Figure 1. Recurrent metastatic melanoma.

(A) Firm subcutaneous nodules in the axillary area and lateral chest wall. (B) ¹⁸F.Fluorodeoxyglucose positron emission tomographic scan showing multiple metastatic lesions in the subcutaneous tissue, lung, breast, adrenal gland, pelvic and perianal area before start of ipilimumab-nivolumab (left). Persistent hypermetabolic metastatic lesions with increase in size an appearance of new lesions after 3 months of ipilimumab-nivolumab (center). Complete metabolic response one year after temozolomide (right). (C) Histopathology of metastatic brain lesions showing in the left malignant cells with an epithelioid appearance, harboring vesicular nuclei, and prominent nucleoli (H&E, 40X). In the right picture immunostain for HMB45 demonstrates strong diffuse cytoplasmic to paranuclear Golgi staining pattern in the tumor cells (B; 40X). (D) histopathology of another resected brain lesion showing reactive changes, hyalinized vessels, bland necrosis, and no evidence of malignancy Post TVEC and Pembrolizumab (consistent with pseudoprogression). (E) Hypo-pigmented macules and patches on the back, anterior chest wall and abdomen.