Ileal intussusception due to primary intestinal melanoma with generalized lymph node metastases- a rare cause of small bowel obstruction
Keywords:Gastrointestinal malignancy, Inguinal lymph node, Cutaneous melanoma, Mesenteric nodes, Palliative chemotherapy
Primary melanomas of small intestine are rare and most of them are metastases from cutaneous melanoma. The features distinguishing primary from metastatic intestinal melanoma are still under debate. Primary intestinal melanoma (PIM) is associated with a worse prognosis and a more aggressive behaviour due to its rapid growth. Hence, we report a case of primary ileal melanoma presenting as intussusception with generalized lymph node metastasis. A 69-year-old lady presented with recurrent abdominal pain, vomiting, distension and low grade fever. On examination, a 4*4 cm right inguinal lymph node was noted with no abnormalities on abdominal and per rectal examination. Computed tomography (CT) revealed ileoileal intussusception which was confirmed on laparotomy and diagnosed as primary ileal melanoma on histopathological examination (HPE). Whole-body Positron Emission Tomography (PET) CT revealed metastasis to lymph nodes all over the body. Intestinal melanomas are rare and mostly occur secondary to primary cutaneous melanoma. The clinical picture of intestinal melanoma is varied, ranging from chronic vague symptoms to surgical emergency such obstruction and bleeding. Treatment of both primary as well as metastatic intestinal melanoma is surgical excision. Intestinal melanoma, in general, carries a bad prognosis than cutaneous melanoma. Owing to the rarity and vague presentation, early diagnosis of intestinal melanoma requires a high index of suspicion, multimodal imaging and timely surgical intervention with adequate resection margins.
Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. Cancer: Interdiscipl Int J Am Canc Soc. 1998;83(8):1664-78.
Sachs DL, Lowe L, Chang AE, Carson E, Johnson TM. Do primary small intestinal melanomas exist? Report of a case. J Am Acad Dermatol. 1999;41(6):1042-4.
Lens M, Bataille V, Krivokapic Z. Melanoma of the small intestine. Lancet Oncol. 2009;10(5):516-21.
Blecker D, Abraham S, Furth EE, Kochman ML. Melanoma in the gastrointestinal tract. Am J Gastroenterol. 1999;94(12):3427-33.
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(4):731-8.
Gill SS, Heuman DM, Mihas AA. Small intestinal neoplasms. J Clin Gastroenterol. 2001;33(4):267-82.
Mishima Y. Melanocytic and nevocytic malignant melanomas. Cellular and subcellular differentiation. Cancer. 1967;20(5):632-49.
Amar A, Jougon J, Edouard A, Laban P, Marry JP, Hillion G. Primary malignant melanoma of the small intestine. Gastroente-rol Clin Biol. 1992;16(4):365.
Letsch A, Keilholz U, Schadendorf D, Assfalg G, Asemissen AM, Thiel E, et al. Functional CCR9 expression is associated with small intestinal metastasis. J Invest Dermatol. 2004;122(3):685-90.
Bender GN, Maglinte DD, McLarney JH, Rex D, Kelvin FM. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. Am J Gastroenterol. 2001;96(8):2392-400.
Wade TP, Goodwin MN, Countryman DM, Johnson FE. Small bowel melanoma: extended survival with surgical management. Eur J Surg Oncol. 1995;21(1):90-1.
Caputy GG, Donohue JH, Goellner JR, Weaver AL. Metastatic melanoma of the gastrointestinal tract: results of surgical management. Arch Surg. 1991;126(11):1353-8.
Liang KV, Sanderson SO, Nowakowski GS, Arora AS. Metastatic malignant melanoma of the gastrointestinal tract. In Mayo Clinic Proceedings 2006;81(4):511-16.
Tarantino L, Nocera V, Perrotta M, Balsamo G, Schiano A, Orabona P, et al. Primary Small‐Bowel Melanoma. J Ultrasound Med. 2007;26:121-7.
Tatlidil R, Mandelkern M. FDG-PET in the detection of gastrointestinal metastases in melanoma. Melanoma Res. 2001;11(3):297-301.
Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol. 2000;12(2):181-5.