Case Presentation: A 38-year-old woman with a medical history of post-excision BRAF-positive cutaneous melanoma in 2018 presented to the Emergency Department with a two-week history of acute onset right-sided chest pain and hemoptysis, which started one day prior to presentation. A CT of the chest revealed a right hilar/perihilar mass measuring 5.3 x 6.7 x 5.9 cm and calcified right hilar and mediastinal lymph nodes. The patient had a fine needle aspiration biopsy of the subcarinal and right interlobar lymph nodes, which revealed benign lymphoid tissue. She was discharged and scheduled for outpatient pulmonary follow-up. She presented to the hospital again six days later for worsening hemoptysis. CT angiogram of the thorax demonstrated a persistent hilar mass without evidence of active extravasation. She underwent a robot-assisted bronchoscopy with endobronchial ultrasound-guided biopsy. Histology of the mass confirmed metastatic melanoma. PET-CT whole body and MRI brain ruled out metastases elsewhere, and she soon began treatment with nivolumab and ipilimumab.
Discussion: Melanoma is the fifth most common malignancy in the United States, with annual incidence increasing over the last several decades. While localized disease is most common, melanoma has the potential to involve nearly any organ system. Recurrence of localized melanoma after initial treatment often occurs within the first 3 years; however, recurrence after 10 years (late recurrence) and greater than 15 years (ultra-late recurrence) is well documented. Hemoptysis, however, is an uncommon presenting symptom for recurrent melanoma even in instances of pulmonary metastasis. Metastatic melanoma can mimic other disease processes, such as a primary lung malignancy, pulmonary embolism, or infection, which makes anchoring bias a common pitfall. Additionally, our patient had an initial non-diagnostic biopsy despite the diagnostic approach being guideline concordant. This highlights the importance of obtaining additional studies and biopsies when clinical suspicion for recurrent melanoma remains high.
Conclusions: This case of recurrent metastatic melanoma seven years after excision underlines the possibility of late disease recurrence even in individuals who are apparently disease-free for a relatively long period of time. In patients with a history of melanoma and new pulmonary lesions, clinicians should maintain a high index of suspicion for melanoma recurrence. Obtaining a reliable biopsy is paramount in establishing a prompt diagnosis and timely treatment. Most notably, an initial non-diagnostic biopsy in the right clinical context does not exclude malignancy, especially with melanoma.