Abstract
INTRODUCTION: While prognosis in metastatic melanoma has traditionally been poor, novel systemic therapies such as immunotherapy and targeted agents have improved overall survival (Steininger et al., 2021). These medications are generally well tolerated but can be associated with immune related adverse events (Remash et al., 2021). Hepatic metastatectomy is an important component of management, conferring a survival benefit over systemic therapy alone in appropriately selected patients (Medina et al., 2020). Gadoxetic acid-enhanced magnetic resonance imaging (GA-MRI) has been demonstrated to have enhanced diagnostic accuracy compared with other imaging modalities for hepatic metastases (Freitas et al., 2021). The risk of tumour seeding associated fine-needle aspiration biopsy (FNAB) of hepatic lesions varies, with most studies reporting a low incidence (Maturen et al., 2006). PRESENTATION OF CASE: In February 2020, a 75-year-old male underwent wide local excision and sentinel lymph node biopsy for stage IIA (T2B, N0, M0) melanoma. Routine surveillance without adjuvant systemic treatment was commenced. In July 2022, he presented with haemoptysis and was subsequently diagnosed with widespread metastatic disease on positive emission tomography (PET). After combination ipilimumab and nivolumab, PET scans in August 2023 revealed new liver lesions with disease response at all other metastatic sites. Following a multi-disciplinary team (MDT) discussion, the patient proceeded to hepatic metastatectomy. Histopathology demonstrated chronic necrotising granulomatous hepatitis. DISCUSSION: This case reflects the challenges involved in investigation and management of hepatic metastases in melanoma. CONCLUSION: Despite the accuracy of modern imaging, this case demonstrates the need for MDT consideration of liver biopsy in patients on anti-CTL4 treatment or with response to systemic treatment at extrahepatic sites.