Small-bowel endoscopy is crucial for diagnosis of melanoma metastases to the small bowel: a case of metachronous small-bowel metastases and review of the literature

Small bowel obstruction caused by hemorrhagic metastatic melanoma: case report and literature review

Melanoma is one of the most common cancers and causes of death from skin cancer. It is also one of the most common malignancies to metastasize to the gastrointestinal tract. However, the incidence of gastrointestinal metastases from unknown primary cutaneous melanoma is reported to be 4–9%. Despite advances in diagnostic techniques, only 1.5–4.4% of metastases to the gastrointestinal tract are detected before death. We report a patient with no prior history of melanoma who presented with both gastrointestinal hemorrhage and small bowel obstruction. Diagnostic laparoscopy, followed by small bowel resection, was performed after a red blood cell radionuclide scan showed active hemorrhage. Pathologic examination confirmed metastatic melanoma of the jejunum. Additional small bowel resections were required for recurrent gastrointestinal bleeding, confirming two additional metastases. A review of the literature on small intestinal melanoma causing hemorrhage and obstruction is discussed.

Metastatic melanoma: An unusual cause of gastrointestinal bleeding and intussusception-A case report

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Malignant melanoma frequently spreads to the gastrointestinal tract (60%).

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Only 1–4% of melanoma metastases to the gastrointestinal tract are detected before death because most patients are asymptomatic.

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Gastrointestinal spread of previously treated malignant melanoma should always be considered in patients with digestive symptoms or ferropenic anemia.

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Small bowel intussusception and gastrointestinal bleeding are unusual presentations of intestinal melanoma metastases.

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Surgical resection remains the mainstay of treatment, not only providing symptomatic control but also leading to improved survival.

Introduction

Malignant melanoma is responsible for 1–3% of all malignancies being the gastrointestinal tract one of the most common metastatic locations.

Presentation of case

We present the case of a 71-year old male with previous history of cutaneous melanoma. Seven years later, while being studied due to suspected small bowel bleeding, he developed small bowel obstruction after being submitted to double balloon enteroscopy. Further investigation revealed small bowel intussusception. He was taken up for emergency laparotomy that confirmed ileal intussusception secondary to an intraluminal mass. We performed segmental enterectomy with primary anastomosis. Histology confirmed intestinal melanoma metastasis.

Discussion

Malignant melanoma frequently spreads to the gastrointestinal tract. The presentation is mainly asymptomatic and the diagnosis is often made only after complications develop. Small bowel intussusception and gastrointestinal bleeding are unusual presentations of metastatic melanoma, with few cases reported. Surgical resection not only provides symptom control but also positively affects prognosis.

Conclusion

Although usually asymptomatic, melanoma metastasis should always be considered in a patient with intestinal symptoms or chronic anemia and personal history of melanoma. Surgical resection is the treatment of choice, leading to an increase in overall survival.

Magnetic resonance enterography: the test of choice in diagnosing intestinal "zebras"

Small bowel tumors and other rare intestinal disorders are often exceedingly difficult to identify. Even cutting-edge technologies, such as push enteroscopy and capsule endoscopy, can fail to determine the cause of a patient's symptoms. At our institution magnetic resonance enterography (MRE) has become an increasingly reliable tool in the difficult-to-diagnose or difficult-to-monitor patient. In this retrospective case series, we discuss four patients with four rare intestinal disorders that were successfully diagnosed using MRE after failing to be diagnosed using more routine technologies, such as CT scans and flexible sigmoidoscopies. With the discussion of these four cases we demonstrate that MRE is a useful diagnostic modality in patients whose surveillance is difficult or to diagnose rare colorectal disease phenomena, colloquially referred to as “zebras.”

Small bowel intussusception secondary to metastatic melanoma 15 years after complete excision of the primary tumor

INTRODUCTION

Primary intestinal melanoma is a rare entity, however the gastrointestinal tract, and particularly the small bowel, is a common site of recurrence from cutaneous melanoma. PRESENTATION OF CASE We report the case of a 48 year old woman with small bowel intussusception secondary to metastatic cutaneous melanoma, 15 years after excision of the primary tumor. The patient underwent an emergency small bowel resection with negative margins on final pathology.

DISCUSSION

Surgical resection is a palliative, yet necessary, procedure in the setting of small bowel obstruction due to intussusception secondary to intestinal metastatic melanoma. In case of bowel metastasis, presenting symptoms are nonspecific and do not provide significant clues to the differential diagnosis of the underlying disease. In some patients, complete surgical resection of early diagnosed bowel metastases is associated with prolonged survival. Systemic chemotherapy in these patients does not provide survival benefit.

CONCLUSION

The occurrence of bowel relapse after very long disease free interval, while highly unlikely in most tumors, should always be considered in the differential diagnosis of patients with previous history of cutaneous malignant melanoma presenting with gastrointestinal symptoms.

Malignant melanoma rather than malignant cutaneous melanoma?

We report a case of an 84-year-old woman with a history of resected cutaneous melanoma who presented with asthenia, weight loss, and severe anemia. An esophagogastroduodenoscopy showed five black-pigmented submucosal tumors with large ulcerations in the antrum of the stomach and in the duodenum, suspected metastases from melanoma. Histopathological examination indicated the presence of melanin-containing tumor cells and confirmed an ulcerated pigmented melanoma. To examine the entire gastrointestinal tract, capsule endoscopy was performed and it showed a simultaneous massive involvement of the jejunum and ileum, with more than 40 lesions. This case highlights the importance of a complete endoscopic gastrointestinal examination in patients with melanoma metastatic to the bowel and suggests that capsule endoscopy is an easy, noninvasive, and effective diagnostic procedure to investigate small-bowel involvement.

A case of malignant melanoma simultaneously found in the lung and small intestine

Metastatic melanoma in the small bowel is a common cause of secondary intestinal tumors. We present a case of a 77-year-old man with melena resulting from melanoma in the small bowel that was simultaneously found with malignant melanoma in the lung. Abdominal contrast-enhanced computed tomography (CT) and position emission tomography (PET) revealed a 30 × 20 mm hypervascular lesion in the small bowel and a 9 × 9 mm right lobe lung mass with metastasis in the mediastinal and peritoneal lymph nodes, and the spleen. The bowel and lung tumor lesions were confirmed by enteroscopy and bronchoscopy, respectively, and were histologically diagnosed as malignant melanoma. In cases of small bowel malignant melanoma, an extraintestinal origin should always be suspected because intestinal melanomas are almost always metastatic. PET/CT is an effective tool for confirming intestinal melanomas because of its high sensitivity and specificity.

Melanoma of unknown primary as a cause of intestinal obstruction - a case description

Melanoma of unknown primary applies to 1-8% of all diagnosed melanomas, whereas primary melanoma of the small intestine is a extremely rare case. One of the melanoma characteristics is its capability of forming metastases in the small intestine which very often are diagnosed during autopsy.We present a case report of diagnosed melanoma of unknown primary, whose first symptom was intestinal obstruction. Before admission to the hospital cause of intestinal obstruction, the patient didn't present any signs and symptoms. All typical localizations of primary melanoma were excluded during diagnostic procedure. Palliative right hemicolectomy and segmental small intestine resection were performed. There were no complications in the postoperative course. On the ninth day the patient was discharged from hospital.Quick identification and radical resection of melanoma metastases in the alimentary tract may improve the survival rate in this group of patients. Resection, even if it is palliative by assumption, is not only the best method of elimination of persistent symptoms but it also gives hope for longer survival.

Intestinal melanoma: A broad spectrum of clinical presentation

INTRODUCTION

Small intestine melanomas are rare and the most of them are metastases from primary cutaneous neoplasms.

PRESENTATION OF CASE

Below, we report two cases of small intestine metastatic melanoma with very different clinical presentation.

DISCUSSION

Still now, primary versus metastatic origin is often unclear. Small bowel melanoma is often asymptomatic. However, clinical picture can be various; it may occurs with non specific symptoms and signs of gastro-intetstinal involvement, like chronic abdominal pain, occult or gross bleeding and weight loss, or with an emergency picture due to intestinal intussusception, obstruction or, rarely, perforation.

CONCLUSION

Small bowel melanoma is rare and the diagnosis done late. Imaging techniques are recommended in order to obtain early diagnosis of gastrointestinal metastases.

Current advance in small bowel tumors

Small intestinal tumors are difficult challenge to gastroenterologists. The difficulty in making a diagnosis of small intestinal tumor lies in the relative inaccessibility and absence of typical presentation. New endoscopic and radiologic technologies provide clear and fine anatomical visualization of the small bowel and are approved to improve the diagnostic sensitivity and accuracy. Patients at risk of small intestinal tumors might gain a benefit from proper surveillance with this new technology. Minimally invasive therapy is now available with advance of balloon assisted enteroscopy. This review describes the general aspect of the small intestinal tumors, focusing on the new modalities for diagnosis.

Capsule endoscopy versus positron emission tomography for detection of small-bowel metastatic melanoma: a pilot study

BACKGROUND

Melanoma is the most common tumor to metastasize to the GI tract, where it mainly involves the small bowel.

OBJECTIVE

To compare capsule endoscopy (CE) and (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT scanning, the current standard and most sensitive investigation modality, in detecting small-bowel metastases in patients with metastatic melanoma.

DESIGN

A prospective study of patients with metastatic melanoma who were undergoing FDG PET-CT scanning. CE was performed and the results read by two independent observers without knowledge of the other investigation results.

SETTING

Tertiary care centers.

PATIENTS

This study involved 21 patients with a median age of 52 years (range 22-88 years).

INTERVENTION

CE.

MAIN OUTCOME MEASUREMENTS

Detection of small-bowel melanoma.

RESULTS

FDG PET-CT scanning showed increased abdominal uptake in 12 patients, but only 5 of these patients were found to have small-bowel melanoma on CE. Importantly, in 1 patient with a bleeding small-bowel tumor on CE, the FDG PET-CT scan result was negative. One patient with positive FDG PET-CT scan results and negative CE results subsequently developed symptomatic small-bowel melanoma 10 months after CE.

LIMITATIONS

Small-bowel melanoma could not be excluded entirely in 7 patients with positive FDG PET-CT scan results and negative CE results, and follow-up is ongoing. The number of patients in this study was small.

CONCLUSION

CE was better than FDG PET-CT scanning in localizing small-bowel melanoma. This study suggests that CE is an ideal complementary investigation modality for patients with known metastatic melanoma undergoing preoperative work-ups and in those with unexplained anemia or GI symptoms.

Melanoma of the small intestine

Intestinal melanomas can be primary tumours or metastases of cutaneous, ocular, or anal melanomas. Primary intestinal melanoma is extremely rare, whereas metastatic melanoma of the small bowel is common because of the tendency for cutaneous melanoma to metastasise to the gastrointestinal tract. Because distinguishing between primary and metastatic intestinal melanoma can be difficult, the main features of each are discussed, and the diagnostic images used to detect intestinal melanoma are assessed. Routine barium examinations and CT have limited sensitivity, but PET imaging can improve detection of melanoma metastases to the small bowel. Although various treatment strategies have been tried in patients with intestinal melanoma, surgical removal of intestinal metastases is the treatment of choice in patients with resectable tumours. No systemic therapy improves survival in patients with melanoma metastatic to the intestines; thus, the prognosis for these patients is poor. Patients with primary melanoma of the small intestine have a worse prognosis than do patients with metastases of cutaneous melanoma.