61M w/ hx of hemorrhoids presented 10 months ago with 8 week | Figure 1

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61M w/ hx of hemorrhoids presented 10 months ago with 8 weeks of increased bloody and melanotic stool and 15lb weight loss. Exam notable for conjunctival pallor, no skin lesions, and a mass palpated on DRE. Initial labs just notable for hgb 9. Flex sig was pursued, which showed necrotic rectal mass, biopsy showing pigmented, malignant epithelial cells invasive through the muscularis mucosa. ICH showed MART-1+/SOX10+ staining c/w mucosal melanoma. Genomic analysis was negative for BRAF and CKIT mutations, positive for IDH and CDKN2A mutations. Body imaging revealed significant metastatic burden in lungs but no CNS dz or any other metastatic sites. Overall, consistent with primary rectal mucosal melanoma. Rectal mass was surgerized and pt had diverting sig colostomy. Lung lesions rapidly progressed on dual checkpoint blockade (ipi/nivo) with additional development of multiple subcutaneous nodules. Tumor infiltrating lymphocyte therapy was deemed only viable option given rapid progression and otherwise good functional status. He was admitted and completed conditioning and TIL infusion without issue. He received IL2 on cell d+1-3 per protocol, but became altered and critically hypotensive/hypoxic on d+3, requiring MICU admission for pressors and diuresis. He recovered and discharged to home d+11. Imaging on admission for TIL (right) and on day of discharge (left). Follow up scans 3 months later NED.

Even among melanomas, mucosal dz is a particularly stubborn cancer. They present later since there are no skin lesions. The targetable mutations frequently present in cutaneous dz are usually absent. ICI fails more often. This man had a remarkable response to TIL, which unfortunately is not always the case. What does seem to happen invariably is the distributive shock-picture during IL2 infusion, particularly dangerous as this is often when the pt is most sick from all the other treatments and progression of disease. What have you seen in your practice? How do you prepare for such complications? Are your pts by default managed in the MICU or if not what are the triggers for escalation?

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A 46‐year‐old woman, with no personal or family history of melanoma, consulted for a naevus review. A 6‐mm brownish pigmented lesion was found in the abdomen, showing regular morphology and colour. Dermoscopic examination revealed a typical globular pattern with numerous white roundish structures distributed all over the lesion. The dermoscopic finding of white globules seems to correlate with nests of balloon cells. This finding should not be confused with milia‐like cysts. Balloon cells are melanocytes with extensive, pale‐staining and vacuolated cytoplasms, which often have a defect in melanosome formation. Reflectance confocal microscopy (RCM) showed larger cells with a central, roundish and large hyporefractive nucleus and a moderately refractive surrounding part, arranged in dense nests (blue arrows). The presence of typical globular pattern, the normal architecture and the absence of atypical cells on the RCM helps to identify this naevus. HE, haematoxylin and eosin.

60s yo female adm for mechanical fall w headache. 2 months previously dx and treated for lung cancer. Deconjugate gaze, and poor cerebellar function, dysarthric. Multiple supra and infratentorial sub centimeter lesions. Larges lesion was right cerebellar w mass effect on 4th ventricle. Extensive conversation w pt and family, they requested surgery. Path c/w metastatic small cell carcinoma. Post op cerebellar function improved, and participated well w therapy. Ultimately passed 3 weeks after resection due to pulmonary deterioration and family desire for hospice.

Image description: Axial contrast-enhanced CT of the abdomen shows a large mass arising from the tail of the pancreas (arrow). Metastatic lesions are present in the liver (arrowhead). Metastatic lymphadenopathy encases the vasculature of the left kidney. Teaching point: Pancreatoblastoma is a rare malignant pancreatic tumor of infancy and early childhood. It is associated with Beckwith-Wiedemann syndrome and familial adenomatous polyposis. Serum alpha-fetoprotein is frequently elevated and can be useful for diagnosis and treatment monitoring. At presentation, the tumor is often large and metastatic, commonly involving the liver and regional lymph nodes.

A 71 year old man experienced a 40 lb weight loss and was found to be anemic with a hemoglobin of 10.6. PSA was normal. EGD showed gastritis, colonoscopy was normal. He developed back pain and a CT showed a T3 vertebral lesion with extraosseous extension. A corpectomy was performed and a post op PET CT showed hypermetabolic adrenal masses, right acetabular and pubic symphysis lesions. Initial pathology from the corpectomy showed sarcomatoid carcinoma. Radiation was administered to the bone lesions. He was given gemcitabine and paclitaxel by an outside oncologist and tolerated it poorly. He was monitored for over a year and had enlargement of his adrenal masses. A biopsy was performed and the pathology is attached, demonstrating a sarcomatoid carcinoma. Genomic studies showed a FLT1, DNMT3A, SETD2 mutations and was microsatellite stable. Radiation was given to the adrenal lesion and he now presents with progression in those lesions and enlarging intraabdominal lymphadenopathy.