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19 replies to this topic

#1
ken481

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Dear All

 

My Mother was diagnosed with ocular melanoma in Dec 2012 - she had enucleation in liverpool.

 

Has CT Trunk and MRI liver - no metastasis.

 

Had Genetic testing - Monosomy 3 - High risk

 

We started 6 monthly Liver MRI.

 

MRI done in Feb 2015 showed

 

Following triplanar localising sequences, axial and coronal pre and post IV contrast (10mL

Omniscan) T1-w and axial T2-w scans were obtained through the liver. Additional axial scans

were obtained on 16/02/2014 including DWI (B0,50,400,800,1000), T1-w in/out phase, T1-VIBE

FatSat and T2-HASTE FatSat scans. Comparison is made with previous scans dated between

19/08/2014.

The 1.4cm lesion located centrally in segment 6 is unchanged and shows an enhancement

pattern compatible with a haemangioma. Five additional lesions of high T2 and low T1 signal do

not show typical contrast enhancement; these are located in segt 2 (6mm), segt 3( 7mm), segt 4

(13mm), segt 6 (6mm) and segt 7 (6mm). All above lesions show no change in size.

There are however multiple small new focal lesions (10 counted), all showing high T1 and mildly

high T2 signal measuring up to 1.1cm in diameter located in segments 2, 4, 7 and 8. The largest

lesion is in segt 8. These new lesion are best seen on T1-VIBE and T2-HASTE scans.

A new 1.4cm lesion is seen in the subcutaneous tissues of the right anterior lower flank, which

has low T1 and high T2 signal and shows no significant contrast enhancement.

Conclusion:

Multiple new liver lesions with signal characteristics compatible with melanoma metastases.

Previously noted stable liver lesions are compatible with haemangiomas. Subcutaneous lesion in

the right lower flank that in view of the clinical history may represent a resolving haematoma,

however a heavily nectrotic metastatic lesion cannot be excluded; this could be confirmed by

biopsy if clinically relevant.

 

A Pet CT scan was done on 25th February and this showed further skin and bone metastasis.  Also the possibility of one lesion in the lung.

Pet CT Report

There are various small inhomogeneous foci of abnormal tracer uptake in the liver

Moreover there are numerous abnormal foci of increased tracer uptake corresponding to multiple skeletal segments including left scapula, vertebrae and ribs

Another focus of uptake seems to project in the region of the apex of the left lung

This could also represent skeletal (rib) origin (data misregistration?)

There are at least five abnormal foci of soft tissue accumulation in the right side of the back, in the left flank, sacral and left gluteal region (please refer to PACS images)

No other evidence of abnormal tracer accumulation noted in the imaged body segments (within the limits of system spatial resolution of 4-5mm).

Conclusion:

Multiple hepatic, skeletal and soft tissue secondary

Another abnormal focus of uptake seems to project in the region of the apex of the left lung, possibly suggestive of a lung metastasis. This could also represent skeletal (rib) origin (data misregistration?)

Blood Investigations

Blood investigations done on 24th February – Normal LFT, Normal LDH, Normal CBC, Normal Biochemistry

 

Was seen at Southampton - and had 4 infusions of IPI

 

One of the Subcutanous Lumps was removed and testing was done

 

BRAF Neg

C-Kit Neg

Pd1 Receptor Positive and immune cells present

 

After 2nd infusion of Ipi she developed hepatitis - that resolved without treatment

 

An MRI was done

 

MRI Liver done – 30/04/15

Note is made of the previous imaging findings.

Foci showing high Ti signal and restricted diffusion are seen throughout both liver lobes - these measure 4 mm to 11 mm and are unchanged in size / number as compared to the previous study done in another institution in February 2015. Note is also made of two haemangmas (segment V/Vlll - 17 mm and segment lVb - 15 mm). Number of simple cysts are also noted, the largest measures 8 mm and lies in the left liver lobe.

Note is also made of at least four similar foci within the head and neck of the pancreas, measuring up to 7 mm in diameter, also in keeping with uveal melanoma metastasis.

There are multiple bone lesions reported in on the previous studies are again noted. Multiple lesions are also noted in the subcutaneous fat, as previously described.

</CONCLUSION/>

Stable findings regarding the liver lesions.

New intrapancreatic lesions, also compatible with melanoma metastasis.

Metastatic lesions also noted in the subcutaneous fat and bones - unchanged

 

3rd Infusion given on 7th May – She got a worse hepatitis reaction, than after the 3rd dose.  LFT where taken frequently. Yet also her headache worsened and a brain MRI was done to exclude brain mets, eventually it was concluded that the headache was due to Hypophysitis with Hypoadrenalism – she was started on prednisolone 40mg - with immediate relief of her symptoms.  As the dose of the steroids was being gradually reduced she developed shoulder girdle pain. The 4th dose was delayed by a week to give time for the LFT to improve more.

MRI Brain – 14/05/15

Normal gray - white matter differentiation. No space-occupying lesions are identified. No mass effect.

No foci of restricted diffusion.

Postoperative changes are seen in the right orbit.

 

4th Infusion given on the 4th June – Post infusion still complaining of shoulder girdle pain and started to note three small lumps on her scalp.  As we tried to decrease the prednisolone dose below 20mg the shoulder pain increased – so she was left on 20mg prednisolone for a few days. As from the 13th July we retried to decrease the steroids gradually again and to date she is on 7.5mg dly with little joint pain left.

CT Trunk and MRI Liver 140715

 

Progression of disease is evident with increase in size and number of the numerous bilobar liver metastasis, the largest

of which now measures 3 cm (this metastatic deposit measured 1.7 cm on this study done in April 2015).

As previously noted, metastatic deposits are seen within the pancreas, posterior mediastinal lymph nodes, the visible

portions of the axial skeleton, and also throughout the subcutaneous fat. These deposits have also increased in size

and number.

 

So it seemed that Ipi did not work

 

Next in line was imcgp100 trial in oxford - we did HLA test unfortunately she is HLA 1 & 33 - therefore not eligible for trial.

 

Now plan is to give her anti-pd1 and SIRT or delcath to liver.  She has also been started on epilin chrono 1g at night.

 

Anyone can suggest any alternative that might be more promising.  I understand that MEK inhibitors are not that promising as per latest results of trials.  What about c-met inhibitors?

 

Thanks Ken

 

Update - 18/01/16

 

She was started on Anti-PD1 Pembrolizumab on 27th August 2015

 

MRI Liver – 04/09/15

Comparison is made to previous study done in July 2015.

Significant interval change is seen with an increase in the number and size of the liver, pancreatic, and soft tissue

metastasis. The same applies for the bone metastases which are present throughout the imaged skeleton.

No intra or extrahepatic biliary dilatation. The pancreatic duct is of a normal alibre. The spleen is normal in size.

No significant renal or adrenal abnormalities.

Progression of disease as described.

Chest X-Ray at Southampton – 17/09/15

Normal

 

Routine blood tests taken for pre and post Keytruda – always normal (Aptt/INR – taken 270815 – Normal)

Pembrolizumab administered on

27th August 2015

17th September 2015

8th October 2015

29th October 2015

 

SIRT was given at Southampton by Dr Brian Stedman on 12th November 2015

 

Pembrolizumab administered on

19th November 2015

10th December 2015

 

MR Liver/Spleen of 22-DEC-2015:

Comparison is made to the study done in September 2015.

The cutaneous metastases have increased slightly in size. Progression of disease is also seen in the precardiac and

posterior mediastinal lymph nodes and in the bone metastases. The pancreatic metastatic deposits are stable in size.

Note is also made of the intra and retroperitoneal metastatic deposits, which have also increased in size.

The previously-described bilobar multiple liver metastases are overall stable in size and appearances, some have also

decreased in size with internal necrosis.

</CONCLUSION/>

Progression of disease as described in detail above.

 

 

NOTES: During this period some of the subcutaneous lumps started hurting her and got inflamed – then after a few days the pain and inflammation would settle – some of the lumps would shrink significantly, others would remain the same size.

 

 

CT Brain performed in 22-DEC-2015:

Pre and post administration of IV contrast scans were performed.

Findings:

There is no space-occupying lesion in the cerebral and cerebellar parenchyma.

No intra or extra-axial haemorrhage is seen.

The ventricles are symmetrical and there is no midline shift.

Normal grey-white matter differentiation is noted throughout.

Postoperative changes are seen in the right orbit.

There are multiple metastatic deposits in the subcutaneous tissues of the skin of the scalp.

Conclusion:

Subcutaneous scalp deposits as described above which were not present on a CT brain dated December 5th, 2012.

 

Pembrolizumab administered on

7th January 2016

 

Plan at this point is to continue Pembro and to try to get assess to T-Vec to inject the subcutaneous nodule

 

Anyone can bring forward any other options please?


Edited by ken481, 18 January 2016 - 10:16 PM.


#2
Michael London

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I agree with SIRT + pembro. Alternative would be TACE (+/- pembro) or Delcath.

Need to ensure that pembro side effects do not delay liver-directed- do SIRT first?

 

It seems to me that she had always had liver-dominant disease. I do not understand the prior decision to do ipi (objective response 5%) as opposed to liver-directed.



#3
ken481

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Well actually after the findings of Liver mets on MRI PEt scan showed multiple skeletal and subcutanous lesion - that is the reason why it was decided to go for systemic therapy first.

 

Can TACE be used in this case? - cause southampton claim that TACE is not ideal - SIRT or Delcath are better options



#4
ken481

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What do you think of C-Met inhibitors?



#5
Michael London

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Hi Ken,

I am afraid I am traveling now, but for the moment may I politely suggest that you kindly consider looking for those topics at http://www.eyecancer...ts-of-the-body/ including topics that you may need to go to page 2 or 2 of topics list to view.

If this is still unclear please let us know.

Best,
Michael

#6
ken481

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Hi all i have just updated my mothers case - see above - 1st post - would appreciate any feedback or ideas from anyone of you

 

Ken



#7
Brendan

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Hi Ken, Sorry I dont have much to give. I think the T-VEC is well worth a shot to see what happens. If you get a bounce it would be interesting to see if they would do deep tissue injections.

Good luck.

Bren



#8
ken481

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Thanks Bren - plan is to inject subcutanous nodules at this point - currently in contact with Amgen to see if they could provide vaccine on compassionate basis



#9
Michael London

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Overall treatment strategy as at 18 Aug above.

Absolutely, meaningful clinical trials should be considered that you are already doing.

Seems to have a minor benefit from pembro, would not take her off with no other good options ready to go. Of course c-met inhibitors can be considered (cabozantinib or crizotinib, but please do not expect any miracles with them, just like with other drugs in OM)

Would add SIRT, or TACE or Delcath, depending on the number and average size of lesions, as well as liver vasculature in particualr patient - discuss with stedman and ottendmeier

If she has liver-dominant disease, liver directed are priority

If really bad side effects from treatment, discontinuation and palliative care should also be considred

I am sorry to say that there are difficult times ahead.



#10
ken481

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HI Michael

 

Mum had SIRT on 12th November with very good response in liver - so that is done.

 

We are waiting for a reply from AMGEN at this point to get assess to T-Vec



#11
Michael London

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You mean you personally contacted Amgen or your physician did it?
Is there a procedure for that?

#12
Michael London

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You mean you personally contacted Amgen or your physician did it?
Is there a procedure for that?

#13
Michael London

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iphone duplicate



#14
ken481

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I am a doctor myself - i am a general practitioner.

 

I contacted Amgen personally and they send me a letter asking Profs Ottensmeier to contact them himself - he sent them a letter and we are waiting for an answer



#15
Michael London

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Has the tvec eap started?

#16
Ginge

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Morning

Waiting for outcome of further investigations of suspicious chest x-ray.

Does anyone have any recent experience of mets to lungs.

Any advice/guidance appreciated.

Cheers
STH

#17
Ginge

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Morning

Waiting for outcome of further investigations of suspicious chest x-ray.

Does anyone have any recent experience of mets to lungs.

Any advice/guidance appreciated.

Cheers
STH

#18
Brendan

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Hi Ginge,

 

Not many people around here these days. The liver is the main issue with OM mets - How is yours is it only the lung thats at issue?. Is it big or small the suspicious thing.  

 

BTW check out the FaceBook pages bit more life over there.

 

Bren



#19
Ginge

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Strangely I was just about to check out FB, will probably get round to it this evening.

To be honest won't even know if it has spread until next appmnt.

I was mainly curious because I was expecting, if anything, it would be the liver, in which case there is now quite a bit of info available.

Was hoping to see if anyone else had had initial spread to lungs, so that I could take advantage of their experience in preparation for the appointment.

Thanks for the response I will tap the knowledge/experience pool available on FB.

Cheers
STH

#20
Ginge

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Strangely I was just about to check out FB, will probably get round to it this evening.

To be honest won't even know if it has spread until next appmnt.

I was mainly curious because I was expecting, if anything, it would be the liver, in which case there is now quite a bit of info available.

Was hoping to see if anyone else had had initial spread to lungs, so that I could take advantage of their experience in preparation for the appointment.

Thanks for the response I will tap the knowledge/experience pool available on FB.

Cheers
STH




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