|
Keywords
Duodenum, esophagus, metastatic melanoma, mucosal melanoma, stomach.
Disclaimer
No experimental devices or medications were used in this report.
Introduction
Melanoma is an aggressive malignancy with a predisposition to metastasize through out the body. Gastrointestinal involvement is common. This case presents a mucosal melanoma with extensive gastrointestinal spread presenting with dysphagia.
Methods for Image Capture/Processing
SVHS tape recording with digitalization through a Dazzle capture board was utilized.
Case/Body
A 57-year-old man presented to his physician complaining of a “sore throat." Oral exam showed a 2 cm by 1 cm lesion along the gingivobuccal sulcus. Biopsy revealed a malignant melanoma. He underwent a wide local excision. Margins were clear and the lesion was staged as a Breslow IV, 3.1 cm by 1.4 cm in size, 1.35 mm in thickness. No evidence of further disease was found.
Eighteen months after his original presentation, the patient presented with weight loss, dysphagia, and constipation.
His past medical history was significant for a complex partial seizure disorder and gastroesophageal reflux symptoms.
He was a regular user of tobacco and alcohol.
Medications included Dilantin, Neurontin, Trileptal, Depakote, ferrous sulfate 325, and Zyrtec.
Family history revealed metastatic lung cancer in both brother and father.
Physical exam revealed some evidence of muscle wasting, three to four small pigmented spots on his chest, and firm cervical adenopathy.
An upper gastrointestinal endoscopy was performed. Video Clip 1 shows several small spots in the duodenum and a nodule in the stomach. Video clip 2 shows massive infiltration of the esophagus by tumor. Biopsy from the duodenum, stomach, and esophagus were consistent with metastatic melanoma.
An abdominal CT scan showed periaortic adenopathy and liver lesion consistent with metastasis.
Palliative dilation to 15 mm using Savery dilators was performed, and the patient was transferred to hospice care.
Discussion
Cutaneous malignant melanoma is a relatively common malignancy thought to be related to ultraviolet light exposure. In contrast, primary mucosal melanomas are much less common and do not appear to have the same casual risk factors (1-3). Cutaneous melanoma is about 100 times more frequent than mucosal melanoma. Generally, mucosal melanoma is diagnosed at a later stage than cutaneous melanoma and carries a poorer prognosis (1-3).
Melanoma is a relatively unpredictable neoplasm. Both mucosal and cutaneous melanomas can vary markedly in their rate of growth, and are able to metastasize to any and all organs. Melanoma metastasizes to the gastrointestinal tract relatively more frequently than other tumors. As in our case, small bowel, stomach, and esophageal lesions are encountered (4,5). It is very unusual for the esophagus to be the only site of metastasis (6).
As illustrated in the video clips, most of the time, metastasis to the intestine are small and are often pigmented (4,5,7) (Video Clip 1). Giant metastasis (Video Clip 2) are less common (7). Gastrointestinal involvement by melanoma can be symptomatic, but usually the symptoms are due to bleeding or obstruction (8). Dysphagia is rare, but can be disturbing (6).
This case illustrates a variety of different gastrointestinal metastatic lesions in an unfortunate person with an aggressive mucosal melanoma. Although the presentation of our case is dramatic, it is important to be aware of the endoscopic appearance of melanoma when evaluating patients, particularly those with a past history of melanoma.
References
1. DeMatos P, Tyler DS, Seigler HF. Malignant melanoma of the mucous membranes: a review of 119 cases. Ann Surg Oncol. 1998 Dec;5(8):733-42.
2. Gutman M, Inbar M, Chaitchik S, Merhav A, Pausner D, Skoznik Y, Ilie B, Rozin RR, Klausner JM. Malignant melanoma of the mucous membranes. Eur J Surg Oncol. 1992 Aug;18(4):307-12.
3. Tomicic J, Wanebo HJ. Mucosal melanomas. Surg Clin North Am. 2003 Apr;83(2):237-52.
4. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol. 2000 Mar;12(2):181-5.
5. Blecker D, Abraham S, Furth EE, Kochman ML. Melanoma in the gastrointestinal tract. Am J Gastroenterol. 1999 Dec;94(12):3427-33.
6. Schneider A, Martini N, Burt ME. Malignant melanoma metastatic to the esophagus. Ann Thorac Surg. 1993 Feb;55(2):516-7.
7. Silverman JM, Hamlin JA. Large melanoma metastases to the gastrointestinal tract. Gut. 1989 Dec;30(12):1783-5.
8. Geboes K, De Jaeger E, Rutgeerts P, Vantrappen G. Symptomatic gastrointestinal metastases from malignant melanoma. A clinical study. J Clin Gastroenterol. 1988 Feb;10(1):64-70.
|
