Correct!
2. Radiation and oncology consultation should be obtained
Metastatic melanoma without a primary site is seen in about 2-3% of patients with melanoma (1). There is no indication for bronchoscopy. Radiation therapy and oncology consultation were obtained and the patient received radiation therapy followed by gemcitabine and docetaxel. He was later switched to pembrolizumab (Keytruda®).
Nineteen months later a repeat PET/CT scan was suspicious for metastatic liver disease (Figure 2, Panel A) but his neck (Figure 2, Panel B) and chest (Figure 2, Panel C) showed no increased tracer uptake.
Figure 2. Panel A: Abdominal PET/CT scan showing increased uptake within the liver. Panel B: Neck PET/CT showing no increase in uptake. Panel C: Chest PET/CT showing no increased uptake.
His chemotherapy was subsequently switched to a combination of ipilimumab (Vervoy®) and nivolumab (Opdivo®).
A repeat PET/CT scan 3 months later showed the liver lesions were no longer present but increased uptake within the chest (Figure 3).
Figure 3. PET/CT scan of the chest showing multiple areas of increased uptake.
Which of the following are indicated at this time? (Click on the correct answer to proceed to the third of four pages)