Case Report
From the Pleura to the Skin: A Case of Metastatic Melanoma
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(b) Simulation of the patient's position in the operating theatre and possible direction of the trocar for penetrating the thorax. Insert: working control of the arthroscope with the sharp trocar used. (c) Wound in the lung parenchyma located immediately below the chest wall injury (arrow). (d) Healing of the arthroscopy incisions. The arrow points to the trocar incision causing the pneumothorax. (e) Chest X-ray in AP showing complete right pneumothorax accompanied by subcutaneous emphysema.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura Sacristán, Montserrat Blanco, Manuel Castro" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "Sacristán" ] 1 => array:2 [ "nombre" => "Montserrat" "apellidos" => "Blanco" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Castro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S030028962300162X?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000008/v3_202311210631/S030028962300162X/v3_202311210631/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289623001540" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.05.001" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "3313" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2023;59:516-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Thoracic Surgical Management of Chylothorax Caused by a Neck Stab Wound" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "516" "paginaFinal" => "517" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 343 "Ancho" => 1005 "Tamanyo" => 41009 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Chest X-ray showing a left massive pleural effusion, pneumomediastinum and neck subcutaneous emphysema. (b) Postoperative chest X-ray, 24<span class="elsevierStyleHsp" style=""></span>h after right VATS for clipping the thoracic duct. (c) Chest CT showing disseminated lung septic emboli. A metallic clip can be detected (black arrow), at T9 level, between the aorta and the azygos vein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos Enrique García Franco, Mohammad Lamfon, Ahmed Alfitiani, Hani Saiedi" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Carlos Enrique" "apellidos" => "García Franco" ] 1 => array:2 [ "nombre" => "Mohammad" "apellidos" => "Lamfon" ] 2 => array:2 [ "nombre" => "Ahmed" "apellidos" => "Alfitiani" ] 3 => array:2 [ "nombre" => "Hani" "apellidos" => "Saiedi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001540?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000008/v3_202311210631/S0300289623001540/v3_202311210631/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "From the Pleura to the Skin: A Case of Metastatic Melanoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "518" "paginaFinal" => "519" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Amina Bekki, Nuria Mancheño-Franch, Andrés Briones-Gómez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Amina" "apellidos" => "Bekki" "email" => array:1 [ 0 => "amina.bekki.gva@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Nuria" "apellidos" => "Mancheño-Franch" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Andrés" "apellidos" => "Briones-Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 990 "Ancho" => 2925 "Tamanyo" => 611276 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(1.1) Chest computed tomography images. (A and B) Mediastinal window. (C) Parenchymatous window. Massive right pleural effusion (white arrows) associated with focal pleural thickening (red arrows), mediastinal structures shifted to the left (yellow arrow), and right paratracheal mediastinal lymph nodes (blue arrow) are observed. (1.2) Results of the study of pleural fluid obtained by thoracentesis. (1.3) Panoramic image of pleural tumor infiltration (H–E 20×). (B) Detail of medium-sized plasmacytoid cell types and lateralized basophil nuclei, occasional nucleoles, and scant or moderate cytoplasms arranged in threads, strings or diffusely (H–E 40×). (C) Absence of epithelial marker expression (CK AE1-3 10×). (D) Intense diffuse cytoplasmic expression to melanocytic markers (HMB-45 10×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Metastatic cutaneous melanoma is a cancer that accounts for only 4% of all skin tumors, but one that confers high morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It causes approximately 5% of secondary malignancies of the lung, yet only 2% of patients with thoracic metastases develop pleural effusions.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This case is of interest given the unusual primary presentation and the fact that the histological diagnosis was based on a sample of pleural tissue.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 32-year-old man with no drug allergies, no recurrent infections in childhood, and no significant medical or surgical history. He was admitted to the respiratory medicine department for large right pleural effusion associated with progressive dyspnea on exertion and pleuritic pain. Contrast-enhanced chest computed tomography (CT) revealed right tension hydrothorax with focal areas of nodular thickening in the parietal pleura (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1.1</a>), lymphadenopathies in the right cardiophrenic angle, and right mammary, hilar, right paratracheal, infracarinal and bilateral prevascular chains. Abdominal and pelvic CT showed retrocaval, intercaval-aortic and preaortic lymphadenopathies and lytic lesions in L5 and S3. Brain magnetic resonance imaging was significant for multiple punctiform bone lesions in the frontal and parietal bones. HIV serologies and hepatotropic viral testing were negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Chest ultrasound showed a large collection of free anechoic pleural fluid in the right hemithorax. A total of 1200<span class="elsevierStyleHsp" style=""></span>ml of hematic serous exudate-type fluid was extracted for diagnostic and therapeutic thoracentesis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1.2)</a>. The study was completed with a percutaneous pleural biopsy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1.3</a>). The results were consistent with a melanocytic lesion, so the studies were extended to rule out a metastatic origin.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Dermatological assessment and ophthalmological studies were performed, ruling out lesions suggestive of melanoma. The genetic study did not show BRAF mutations that are typically related with more aggressive disease with a high metastatic potential.</p><p id="par0025" class="elsevierStylePara elsevierViewall">He was referred to the medical oncology department where treatment with immunotherapy was initiated (4 cycles of nivolumab and ipilimumab). Despite treatment, the patient's general condition deteriorated. He was admitted twice for respiratory sepsis and died 3 months after diagnosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Metastatic melanoma is a rare entity<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> in which a mucosal-visceral origin should be considered in the absence of identifiable lesions. Diagnosis is difficult, and the prognosis is usually worse than in cutaneous melanoma.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> It is known to be associated with lung metastases, but data on pleural metastases are scant.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Pleural metastases alone are considered a poor prognostic factor with a 1-year survival of 33%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Early diagnosis may improve prognosis, although there is insufficient evidence to confirm this. In our patient, pleural biopsy – in the absence of other detectable locations – was essential for histological diagnosis and the initiation of oncological treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In a patient with pleural melanoma, the primary site should be re-evaluated to differentiate between primary and secondary melanoma. This can be complicated in clinical practice, but the pleural location should be taken into consideration despite its rarity.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0010" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 990 "Ancho" => 2925 "Tamanyo" => 611276 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(1.1) Chest computed tomography images. (A and B) Mediastinal window. (C) Parenchymatous window. Massive right pleural effusion (white arrows) associated with focal pleural thickening (red arrows), mediastinal structures shifted to the left (yellow arrow), and right paratracheal mediastinal lymph nodes (blue arrow) are observed. (1.2) Results of the study of pleural fluid obtained by thoracentesis. (1.3) Panoramic image of pleural tumor infiltration (H–E 20×). (B) Detail of medium-sized plasmacytoid cell types and lateralized basophil nuclei, occasional nucleoles, and scant or moderate cytoplasms arranged in threads, strings or diffusely (H–E 40×). (C) Absence of epithelial marker expression (CK AE1-3 10×). (D) Intense diffuse cytoplasmic expression to melanocytic markers (HMB-45 10×).</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 1102669 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastatic melanoma in the thorax: report of 130 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.T. Chen" 1 => "N.S. Dahmash" 2 => "C.E. 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Mondello" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2020.09.088" "Revista" => array:5 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2021" "volumen" => "112" "paginaInicial" => "e103" "paginaFinal" => "e105" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Managing malignant melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "W.W. Dzwierzynski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PRS.0b013e31829d411" "Revista" => array:5 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2013" "volumen" => "132" "paginaInicial" => "446e" "paginaFinal" => "460e" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mucosal melanoma: epidemiology, biology and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.R. Spencer" 1 => "J.M. Mehnert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/978-3-319-22539-5_13" "Revista" => array:5 [ "tituloSerie" => "Cancer Treat Res" "fecha" => "2016" "volumen" => "167" "paginaInicial" => "295" "paginaFinal" => "320" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mucosal melanoma: a clinically and biologically unique disease entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.D. Carvajal" 1 => "S.A. Spencer" 2 => "W. Lydiatt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.6004/jnccn.2012.0034" "Revista" => array:5 [ "tituloSerie" => "J Natl Compr Canc Netw" "fecha" => "2012" "volumen" => "10" "paginaInicial" => "345" "paginaFinal" => "356" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005900000008/v3_202311210631/S0300289623001576/v3_202311210631/en/main.assets" "Apartado" => array:4 [ "identificador" => "93562" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005900000008/v3_202311210631/S0300289623001576/v3_202311210631/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001576?idApp=UINPBA00003Z" ]
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