SHM Converge Scientific Abstract ePoster Gallery-A Red Herring: Hemoptysis as the First Sign of Recurrent Metastatic Melanoma

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This case report describes a 38-year-old woman with a history of BRAF-positive cutaneous melanoma excised 7 years earlier who presented with 2 weeks of progressive chest pain and hemoptysis shortly after hysterectomy for cervical adenocarcinoma. Initial CTA at an outside hospital showed a large right hilar/perihilar mass with calcified hilar and mediastinal lymph nodes. An endobronchial ultrasound-guided FNA of lymph nodes was nondiagnostic, showing benign lymphoid tissue, and she was discharged with pulmonary follow-up.<br /><br />She returned 6 days later with persistent hemoptysis, including 150 cc of blood in the emergency department. She remained hemodynamically stable, and repeat CTA showed a persistent hilar mass involving the pulmonary artery and pericardium without active bleeding. A repeat EBUS-guided biopsy of the mass confirmed metastatic melanoma, with BRAF V600E positivity on immunohistochemistry.<br /><br />Because of invasion of critical structures, cardiothoracic surgery advised against resection. Further staging with PET-CT and brain MRI found no other metastatic disease. She was started on nivolumab and ipilimumab by hematology-oncology.<br /><br />The report emphasizes that melanoma can recur many years after initial treatment, including very late recurrences, and can metastasize to nearly any organ. Hemoptysis is an uncommon presenting symptom and may be mistaken for more common pulmonary conditions, creating risk for anchoring bias. The case also highlights the importance of obtaining a definitive biopsy when initial sampling is nondiagnostic.

Asset Subtitle

Brian P. Kunkel

Meta Tag

Author List Anacleto Diaz, Brian P. Kunkel, Cesar Alcid

Category Clinical Vignettes

Concept Metastatic Melanoma

Concept Late Recurrence

Concept Differential Diagnosis

Concept Biopsy

Concept Systemic Immunotherapy

Distinguished Non-Finalist

Presenter Organization Corewell Health Grand Rapids

Presenting Author Brian P. Kunkel

Track Adult

Keywords

metastatic melanoma

hemoptysis

right hilar mass

BRAF V600E

endobronchial ultrasound

nondiagnostic biopsy

late melanoma recurrence

pulmonary artery invasion

nivolumab

ipilimumab

Metastatic Melanoma

Late Recurrence

Differential Diagnosis

Biopsy

Systemic Immunotherapy