476
Letters to the Editor
sedation requirement has been shown by Dr Ramirez in patients who received full conscious sedation (5) and by Dr Leung in patients who accepted the option of sedation on demand (6) in the United States. They accomplished cecal intubation in a much shorter time and achieved pain reduction with the WE method (5,6). The WE group showed numerically higher but not statistically significant adenoma detection rate (ADR), possibly due to a type II error (sample size was not large enough). We and others are evaluating the impact of WE on ADR. We would welcome Dr Feuerstein and other interested colleagues to consider participating in such an evaluation. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Hsieh Y-H, Koo M, Leung FW. A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014; 109:1390–400. 2. Feuerstein JD. The ideal insertion method for colonoscopy is in the eye of the beholder. Am J Gastroenterol 2015;110:475 (this issue). 3. Hsieh YH, Lin HJ, Tseng KC. Limited water infusion decreases pain during minimally sedated colonoscopy. World J Gastroenterol 2011;17:2236–40. 4. Hsieh Y, Tseng K, Hsieh J et al. Feasibility of colonoscopy with water infusion in minimally sedated patients in an Asian community setting. J Interv Gastroenterol 2011;1:185–90. 5. Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011;1:130–5. 6. Leung JW, Mann SK, Siao-Salera RM et al. A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011;73:103–10.
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An Unusual Presentation of Malignant Melanoma: Amelanotic Gastric Metastasis Omer Ozturk, MD1, Omer Basar, MD1, Seyfettin Koklu, MD1, Osman Yuksel, MD1, Tugrul Purnak, MD1 and Cenk Sokmensuer, MD2 doi:10.1038/ajg.2014.434
To the Editor: The gastrointestinal tract is one of the most common sites for melanoma metastasis. Metastasis can be at the time of primary diagnosis or years after the diagnosis (1). Approximately 7% of GI metastases of melanoma are found in the stomach (1,2). Amelanotic malignant melanoma (AMM) is an unusual type of the disease, representing 2% of all malignant melanomas, and amelanotic gastric metastasis is extremely rare (3). Gastric metastases of the malignant melanoma
are usually polypoid lesions that have little pigmentation. They are often ulcerated but rare presentations such as solitary melanotic tumors are also observed (1,3). Here we report a case of metastatic AMM of the stomach. A 54-year-old man was admitted to the gastroenterology department with a complaint of mild epigastric pain for the last 2 months. In his past medical history, he was diagnosed as having malignant melanoma of the skin 4 months ago. Physical examination was within normal limits except for periumbilical tenderness. Laboratory findings showed normal blood count and biochemical parameters. Upper gastrointestinal endoscopy showed a 10-mm nonpigmented polypoid lesion in the fundus of the stomach (Figure 1) and endoscopic biopsy showed metastasis of the dermal malignant melanoma (Figure 2). Positron emission tomography–computed tomography revealed liver, adrenal, and brain metastasis. Dexamethasone plus biologic therapy with ipilimumab was initiated and cranial radiotherapy was given. He is still continuing his chemotherapy protocol. The stomach is an unusual location for metastasis of malignant melanoma and
1
Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; 2Tzu Chi University, School of Medicine, Hualien, Taiwan; 3 Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, California, USA; 4David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Correspondence: Yu-Hsi Hsieh, MD, Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi 62247, Taiwan. E-mail: [email protected]
The American Journal of GASTROENTEROLOGY
Figure 1. Endoscopic appearance of amelanotic malignant melanoma.
VOLUME 110 | MARCH 2015 www.amjgastro.com
Letters to the Editor
nature publishing group
of AMM metastasis and physicians should be aware of melanoma involvement when there are unrelated symptoms at other sites. In addition, endoscopists should pay attention to lesions in endoscopy when there is a history of melanoma. CONFLICT OF INTEREST The authors declare no conflict of interest.
Figure 2. (a) Subepithelial layers are infiltrated by atypical cells (HE, ×10). (b) Subepithelial cells are positive with S-100 immunohistochemical stain confirming their melanocyte origin (×10).
more than half of tumor metastases occur in the initial year of diagnosis (1,3). Symptoms such as epigastric pain, nausea, and vomiting are usually nonspecific and upper gastrointestinal bleeding is an extremely rare presentation (1,2). Endoscopy is the best diagnostic method for diagnosis of the metastasis. On the other hand, in contrast to pigmented lesions, amelanotic melanoma is more difficult to diagnose, which results in a delay in initiating treatment and the prognosis tends to be poorer (3). In the endoscopic view, the lesion is
© 2015 by the American College of Gastroenterology
grayish white or white and is difficult to differentiate from gastrointestinal stromal tumors or undifferentiated cancers of the stomach, so that it must be confirmed histopathologically (3). Metastatic malignant melanomas are treated with the same protocols as the other sites of involvement (2,3). In our case, the malignant melanoma of the skin was diagnosed only 4 months ago and he had mild epigastric pain for only the last 2 months. In conclusion, the gastrointestinal system, especially the stomach, can be a site
REFERENCES 1. Köklü S, Gültuna S, Yüksel I et al. Diffuse gastroduodenal metastasis of conjunctival malignant melanoma. Am J Gastroenterol 2008;103:1321–3. 2. Reintgen DS, Thompson W, Garbut J et al. Radiologic, endoscopic, and surgical consideration of melanoma metastatic to the gastrointestinal tract. Surgery 1984;95:635–9. 3. Suganuma T, Fujisaki J, Hirasawa T et al. Primary amelanotic malignant melanoma of the small intestine diagnosed by esophagogastroduodenoscopy before surgical resection. Clin J Gastroenterol 2013;6:211–6.
1 Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey; 2Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey. Correspondence: Omer Ozturk, MD, Department of Gastroenterology, Hacettepe University School of Medicine, Sihhiye 06100, Ankara, Turkey. E-mail: [email protected]
The American Journal of GASTROENTEROLOGY
477
Letters to the Editor
sedation requirement has been shown by Dr Ramirez in patients who received full conscious sedation (5) and by Dr Leung in patients who accepted the option of sedation on demand (6) in the United States. They accomplished cecal intubation in a much shorter time and achieved pain reduction with the WE method (5,6). The WE group showed numerically higher but not statistically significant adenoma detection rate (ADR), possibly due to a type II error (sample size was not large enough). We and others are evaluating the impact of WE on ADR. We would welcome Dr Feuerstein and other interested colleagues to consider participating in such an evaluation. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Hsieh Y-H, Koo M, Leung FW. A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014; 109:1390–400. 2. Feuerstein JD. The ideal insertion method for colonoscopy is in the eye of the beholder. Am J Gastroenterol 2015;110:475 (this issue). 3. Hsieh YH, Lin HJ, Tseng KC. Limited water infusion decreases pain during minimally sedated colonoscopy. World J Gastroenterol 2011;17:2236–40. 4. Hsieh Y, Tseng K, Hsieh J et al. Feasibility of colonoscopy with water infusion in minimally sedated patients in an Asian community setting. J Interv Gastroenterol 2011;1:185–90. 5. Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011;1:130–5. 6. Leung JW, Mann SK, Siao-Salera RM et al. A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011;73:103–10.
nature publishing group
An Unusual Presentation of Malignant Melanoma: Amelanotic Gastric Metastasis Omer Ozturk, MD1, Omer Basar, MD1, Seyfettin Koklu, MD1, Osman Yuksel, MD1, Tugrul Purnak, MD1 and Cenk Sokmensuer, MD2 doi:10.1038/ajg.2014.434
To the Editor: The gastrointestinal tract is one of the most common sites for melanoma metastasis. Metastasis can be at the time of primary diagnosis or years after the diagnosis (1). Approximately 7% of GI metastases of melanoma are found in the stomach (1,2). Amelanotic malignant melanoma (AMM) is an unusual type of the disease, representing 2% of all malignant melanomas, and amelanotic gastric metastasis is extremely rare (3). Gastric metastases of the malignant melanoma
are usually polypoid lesions that have little pigmentation. They are often ulcerated but rare presentations such as solitary melanotic tumors are also observed (1,3). Here we report a case of metastatic AMM of the stomach. A 54-year-old man was admitted to the gastroenterology department with a complaint of mild epigastric pain for the last 2 months. In his past medical history, he was diagnosed as having malignant melanoma of the skin 4 months ago. Physical examination was within normal limits except for periumbilical tenderness. Laboratory findings showed normal blood count and biochemical parameters. Upper gastrointestinal endoscopy showed a 10-mm nonpigmented polypoid lesion in the fundus of the stomach (Figure 1) and endoscopic biopsy showed metastasis of the dermal malignant melanoma (Figure 2). Positron emission tomography–computed tomography revealed liver, adrenal, and brain metastasis. Dexamethasone plus biologic therapy with ipilimumab was initiated and cranial radiotherapy was given. He is still continuing his chemotherapy protocol. The stomach is an unusual location for metastasis of malignant melanoma and
1
Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; 2Tzu Chi University, School of Medicine, Hualien, Taiwan; 3 Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, California, USA; 4David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Correspondence: Yu-Hsi Hsieh, MD, Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi 62247, Taiwan. E-mail: [email protected]
The American Journal of GASTROENTEROLOGY
Figure 1. Endoscopic appearance of amelanotic malignant melanoma.
VOLUME 110 | MARCH 2015 www.amjgastro.com
Letters to the Editor
nature publishing group
of AMM metastasis and physicians should be aware of melanoma involvement when there are unrelated symptoms at other sites. In addition, endoscopists should pay attention to lesions in endoscopy when there is a history of melanoma. CONFLICT OF INTEREST The authors declare no conflict of interest.
Figure 2. (a) Subepithelial layers are infiltrated by atypical cells (HE, ×10). (b) Subepithelial cells are positive with S-100 immunohistochemical stain confirming their melanocyte origin (×10).
more than half of tumor metastases occur in the initial year of diagnosis (1,3). Symptoms such as epigastric pain, nausea, and vomiting are usually nonspecific and upper gastrointestinal bleeding is an extremely rare presentation (1,2). Endoscopy is the best diagnostic method for diagnosis of the metastasis. On the other hand, in contrast to pigmented lesions, amelanotic melanoma is more difficult to diagnose, which results in a delay in initiating treatment and the prognosis tends to be poorer (3). In the endoscopic view, the lesion is
© 2015 by the American College of Gastroenterology
grayish white or white and is difficult to differentiate from gastrointestinal stromal tumors or undifferentiated cancers of the stomach, so that it must be confirmed histopathologically (3). Metastatic malignant melanomas are treated with the same protocols as the other sites of involvement (2,3). In our case, the malignant melanoma of the skin was diagnosed only 4 months ago and he had mild epigastric pain for only the last 2 months. In conclusion, the gastrointestinal system, especially the stomach, can be a site
REFERENCES 1. Köklü S, Gültuna S, Yüksel I et al. Diffuse gastroduodenal metastasis of conjunctival malignant melanoma. Am J Gastroenterol 2008;103:1321–3. 2. Reintgen DS, Thompson W, Garbut J et al. Radiologic, endoscopic, and surgical consideration of melanoma metastatic to the gastrointestinal tract. Surgery 1984;95:635–9. 3. Suganuma T, Fujisaki J, Hirasawa T et al. Primary amelanotic malignant melanoma of the small intestine diagnosed by esophagogastroduodenoscopy before surgical resection. Clin J Gastroenterol 2013;6:211–6.
1 Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey; 2Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey. Correspondence: Omer Ozturk, MD, Department of Gastroenterology, Hacettepe University School of Medicine, Sihhiye 06100, Ankara, Turkey. E-mail: [email protected]
The American Journal of GASTROENTEROLOGY
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