Moffitt Cancer Center; and University of South Florida, Tampa, FL
Georgetown-Lombardi Comprehensive Cancer Center; and Medstar-Georgetown University Hospital, Washington, DC.
J Clin Oncol. 2015 Jun 10;33(17):1873-7. doi: 10.1200/JCO.2014.60.1807. Epub 2015 May 11.
A 40-year-old man with stage III melanoma arising from his left shoulder underwent wide local excision, sentinel lymph node biopsy, and lymph node dissection. Nine months after receiving adjuvant biochemotherapy with cisplatin, vinblastine, dacarbazine, interleukin-2 (IL-2), and interferon alfa as part of a clinical trial, he developed headaches and right-hand weakness and was found to have a 2-cm left parietal CNS metastasis. A comprehensive staging workup identified multiple nonspecific subcentimeter pulmonary nodules. The brain mass was resected and confirmed to be metastatic melanoma; the surgical bed was treated with stereotactic radiosurgery. He was monitored off therapy, but 5 months later, he developed a second left parietal CNS metastasis and enlarging lung nodules. The new brain lesion was treated with stereotactic radiosurgery, and he began systemic therapy with ipilimumab on a clinical trial. After the third dose, he presented with headache, nausea, and vomiting; a brain magnetic resonance imaging scan showed left anterior temporal enhancement, possibly representing new disease. His symptoms improved with a course of corticosteroids. Restaging of the chest showed a mixed response among the pulmonary nodules. After tapering off corticosteroids, he received the fourth dose of ipilimumab, which was complicated by grade 3 transaminitis and hypophysitis with documented hypothyroidism and adrenal insufficiency. They were managed with corticosteroids and thyroid and adrenal hormone replacement. Restaging scans showed further disease regression except for new confluent enhancing nodules and edema in the left temporal lobe. Craniotomy and resection of this area showed only necrotic tissue with no viable melanoma cells. Nine years after treatment with ipilimumab, he is alive and shows no evidence of melanoma on the basis of annual computed tomography scans of the chest, abdomen, and pelvis and magnetic resonance imaging scans of the brain. He has full neurologic function but still requires hormone replacement for persistent hypopituitarism.
一位 40 岁男性，左侧肩部 III 期黑色素瘤，行广泛局部切除术、前哨淋巴结活检术和淋巴结清扫术。在接受顺铂、长春碱、达卡巴嗪、白细胞介素-2（IL-2）和干扰素-α辅助化疗 9 个月后，他出现头痛和右手无力，并发现左侧顶叶 CNS 转移 2cm。全面分期检查发现多个非特异性亚厘米肺结节。脑肿块被切除并证实为转移性黑色素瘤；手术床接受立体定向放射外科治疗。他停止治疗后进行监测，但 5 个月后，他出现第二个左侧顶叶 CNS 转移和增大的肺结节。新的脑部病变接受立体定向放射外科治疗，他开始在临床试验中接受伊匹单抗全身治疗。第三次剂量后，他出现头痛、恶心和呕吐；脑磁共振成像扫描显示左前颞叶增强，可能代表新疾病。他的症状在皮质类固醇治疗后得到改善。胸部重新分期显示肺结节混合反应。在皮质类固醇逐渐减少后，他接受了第四次伊匹单抗剂量，并发 3 级肝功能异常和垂体炎，伴有甲状腺功能减退和肾上腺功能不全。用皮质类固醇和甲状腺及肾上腺激素替代治疗。重新分期扫描显示除了新的融合性增强结节和左侧颞叶水肿外，疾病进一步消退。该区域的开颅术和切除显示仅为坏死组织，没有存活的黑色素瘤细胞。在接受伊匹单抗治疗 9 年后，他仍然存活，并且根据每年进行的胸部、腹部和骨盆计算机断层扫描和脑磁共振成像扫描，没有黑色素瘤的迹象。他的神经功能完全正常，但仍需要激素替代治疗以维持持续性垂体功能减退。
