspirin and atorvastatin on post-operative day 6. The patient is doing well 6 months post-operatively.

Discussion: The advent of modern immunotherapy and targeted biological therapies has revolutionized the management of melanoma. Even in the face of widespread metastatic disease, durable disease control, even complete responses, may be achieved. Thus, the role of surgery for advanced melanoma is undergoing a paradigm shift, with the emergence of metastatectomy for single or oligo-progressive disease in carefully selected patients. This case demonstrates that aggressive multi-visceral resection of a metastasis may be performed safely in the appropriate oncologic setting.

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