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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 98-100

Primary jejunal melanoma presenting as gastrointestinal bleeding


Department of General Surgery, Government Medical College, Thrissur, Kerala, India

Date of Submission08-Dec-2021
Date of Decision05-Feb-2022
Date of Acceptance04-May-2022
Date of Web Publication14-Jul-2022

Correspondence Address:
Dr. Bevin Roys Daniel
Department of General Surgery, Government Medical College, Thrissur - 680 596, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_53_21

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  Abstract 


Intestinal melanomas are very rare causes of upper gastrointestinal bleeding and abdominal lump. The occurrence of both primary and secondary in the intestine is an uncommon presentation. Jejunal melanoma is extremely rare, and only <20 cases have been reported in the literature so far. We are presenting a 52-year-old male patient who presented with fatigue, melaena and an abdominal lump of 1-month duration. He was operated on for biopsy as none of the investigations helped in reaching a definitive diagnosis. Peroperative findings were indicative of jejunal melanoma with infiltration to the right colon. Right hemicolectomy with jejunal resection was done. Histopathological examination revealed malignant melanoma with primary from jejunum. This case is discussed because of the rarity of the disease, and better management can be planned if preoperatively diagnosed.

Keywords: Hemicolectomy, intestinal melanoma, colonic secondaries, upper gastrointestinal bleeding


How to cite this article:
Babu A, Haridas T V, Abdul Siyad A K, Daniel BR, Radhakrishnan K N. Primary jejunal melanoma presenting as gastrointestinal bleeding. Kerala Surg J 2022;28:98-100

How to cite this URL:
Babu A, Haridas T V, Abdul Siyad A K, Daniel BR, Radhakrishnan K N. Primary jejunal melanoma presenting as gastrointestinal bleeding. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:98-100. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/98/350905




  Introduction Top


Intestinal melanomas usually present as primary tumors or metastasis of oculocutaneous or anal melanomas. Metastatic melanomas are more common than primary intestinal melanoma. Differentiating between primary and metastatic intestinal melanoma is difficult; the main features of each are discussed, and the diagnostic images used to detect intestinal melanoma are assessed. Positron emission tomography imaging can improve the detection of melanoma metastases to the small bowel than barium examinations and computed tomography examinations. Although various treatment strategies have been tried in patients with intestinal melanoma, surgical removal of intestinal metastasis is the treatment of choice in patients with resectable tumors. 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 those with metastases of cutaneous melanoma.


  Case Report Top


A 52-year-old male patient with no significant past medical history presented with complaints of fatigue, abdominal lump with melaena, loss of appetite and loss of weight. The patient was admitted for evaluation and was found to be having a nodular abdominal mass of size 7 cm × 8 cm, which was firm, non-tender, mobile and intra-abdominal in the umbilical area, 5 cm above the umbilicus towards the right. Per rectal examination confirmed melaena and was evaluated with ultrasonography (USG), upper gastrointestinal (GI) scopy, colonoscopy, double-balloon enteroscopy and contrast-enhanced computed tomography (CECT) abdomen. Differential diagnosis of small bowel GI stromal tumors and lymphoma was made. Upper GI and lower GI scopy revealed only hiatus hernia and haemorrhoids, respectively, double-balloon enteroscopy was also normal, USG abdomen revealed bowel loops in the right hypochondrium with small bowel wall thickening and enlarged lymph nodes; hence, we proceeded with a CECT abdomen which showed a homogenously enhancing circumferential wall thickening involving mid and distal jejunum with loco-regional lymphadenopathy. He was optimised with multiple transfusions in view of anaemia and was prepared for laparotomy and lymph node biopsy. Peroperatively, there was a large nodular blackish mass of 20 cm × 15 cm arising from the distal jejunum and was adherent to the proximal mesentery and right colon; few black lymph nodes were also noted [Figure 1]. He underwent right hemicolectomy and jejunal resection anastomosis based on the above findings. A macroscopic evaluation revealed a large black nodular lesion at the distal jejunum with few enlarged black mesenteric lymph nodes [Figure 2], and the histopathological evaluation [Figure 3] and immunohistochemistry [Figure 4] revealed a case of malignant melanoma jejunum with lymph node metastasis from the same malignancy.
Figure 1: Large nodular blackish mass of 20 cm × 15 cm arising from distal jejunum, adherent to the proximal mesentery and right colon. A few black lymph nodes were also noted

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Figure 2: Large black nodular lesion at distal jejunum with few enlarged black mesenteric lymph nodes

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Figure 3: Histopathological evaluation showing malignant melanoma in the jejunum

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Figure 4: IHC confirming malignant melanoma jejunum. IHC: Immunohistochemistry

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  Discussion Top


Melanoma is a malignant tumour arising from melanocytes which are generally located in the skin, choroid, meninges and anal periphery. Melanoma of the gastrointestinal tract occurs as 1%–3% of all digestive cancers.[1],[2] These are substantially a metastasis of a cutaneous, optical or anal primary lesion.[3] Primary carcinoma of the small bowel is exceptional; only a few cases have been reported in the literature due to the difficulty in banning another primary cancer.[2],[4] Irrespective of its primary or secondary character, intestinal carcinoma remains more aggressive with a poor prognosis compared to other non-digestive locales. The median overall survival is 4–6 months.[3],[5]

Concerning the remedial approach, there is no real agreement in the restorative treatment of primary carcinoma of the gastrointestinal tract. Surgery remains an essential approach for this complaint since effective adjuvant systemic curatives are without benefit for overall survival.[6] Immunotherapy before surgery has no role.[7] The optimal surgical fashion consists of an oncologic resection of the excrescence.

Criteria for the diagnosis of primary melanoma include the absence of other primary site melanoma and no history of removal of melanoma or atypical melanocytic lesions from the skin, retina, anal canal or occasionally at other locations such as oesophagus, penis or vagina.[8] The ileum is the most common point for the development of primary carcinoma of the small intestine,[9] although some authors still deny the actuality of primary carcinoma in the gastrointestinal tract. They argue that primary cutaneous tumour can regress before metastatic instantiations or they are too small to be linked by clinical and laboratory examinations. The gastrointestinal tract is the most common point of cutaneous carcinoma metastasis.[4],[8] In general, they are asymptomatic; metastases are diagnosed at autopsy in cases with cutaneous carcinoma.[10] They may be clinically detected only after treatment of primary carcinoma.

According to amine precursors uptake and decarboxylation (APUD) theory, the ileum that represents the distal end of the umbilical-mesenteric canal should be the most common site of primary malignant melanoma of the small intestine. These potential cells migrate through the umbilical-mesenteric canal and later differentiate into specialised cells, i.e., APUD cells, which undergo neoplastic transformation.[11]


  Conclusion Top


In our case, the histological study verified the opinion of intestinal carcinoma with an accordant immunohistochemical profile; our case had no history of cutaneous carcinoma, and etiological examination identified no other carcinoma. The diagnosis of primary malignant melanoma of the small bowel has been established.

Patient consent

Obtained.

Declaration of patient complaint

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that the name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Castro-Villabón D, Mojica I, López R, Esquinas P, García A, Rodríguez-Urrego P. Melanoma involving the ileum: Report of a case and review of literature. Case Rep Clin Med 2014;3:42-6.  Back to cited text no. 1
    
2.
Blecker D, Abraham S, Furth EE, Kochman ML. Melanoma in the gastrointestinal tract. Am J Gastroenterol 1999;94:3427-33.  Back to cited text no. 2
    
3.
Wilson BG, Anderson JR. Malignant melanoma involving the small bowel. Postgrad Med J 1986;62:355-7.  Back to cited text no. 3
    
4.
Kadivar TF, Vanek VW, Krishnan EU. Primary malignant melanoma of the small bowel: A case study. Am Surg 1992;58:418-22.  Back to cited text no. 4
    
5.
Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol 2000;12:181-5.  Back to cited text no. 5
    
6.
Hao XS, Li Q, Chen H. Small bowel metastases of malignant melanoma: Palliative effect of surgical resection. Jpn J Clin Oncol 1999;29:442-4.  Back to cited text no. 6
    
7.
Elsayed AM, Albahra M, Nzeako UC, Sobin LH. Malignant melanomas in the small intestine: A study of 103 patients. Am J Gastroenterol 1996;91:1001-6.  Back to cited text no. 7
    
8.
Krüger S, Noack F, Blöchle C, Feller AC. Primary malignant melanoma of the small bowel: A case report and review of the literature. Tumori 2005;91:73-6.  Back to cited text no. 8
    
9.
Cheung MC, Perez EA, Molina MA, Jin X, Gutierrez JC, Franceschi D, et al. Defining the role of surgery for primary gastrointestinal tract melanoma. J Gastrointest Surg 2008;12:731-8.  Back to cited text no. 9
    
10.
Poggi SH, Madison JF, Hwu WJ, Bayar S, Salem RR. Colonic melanoma, primary or regressed primary. J Clin Gastroenterol 2000;30:441-4.  Back to cited text no. 10
    
11.
Krausz MM, Ariel I, Behar AJ. Primary malignant melanoma of the small intestine and the APUD cell concept. J Surg Oncol 1978;10:283-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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