A Solitary Pulmonary Micronodule in Melanoma Staging – Metastasis?

Sascha Daniel, MD; Matthias May, MD
Department of Radiology, University Hospital Erlangen, Erlangen, Germany
|2019-12-04

A 38-year-old male patient had undergone resection of a melanoma found on his upper left chest. Prior to surgery, he was asymptomatic and a chest X-ray in two planes was required for primary staging. An ultra-low-dose native CT scan was performed instead, with patient consent, and a solitary pulmonary micronodule, 1 mm in diameter, was visualized in the right upper lobe. No lymphonodal or distant organ metastases were found. 16 months later, the patient returned for a follow-up and an ultra-low-dose native CT examination was once again performed.

In comparison to the prior examination, CT images showed no changes of the solitary pulmonary micronodule in the right upper lobe. The micronodule was therefore characterized as a small post-infection scar and thus non-malignant. No pulmonary metastases or enlarged lymph nodes were seen in either the axillae or the mediastinum. The resection scar on the upper left chest was no longer visible and there were no other suspicious cutaneous lesions.

Micronodule in the right upper lobe when comparing the primary staging
Courtesy of Department of Radiology, University Hospital Erlangen, Erlangen, Germany

Fig. 1: Axial images demonstrate no changes in a micronodule (arrows) in the right upper lobe when comparing the primary staging (Fig. 1b) to the follow-up exam (Fig. 1a).

MIP images (22 mm thickness) show the unchanged micronodule in the follow-up exam.
Courtesy of Department of Radiology, University Hospital Erlangen, Erlangen, Germany

Fig. 2: Axial (Fig. 2a) and coronal (Fig. 2b) views of MIP images (22 mm thickness) show the unchanged micronodule (arrows) in the follow-up exam.

A melanoma is a malignant skin cancer deriving from the pigment-containing melanocytes. The increasing incidence rate[1] demands a staging tool that can detect even small lesions and which is also cost-efficient and has a positive risk-benefit-ratio.[2] The radiation exposure level of a standard posteroanterior and lateral chest X-ray is in average 0.1 mSv.[3] This is similar to that of an ultra-low-dose CT.[4] The reduction in exposure is enabled by an advanced tin filter technology, which optimizes the X-ray spectra and significantly improves the air / tissue contrast. In this case, using SOMATOM go.Top, a pulmonary micronodule with a diameter of only 1 mm is visualized at an effective dose level of 0.17 mSv in primary staging. In the follow-up evaluation, the effective dose level is further reduced to 0.11 mSv using SOMATOM X.cite. Lymph nodes in the axillae and mediastinum could also be evaluated, which is not possible on a regular chest X-ray examination.

Scanner

Scan area

Thorax

Thorax

Scan mode

Spiral scan

Spiral scan

Scan length

328 mm

325 mm

Scan direction

Cranio-caudal

Cranio-caudal

Scan time

1.8 s

3.1 s

Tube voltage

Sn110 kV

Sn140 kV

Effective mAs

35 mAs

6 mAs

Dose modulation

CARE Dose4D

CARE Dose4D

CTDIvol

0.30 mGy

0.24 mGy

DLP

12 mGy cm

8 mGy cm

Effective dose

0.17 mSv

0.11 mSv

Rotation time

0.33 s

0.3 s

Pitch

1.2

0.8

Slice collimation

64 x 0.6 mm

64 x 0.6 mm

Slice width

1 mm

0.8 mm

Reconstruction increment

0.7 mm

0.6 mm

Reconstruction kernel

Br60f (ADMIRE3)

Br60f (ADMIRE3)

1

2

3

4