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Case Reports
. 2023 Feb 1;12(2):160-165.
doi: 10.1007/s13691-023-00597-8. eCollection 2023 Apr.

Proton beam therapy for cervical lymph node metastasis in an octogenarian with melanoma of unknown primary: a case report

Masatoshi Nakamura  1 , Kayoko Ohnishi  1   2 , Fumihiko Uchida  3 , Takashi Saito  1 , Yuri Kitagawa  4 , Ryota Matsuoka  5 , Toru Yanagawa  3 , Hideyuki Sakurai  1
Affiliations
Case Reports

Proton beam therapy for cervical lymph node metastasis in an octogenarian with melanoma of unknown primary: a case report

Masatoshi Nakamura et al. Int Cancer Conf J. .

Abstract

An 80-year-old man with an approximately 3-cm mass in the right submandibular region presented to our institution. Magnetic resonance imaging revealed enlarged lymph nodes (LNs) in the right neck, and fluorine-18-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) indicated positive FDG accumulation in the right neck LNs only. Excisional biopsy was performed for suspected malignant lymphoma, and the biopsy revealed melanoma. Close examination of the skin, nasal cavity, oral pharyngeal and laryngeal cavities, and gastrointestinal tract were performed. No primary tumor was detected by these examinations, and the patient was diagnosed with cervical LN metastasis from melanoma of unknown primary of clinical stage T0N3bM0 stage IIIC. The patient refused cervical neck dissection because of his age and comorbidity of Alzheimer's disease and instead opted for proton beam therapy (PBT) at a total dose of 69 Gy (relative biological effectiveness) in 23 fractions. He did not receive any systemic therapy. The enlarged LNs shrunk slowly, and FDG PET/CT at 1 year after PBT showed that the right submandibular LN had shrunk from 27 to 7 mm in length, and there was no significant FDG accumulation. At 6 years and 4 months after PBT, the patient is alive without any recurrence.

Keywords: Lymph node metastasis; Melanoma of unknown primary; Proton beam therapy.

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Conflict of interest statement

Conflict of interestThe authors declare that they have no conflicts of interest regarding this manuscript.

Figures

Fig. 1
Fig. 1
Magnetic resonance imaging and maximum intensity projection positron emission tomography (PET) images at initial diagnosis. a Short TI inversion recovery images showed a lymph node (LN) of approximately 2.7 cm in maximum diameter in the right submandibular region and LNs of approximately 1.0 cm in the right upper jugular region. b PET showed significant positive fluorine-18-2-deoxy-D-glucose accumulation in the LNs in the right submandibular and upper jugular regions
Fig. 2
Fig. 2
Microscopic images of hematoxylin–eosin and immunohistochemical staining
Fig. 3
Fig. 3
Dose distribution of proton beam therapy. The irradiated fields encompassed the clinically positive LNs and surrounding enlarged LNs in the level Ib, II, and III areas of the right neck. Isodose curves on axial (a), sagittal (b), and coronal (c) images
Fig. 4
Fig. 4
Contrast-enhanced computed tomography and positron emission tomography findings after definitive proton beam therapy. a At pretreatment, the tumor had a diameter of 2.7 cm and fluorine-18-2-deoxy-D-glucose (FDG) accumulation. b At 3 months after proton beam therapy initiation, the tumor diameter was reduced from 2.7 to 2.5 cm, but the FDG accumulation was not reduced. c At 6 months, the tumor diameter had shrunk further to 1.3 cm, and the FDG accumulation had diminished. The lymph nodes in the right neck had also shrunk. d At 12 months, the tumor diameter was further reduced to 0.7 cm, and the FDG accumulation was no longer apparent
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