Gone but Not Forgotten

The persistent NLP vision and interval development of a CRAO raised concern for neoplastic optic nerve infiltration. Re-review of the MRI demonstrated T1-weighted hyperintensity in the left optic nerve, which is seen in melanoma and unusual of other neoplastic infiltrative/inflammatory lesions. The patient was specifically asked regarding a history of melanoma and recalled having a very small lesion removed from her upper back 10.5 years prior. The pathology reports from that time were retrieved and malignant melanoma without ulceration (T1a; 18 x 8 x 4mm; vertical height 0.68mm) was documented.[1] At that time, the only recommended treatment was a larger excision to ensure no residual melanocytic lesion was evident. The subsequent pathology report was clear and no further treatment was recommended given the negligible risk of recurrence or metastasis with a tiny lesion of vertical depth 0.68mm. With this new information, she underwent CT chest/abdomen/pelvis and this revealed numerous liver lesions with the largest measuring 1.1cm and a solitary 0.9cm pulmonary nodule. Biopsy of a liver lesion showed tumor cells positive for HMB-45 and S100, consistent with a diagnosis of melanoma. A final diagnosis of late recurrence (>10 years) of upper back cutaneous melanoma with metastases to the optic nerve, liver and lung was made. The patient was referred for radiation therapy to the left optic nerve (20Gy in 5 fractions). She was also referred to medical oncology and was enrolled in a clinical trial involving an investigational drug with ipilimumab and nivolumab. This treatment was complicated by autoimmune hepatitis and required treatment with intravenous and oral corticosteroids. Repeat MRI 4 months later showed interval improvement in the left optic nerve/optic nerve sheath enhancement and repeat CT abdomen 7 months later showed interval reduction in the size of the liver metastases. She remained NLP OS at 6 month follow-up.