40-year-old woman with melanoma of the right knee

A teaching case from MD Anderson Cancer Center

Behrang Amini

40-year-old woman with right knee melanoma

Wide local excision 6 years ago with negative sentinel lymph node biopsy

Liver and mesenteric mets 1 year ago

Started therapy with dabrafenib and trametinib 2 months ago

Most recent PET was negative

Presents with FDG PET/CT below: 
 

Note multiple sites of new uptake in the lower limbs, more numerous on the left (primary was in the right knee)

Axial fused PET/CT shows subcutaneous location of lesions

Axial CT image shows uptake localizing to subtle increased attenuation

Initial instinct is to call this metastatic disease and change therapy.

This is BRAF inhibitor-induced paniculitis.

Currently three BRAF inhibitors are approved in Europe and US for the treatment of patients with BRAF-mutant advanced melanoma: 

Vemurafenib

Dabrafenib

Encorafenib

What is this Upper Arm Mass?

Case workup and presentation by our Fellow at MD Anderson Cancer Center, Marwa Zaid.

50-year-old woman with right arm pain and swelling. Past medical history significant for right breast cancer.









What's your differential?


We considered angiosarcoma (given breast cancer and chronic lymphedema), massive localized lymphedema (given history and mass-like appearance, though not the typical appearance), and liposarcma (given fatty component).

The answer surprised us.

This is an omental flap for treatment of chronic refractory lymphedema.

The omomentum is a highly vascularized intra-abdominal structure that is basically a flattened lymph node and provides excellent protection against inflammation and irradiation.

The omentum can be exteriorized and lengthened into a vascular pedicle.

Preoperative lymphoscintigraphy with SPECT/CT scan of the affected regional lymph nodes is typically done prior to surgery. Otherwise, imaging has no role.

You can see a video of omental flap harvest here

https://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=658&autoPlay=true

References:

Nguyen AT, et al. Laparoscopic Free Omental Lymphatic Flap for the Treatment of Lymphedema. Plastic and Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 114–118