J Gastrointest Canc DOI 10.1007/s12029-013-9565-8
LETTER TO THE EDITOR
A Rare Cause of Upper Gastrointestinal Bleeding in an Elderly Patient: Primary Duodenal Malignant Melanoma Şahin Çoban & Fuat Ekiz & Ömer Başar
# Springer Science+Business Media New York 2013
Malignant melanoma is a cutaneous tumor which originates from melanocytes. It is the most common tumor metastasizing to the gastrointestinal tract and may generally present with nonspecific symptoms. The prevalence of gastrointestinal (GI) involvement varies between 1 and 4 % in patients with malignant melanoma [1]. Primary melanomas of the mucosa may behave aggressively and may have poor prognosis, despite the fact that they are diagnosed at early stages. Their clinical symptoms are usually similar to those caused by other GI tumors such as mild to severe abdominal pain, fatigue, dysphagia, constipation, tenesmus, small bowel obstruction, hematemesis, and melena [2]. We present a rare cause of malignant melanoma evolving as a duodenal tumor leading to upper gastrointestinal bleeding. We have also discussed relevant literature of gastrointestinal bleeding due to primary malignant melanoma. A 63-year-old female was admitted to our center with abdominal pain, hematemesis, and melena. She had a 9-month history of abdominal pain, fatigue, weakness, occasional nausea, and vomiting. Her nausea had gradually increased with accompanying 15 kg weight loss over the preceding 3 months. On admission, her vital findings were as follows: blood pressure, 120/70 mmHg; pulse, 90/min; temperature, 36.8 °C; and respiration rate, 18/min. The physical examination was unremarkable except epigastric sensitivity and conjunctival paleness. Laboratory findings revealed anemia (Hb, 10.9 g/dl), hypoalbuminemia, and elevated bilirubin levels. Upper GI endoscopy showed a dark black endoluminated and lobulated mass in the second part of the duodenum. The mass had a necrotic surface with peripheral ulceration. There was no active Ş. Çoban (*) : F. Ekiz : Ö. Başar Department of Gastroenterology, Diskapi Yildirim Beyazit Education and Research Hospital, Ogretmenler Cd. Menekse Sitesi, 23/15, Çukurambar Mah, Çankaya, 06520 Ankara, Turkey e-mail: [email protected]
bleeding. Multiple biopsies were obtained from the tumor. Histopathological examination revealed a poorly differentiated neoplasm comprising large, polygonal cells with macronucleoli. Some of the tumor cells showed dark brown pigmentation within the cytoplasm. Subsequent immunohistopathological staining studies showed diffuse HMB-45 and focal S-100 protein positivity in the tumor cells (Fig. 1). The tumor was diagnosed as malignant melanoma. Further investigations did not reveal a primary lesion in the skin, oculus, anus, or any other location. Therefore, we considered this tumor as a primary lesion. A supportive therapy with human albumin infusions, and total parenteral nutrition was administered after the diagnosis was established. In the abdominal CT scan, a lobulated mass measuring 5 cm in diameter was observed in the small intestine (Fig. 2). A surgical operation was not performed because of the patient’s poor performance status and nonacceptance to the surgical operation choice. Despite the supportive treatment, the patient died 3 weeks later. Primary malignant melanoma of the GI tract is very rare. Primary GI melanomas can pigmented or apigmented [2]. Therefore, endoscopic appearance is often inconspicuous. Gastrointestinal melanomas often present as multiple ulcerated nodular lesions [3]. The lesion of our patient was easily noticeable during endoscopy with its dark color. Histopathological and immunohistochemical studies are required to establish a definite diagnosis, ruling out more common lesions. In our case, the diagnosis was established based on the overall structure, the cytological appearance of the tumor cells, and the immunohistochemical profile. The most frequent metastatic site throughout the GI tract of melanoma is the small intestine [3]. Differential diagnosis of primary mucosal melanomas and metastatic melanomas may be challenging. Primary GI melanoma is possible in a patient with no obvious primary cutaneous melanoma and a solitary GI lesion without evidence of extraintestinal metastases. In this case, similarly, there was no
J Gastrointest Canc
Fig. 1 Microscopic appearance of pleomorphic tumor cells growing in diffuse fashion in lamina propria of the duodenum (H&E, ×40). Inset shows strong immunoreactivity for HMB45
other focus of malignant melanoma, which was suggestive of a primary melanoma. Gastrointestinal involvement of malignant melanoma may have various clinical presentations. The presentation of small intestinal lesions consists of acute appendicitis, weight loss, malabsorption, obstruction, protein losing enteropathy, intussusceptions, perforated bowel, and occult blood loss [4]. Malignant melanoma patients may apply with evident GI bleeding as well as occult blood loss. Our case presented with hematemesis and melena, which has been rarely reported in the literature [5, 6]. The prognosis of the patients with GI malignant melanomas is extremely poor with a median survival of only 4–6 months [2]. This must be recognized, as it may be a life-threatening complication often with an acute presentation requiring medical and/or surgical intervention [2]. Often, palliative treatment alone is performed in later stages. Surgical intervention can increase the rate of survival in certain cases [3]. As for our patient, despite intensive supportive treatment, performance of the patient did not improve, and she deceased in a short time after the diagnosis. In conclusion, there may be various presentations of GI malignant melanoma. It should be kept in mind that patients with primary malign melanoma may present with upper gastrointestinal bleeding.
Fig. 2 Abdominal CT showing a lobulated mass measuring 5 cm in diameter in the small intestine
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Patel JK, Didolkar MS, Pickren JW. Metastatic pattern of malignant melanoma. Am J Surg. 1978;135:807–10. 2. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol. 2000;12:181–5. 3. Flechon A, Lombard-Bohas C, Saurin JC, Ponchon T, Partensky C, Scoazec JY. Malignant melanoma presenting as an ampullary tumor. Histopathology. 2002;41:562–3. 4. Wilson BG, Anderson JR. Malignant melanoma involving the small bowel. Postgrad Med J. 1986;62:355–7. 5. Yoshikane H, Suzuki T, Yoshioka N, Ogawa Y, Hamajima E, Hasegawa N, et al. Primary malignant melanoma of the esophagus presenting with massive hematemesis. Endoscopy. 1995;27:397–9. 6. Leong QM, Kam JH. Primary malignant melanoma of the lower oesophagus presenting with dysphagia and upper gastrointestinal bleeding. Cases J. 2008;11:1–28.
LETTER TO THE EDITOR
A Rare Cause of Upper Gastrointestinal Bleeding in an Elderly Patient: Primary Duodenal Malignant Melanoma Şahin Çoban & Fuat Ekiz & Ömer Başar
# Springer Science+Business Media New York 2013
Malignant melanoma is a cutaneous tumor which originates from melanocytes. It is the most common tumor metastasizing to the gastrointestinal tract and may generally present with nonspecific symptoms. The prevalence of gastrointestinal (GI) involvement varies between 1 and 4 % in patients with malignant melanoma [1]. Primary melanomas of the mucosa may behave aggressively and may have poor prognosis, despite the fact that they are diagnosed at early stages. Their clinical symptoms are usually similar to those caused by other GI tumors such as mild to severe abdominal pain, fatigue, dysphagia, constipation, tenesmus, small bowel obstruction, hematemesis, and melena [2]. We present a rare cause of malignant melanoma evolving as a duodenal tumor leading to upper gastrointestinal bleeding. We have also discussed relevant literature of gastrointestinal bleeding due to primary malignant melanoma. A 63-year-old female was admitted to our center with abdominal pain, hematemesis, and melena. She had a 9-month history of abdominal pain, fatigue, weakness, occasional nausea, and vomiting. Her nausea had gradually increased with accompanying 15 kg weight loss over the preceding 3 months. On admission, her vital findings were as follows: blood pressure, 120/70 mmHg; pulse, 90/min; temperature, 36.8 °C; and respiration rate, 18/min. The physical examination was unremarkable except epigastric sensitivity and conjunctival paleness. Laboratory findings revealed anemia (Hb, 10.9 g/dl), hypoalbuminemia, and elevated bilirubin levels. Upper GI endoscopy showed a dark black endoluminated and lobulated mass in the second part of the duodenum. The mass had a necrotic surface with peripheral ulceration. There was no active Ş. Çoban (*) : F. Ekiz : Ö. Başar Department of Gastroenterology, Diskapi Yildirim Beyazit Education and Research Hospital, Ogretmenler Cd. Menekse Sitesi, 23/15, Çukurambar Mah, Çankaya, 06520 Ankara, Turkey e-mail: [email protected]
bleeding. Multiple biopsies were obtained from the tumor. Histopathological examination revealed a poorly differentiated neoplasm comprising large, polygonal cells with macronucleoli. Some of the tumor cells showed dark brown pigmentation within the cytoplasm. Subsequent immunohistopathological staining studies showed diffuse HMB-45 and focal S-100 protein positivity in the tumor cells (Fig. 1). The tumor was diagnosed as malignant melanoma. Further investigations did not reveal a primary lesion in the skin, oculus, anus, or any other location. Therefore, we considered this tumor as a primary lesion. A supportive therapy with human albumin infusions, and total parenteral nutrition was administered after the diagnosis was established. In the abdominal CT scan, a lobulated mass measuring 5 cm in diameter was observed in the small intestine (Fig. 2). A surgical operation was not performed because of the patient’s poor performance status and nonacceptance to the surgical operation choice. Despite the supportive treatment, the patient died 3 weeks later. Primary malignant melanoma of the GI tract is very rare. Primary GI melanomas can pigmented or apigmented [2]. Therefore, endoscopic appearance is often inconspicuous. Gastrointestinal melanomas often present as multiple ulcerated nodular lesions [3]. The lesion of our patient was easily noticeable during endoscopy with its dark color. Histopathological and immunohistochemical studies are required to establish a definite diagnosis, ruling out more common lesions. In our case, the diagnosis was established based on the overall structure, the cytological appearance of the tumor cells, and the immunohistochemical profile. The most frequent metastatic site throughout the GI tract of melanoma is the small intestine [3]. Differential diagnosis of primary mucosal melanomas and metastatic melanomas may be challenging. Primary GI melanoma is possible in a patient with no obvious primary cutaneous melanoma and a solitary GI lesion without evidence of extraintestinal metastases. In this case, similarly, there was no
J Gastrointest Canc
Fig. 1 Microscopic appearance of pleomorphic tumor cells growing in diffuse fashion in lamina propria of the duodenum (H&E, ×40). Inset shows strong immunoreactivity for HMB45
other focus of malignant melanoma, which was suggestive of a primary melanoma. Gastrointestinal involvement of malignant melanoma may have various clinical presentations. The presentation of small intestinal lesions consists of acute appendicitis, weight loss, malabsorption, obstruction, protein losing enteropathy, intussusceptions, perforated bowel, and occult blood loss [4]. Malignant melanoma patients may apply with evident GI bleeding as well as occult blood loss. Our case presented with hematemesis and melena, which has been rarely reported in the literature [5, 6]. The prognosis of the patients with GI malignant melanomas is extremely poor with a median survival of only 4–6 months [2]. This must be recognized, as it may be a life-threatening complication often with an acute presentation requiring medical and/or surgical intervention [2]. Often, palliative treatment alone is performed in later stages. Surgical intervention can increase the rate of survival in certain cases [3]. As for our patient, despite intensive supportive treatment, performance of the patient did not improve, and she deceased in a short time after the diagnosis. In conclusion, there may be various presentations of GI malignant melanoma. It should be kept in mind that patients with primary malign melanoma may present with upper gastrointestinal bleeding.
Fig. 2 Abdominal CT showing a lobulated mass measuring 5 cm in diameter in the small intestine
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Patel JK, Didolkar MS, Pickren JW. Metastatic pattern of malignant melanoma. Am J Surg. 1978;135:807–10. 2. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol. 2000;12:181–5. 3. Flechon A, Lombard-Bohas C, Saurin JC, Ponchon T, Partensky C, Scoazec JY. Malignant melanoma presenting as an ampullary tumor. Histopathology. 2002;41:562–3. 4. Wilson BG, Anderson JR. Malignant melanoma involving the small bowel. Postgrad Med J. 1986;62:355–7. 5. Yoshikane H, Suzuki T, Yoshioka N, Ogawa Y, Hamajima E, Hasegawa N, et al. Primary malignant melanoma of the esophagus presenting with massive hematemesis. Endoscopy. 1995;27:397–9. 6. Leong QM, Kam JH. Primary malignant melanoma of the lower oesophagus presenting with dysphagia and upper gastrointestinal bleeding. Cases J. 2008;11:1–28.
