Asad-Ur-Rahman Fnu, Abbass Aamer, Majeed Umair, Navaneethan Udayakumar
Internal Medicine Residency, Florida Hospital-Orlando.
Center for Interventional Endoscopy, Florida Hospital-Orlando.
Cureus. 2016 May 13;8(5):e608. doi: 10.7759/cureus.608.
Symptomatic gastrointestinal (GI) involvement of melanoma is rare, however, it is a frequent autopsy finding in patients with primary cutaneous melanoma. We present a case of metastatic cutaneous melanoma with initial asymptomatic jejunal involvement as found on a positron emission tomography (PET) scan, with subsequent duodenal perforation. A 69-year-old man presented to the hospital with a three-week history of worsening headache, dizziness, and vomiting with a history of Clark level III malignant melanoma that was completely excised from the right flank three years ago at the hospital. A magnetic resonance image of his brain revealed a subacute right-sided cerebellar hemorrhage adjacent to a 1-cm nodule. He underwent a right suboccipital craniomy with resection; the biopsy of which revealed metastatic malignant melanoma. A staging positron emission tomography (PET) scan revealed areas of increased uptake of fludeoxyglucose (FDG) in the left lower lung and left upper quadrant of the abdomen abutting the small bowel. Subsequent enteroscopy revealed a 40-mm cratered jejunal ulcer with heaped edges; the biopsy of which also revealed malignant melanoma. Since he had widespread disease, abdominal surgery was deferred, and treatment with ipilimumab and radiotherapy to the brain was initiated. He presented three months later with acute abdominal pain and diarrhea. A computed tomography scan of his abdomen revealed free peritoneal air, and an exploratory laparotomy revealed a mass at the antimesenteric border of the duodenum with a biopsy consistent with melanoma. The perforated area was resected and an end-to-end anastomosis was performed. Unfortunately, our patient had a postoperative intracranial hemorrhage and was referred to palliative care. Our case portrays how malignant melanoma may metastasize insidiously and widely and present as a catastrophe. Melanoma involvement in the GI tract is a poor prognostic marker. Our case offers a unique illustration of both the occult and manifest gastrointestinal involvement of melanoma and underscores the importance of clinical suspicion in patients with a history of melanoma who present with unexplained GI symptoms.
黑色素瘤出现有症状的胃肠道受累情况较为罕见，不过，在原发性皮肤黑色素瘤患者的尸检中却很常见。我们报告一例转移性皮肤黑色素瘤病例，正电子发射断层扫描（PET）显示最初为空肠无症状受累，随后出现十二指肠穿孔。一名69岁男性因头痛、头晕和呕吐加重三周入院，他有三年前在本院从右侧腹部完全切除的Clark III级恶性黑色素瘤病史。其脑部磁共振成像显示右侧小脑有一个亚急性出血，邻近一个1厘米的结节。他接受了右枕下开颅切除术；活检显示为转移性恶性黑色素瘤。分期正电子发射断层扫描（PET）显示左下肺和腹部左上象限靠近小肠处有氟脱氧葡萄糖（FDG）摄取增加区域。随后的肠镜检查发现一个40毫米边缘隆起的空肠溃疡；活检也显示为恶性黑色素瘤。由于他已出现广泛转移，腹部手术被推迟，并开始使用伊匹单抗和脑部放疗。三个月后，他出现急性腹痛和腹泻。腹部计算机断层扫描显示有游离腹腔积气，剖腹探查发现十二指肠系膜对侧缘有一个肿块，活检结果与黑色素瘤相符。穿孔区域被切除并进行了端端吻合术。不幸的是，我们的患者术后发生颅内出血，随后被转诊至姑息治疗。我们的病例描述了恶性黑色素瘤如何可能隐匿且广泛地转移并导致灾难性后果。黑色素瘤累及胃肠道是一个不良预后指标。我们的病例独特地展示了黑色素瘤隐匿性和显性胃肠道受累情况，并强调了对有黑色素瘤病史且出现不明原因胃肠道症状患者进行临床怀疑的重要性。
