Metastatic Malignant Melanoma

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Image Source: The New England Journal of Medicine©

An 85-year-old man was brought to the emergency room with a short history of loss of consciousness, followed by a collapse. By the time the patient reached the emergency department, he had regained consciousness.

The man gave a history of passing dark stools for the past two weeks

The patient had a positive history of breast cancer and nodular melanoma. He was being treated with goserelin and letrozole for breast cancer. For nodular melanoma, a wide local excision had been performed on his right arm along with the dissection of the axillary lymph nodes 5 months earlier.

On physical examination, he was pale, and his vitals were:
Heart rate  -110 beats per minute
Blood pressure – 115/70.

The complete blood count result revealed a hemoglobin level of 7.6 g per deciliter (normal range, 11.5 to 15.5); therefore, he was transfused one unit of red cells.
Upon endoscopy, numerous polypoid, umbilicated nodules were seen in the stomach with evidence of recent, but not active, bleeding.

Histopathological evaluation was consistent with metastatic melanoma.

Computed tomography showed thickened stomach wall lining, with evidence of metastases in the brain, lung, and liver.

Due to the dissemination of the disease, palliative treatment with radiation, and pembrolizumab was initiated. At the three month follow-up, his melena had further worsened with multiple associated complications.

He was shifted to hospice care and, unfortunately, died shortly.

Melanoma, also known as malignant melanoma, is the cancerous growth of the pigment cells, called melanocytes. Typically, melanoma is cutaneous, i.e., it occurs in the skin, but it may involve other parts, including oral cavity, gastrointestinal tract.

Cutaneous manifestation of melanoma
Image Source: Medscape©

The gastrointestinal tract is the most common non-cutaneous metastatic location of the melanoma, 60% of the patients with metastatic melanoma show involvement of the digestive system.

Metastasis to the GI tract is most commonly to the small bowel (51–71%); other affected GI organs can be stomach (27%) and colon (22%).

Mostly, patients with GI metastasis remain asymptomatic or develop symptoms late in the course of the disease when complications have already developed. However, any patient with a history of melanoma presenting with manifestations of anemia or GI symptoms should be evaluated for GI metastases.

CT scan, PET scan, and endoscopy remain the diagnostic modalities of choice. Endoscopy with biopsy is an indispensable investigation.

Surgical resection of metastatic disease has a substantial impact on overall survival. However, many patients have a widely disseminated disease making it inoperable; in that case, palliative treatment with chemotherapy, radiotherapy, and immunotherapy may have a role in improving the quality of life.

References:

Amanda H.W. Lim, M. B. (2020, January 30). Gastrointestinal Bleeding from Metastatic Melanoma. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1909170

Silva, S., Tenreiro, N., Melo, A., Lage, J., Moreira, H., Próspero, F., & Avelar, P. (2018). Metastatic melanoma: An unusual cause of gastrointestinal bleeding and intussusception-A case report. International journal of surgery case reports, 53, 144–146. https://doi.org/10.1016/j.ijscr.2018.10.057

Patti R., Cacciatori M., Guercio G., Territo V., Di Vita G. Intestinal melanoma: a broad spectrum of clinical presentation. Int. J. Surg. Case Rep. 2012;3:395–398

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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