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Anesthetic Management of a Parturient With Primary Spinal Malignant Melanoma: A Case Report and Review of the Literature
Abstract Number: FC10-110
Abstract Type: Case Report Case Series
A 30-year old patient scheduled for an elective repeat cesarean section at 37 weeks was referred to anesthesia for preoperative assessment. During her previous pregnancy, she was diagnosed with an primary spinal malignant melanoma, levels C1-C3. An emergency cesarean section (CS) under general anesthesia (GA) was required at 31 weeks gestational age due to acute development of refractory pain and lower limb weakness. Acute onset quadriplegia and dyspnea following extubation necessitated emergency surgical tumor removal & irradiation of the surgical bed.
The patient had regular follow-up cervical MRIs since then. At 6 weeks of her following pregnancy , her MRI showed T1 hyperintense/ T2 isointense foci at C3-C4. These findings suggested possible leptomeningeal malignancy. A follow-up MRI was planned in a few months, followed by contrast enhanced imaging after delivery. The follow-up MRI findings five months later were the same.
Our main concern was airway manipulation/difficulty due to her history. We therefore recommended a spinal anesthetic. However, we requested a lumbar MRI to exclude recurrence of malignancy.
Her lumbar MRI unfortunately showed the presence of numerous nodular foci along the cauda equina roots, suggestive of leptomeningeal malignancy.
Her delivery was therefore rescheduled to an earlier date to start investigations & treatment as needed. Our initial decision was reconsidered in favor of GA to avoid causing any complications by interfering in an area of the dura with a possible malignancy, such as failure to achieve an adequate block and development of postoperative neurological deficits, as well as possible ‘seeding’ malignant cells further into the neuroaxis.
Imaging studies done after delivery supported the initial impression of malignant recurrence, in addition to metastatic findings in her brain MRI.
Primary CNS malignant melanomas are quite rare, accounting for 1% of all CNS tumors. Their diagnosis is done by using Hayward’s criteria(1), which are: absence of melanoma outside the CNS, absence of this lesion elsewhere in the CNS & histopathological confirmation. Little data on recurrence rate and prognosis is available due to its rarity. We found 58 cases while reviewing literature, only two of which were also pregnant.
(1)Hayward RD. Malignant melanoma and the central nervous system. A guide for classification based on the clinical findings. J Neurol Neurosurg Psychiatry. 1976;39(6):526-30.