Primary melanocytic tumors of the CNS are extremely rare conditions, encompassing different disease processes including meningeal melanoma and meningeal melanocytosis. Its incidence range between 3-5%, with approximately 0.005 cases per 100,000 people. Tumor biological behavior is commonly aggressive, with poor prognosis and very low survivability, and a high recurrence rate, even after disease remission with multimodal treatments. Specific genetic alterations involving gene transcription, alternative splicing, RNA translation, and cell proliferation are usually seen, affecting genes like BRAF, TERT, GNAQ, SF3B1, and EIF1AX. Here we present an interesting case of a 59-year-old male presenting with neurologic symptoms and a further confirmed diagnosis of primary meningeal melanoma. Multiple therapy lines were used, including radiosurgery, immunotherapy, and chemotherapy. The patient developed two relapses and an evolving genetic makeup that confirmed the disease’s clonal origin. We also provide a review of the literature on the genetic basis of primary melanocytic tumors of the CNS.

Conclusions In conclusion, although PMM is a rare entity and its presentation is aggressive in most cases, understanding gene expression, signaling pathways, and determining cancer genomics enables better performance in targeted treatments; however, more studies are still required better to understand the pathogenesis and early treatment of this pathology. Furthermore, the comprehensive and integrated approach with neurosurgery, radiotherapy, pathology, clinical oncology, and the early initiation of medications is fundamental to improve survival, prognosis and decrease disease recurrences

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