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    • br Discussion It is generally known that primary CNS melanom

    2019-04-15


    Discussion It is generally known that primary CNS melanomas are rare and difficult to diagnose prior to biopsy. According to tumor melanin content, four subtypes of malignant intracranial melanoma have been proposed, associated with different MRI image presentations. These subtypes are: 1) melanoma, characterized by hyper-intense T1 image and hypo- or iso-intense on T2 image; 2) non-melanoma, characterized by hypo- or iso-intense on T1 image and hyper- or iso-intense on T2 image; 3) uncertain or mixed, characterized by mixed MRI signal; and 4) hemorrhagic lesions, characterized by different stage of hemorrhage on MRI. The melanoma and hemorrhagic-type lesions account for approximately 70% of malignant intracranial melanomas. In spite of characteristic differences in presentation on MRI imaging, differential diagnosis from meningioma or glioma is frequently difficult. Due to the rarity of incidence of primary intracranial melanoma, optimal treatments had not yet been established until recently. Complete surgical resection followed by focal radiotherapy by radiosurgery or whole 4-ethylphenyl sulfate irradiation has remained the mainstream treatment for malignant intracranial melanoma. Many scholars have claimed that melanoma is radiation-resistant to the commonly used dose of 3000 cGy; therefore, high radiation dose such as 5000 cGy or stereotactic radiosurgery were suggested for better focal control after surgical resection. Radiosurgery for small lesions (less than 3 cm) showed encouraging result in several reports, with a focal tumor control rate exceeding 80%. Therefore, to address a residual tumor or small deep seated melanoma, stereotactic radiosurgery is an acceptable option to control the tumor and minimize neurological deficits. In our presented case, the patient experienced a long-term tumor-free survival after completion of a tumor resection followed by whole brain irradiation of 5000 cGy in 20 fractions. We believe complete tumor excision was the most important factor for outcome.
    Conflict of interest
    Introduction The greater omentum is a predominantly fat-containing intraabdominal structure, normally appearing as a band of fatty tissue with variable width on computed tomographic (CT) imaging. However, while the greater omentum is involved in inflammatory, infectious, and neoplastic processes, its inherent contrast on CT might be more apparent. Early omental disease manifests on CT as a permeated or smudged appearance of the omental fat, then progresses to enhanced soft tissue nodule formation as the disease becomes more sever. Ultimately, these nodules coalesce to form a diffusely thickened mass which can displace bowels, i.e., the so-called “omental cake”. This classic radiological sign was first described in surgical literature in the early 1900s. While neoplastic processes occur, secondary malignant origins far exceed primary tumors. In most situations, the peritoneal surface is secondarily affected by three cell lines: 1) epithelial (carcinomatosis); 2) mesenchymal (sarcomatosis); and 3) lymphoid (lymphomatosis). Non-Hodgkin\'s lymphoma-associated omental cake occurs often with the presence of diffuse peritoneal disease and is not very rare. However, other hematological malignancies rarely present with omental cake. Plasma cell leukemia (PCL) is a rare and very aggressive neoplasm of plasma cells. It is characterized by clonal plasma cell expansion comprising more than 20% of the peripheral blood leukocytes and/or an absolute clonal plasma cell count of more than 2 × 109/L. PCL accounts for 2–4% of plasma cell dyscrasias and is more common in African Americans compared to Caucasians. PCL occurring de novo without prior evidence of multiple myeloma (MM) is termed primary PCL (PPCL) and PCL evolving from a pre-existing MM is termed secondary PCL (SPCL). PPCL accounts for 60–70% of PCLs and the other 30–40% are SPCL. Additionally, it has been observed that PPCL occur about 10 years earlier than MM and SPCL, and patients with PPCL present with more serious symptoms than patients with MM. Because of common extensive infiltration of the bone marrow by clonal anaplastic and plasmablastic plasma cells, the most frequent symptoms are dyspnea and pallor, due to severe anemia or hemorrhagic diathesis due to thrombocytopenia. There is a higher proportion of patients with PPCL who have significant leukocytosis as well as elevated serum levels of lactic dehydrogenase and β2-microglobulin than patients with MM. The presence of osteolytic bone lesions is lower than in patients with MM (PPCL 35%, SPCL 53%, MM 80%); this is probably related to an elevated aggressiveness of PPCL or differing disease biology. Physical examination may show hepatosplenomegaly, lymphadenopathy, pulmonary effusion, neurologic deficit related to central nervous system involvement, and extramedullary soft-tissue plasmacytomas. PPCL tend to secrete only free-light chains as compared with MM (26–44% vs. 15%). Since PPCL is an uncommon disease, PPCL presenting with omental cake is extremely rare. Here, we present an interesting case of PPCL with a rare presentation of omental cake.