Abstract Introduction Metastatic melanoma constitutes about 5% of all secondary malignancies of the lung, yet only 2% of patients with thoracic metastases have pleural effusions. We report a case of a patient with left-sided pleural effusion secondary to pleural melanoma metastasis diagnosed by thoracoscopy with pleural biopsy. Case Presentation 50-year-old female with the history of asthma presented to emergency department with shortness of breath and recurrent left side pleural effusion. Patient had reported history of cutaneous melanoma on the neck which was excised surgically in 2006. Patient reported that she was found to have left sided pleural effusion two weeks ago at outside hospital and thoracentesis was performed. Pleural fluid analysis was negative for any infections or malignancy. In the emergency department, patient’s vital signs and laboratory workup were unremarkable. A chest-X-ray was completed which showed large left sided pleural effusion with complete white-out of the left hemithorax. This was followed by computed tomography (CT) of the chest which was consistent with large left sided effusion with left sided pleural nodularity suspicious for malignancy (see image). Chest tube was placed at bedside in the emergency department. Pleural fluid analysis revealed lymphocyte predominant pleural fluid with high lactate dehydrogenase (LDH) levels consistent with exudative fluid. A CT of abdomen and pelvis with MRI of the brain was done with no evidence of metastatic disease. Due to high suspicion for malignancy in the setting of recurrent left sided pleural effusion, left sided thoracoscopy with pleural biopsy and PleurX catheter placement was performed by our interventional pulmonary team. Pleural surface was noted to be nodular with lesions noted both on parietal and visceral pleural as well as left lung (see image). Pleural biopsy displayed a positive immunoreaction for melanocytic markers (S100 and HMB-45) consistent with metastatic melanoma with positive BRAF V600 mutation. Oncology was consulted and plan was made to start immunotherapy after discharge. Discussion Lung metastasis from cutaneous melanoma is one of the most frequent sites of metastasis, but pleural metastasis alone is a rare condition. Pleural metastases alone are considered a poor prognostic factor with a 1-year survival of 33% . Early identification is important because the most common cause of death in metastatic melanoma is respiratory failure secondary to lung or pleural involvement. In our patient, pleural biopsy with the help of medical thoracoscopy - in the absence of other detectable locations - was essential for histological diagnosis and the initiation of oncological treatment. This abstract is funded by: None
Bajwa et al. (Fri,) studied this question.