A CHALLENGING CASE OF LATE RECURRENT MELANOMA MIMICKING INTESTINAL POLYPOID SYNDROME

The small bowel only rarely develops malignant or even benign tumors, involving merely 3% among neoplasms of the digestive tract, often undiagnosed. Inherited syndromes can justify an increased incidence of small intestinal adenocarcinomas, carcinoid tumors, primary lymphomas, mesenchymal tumors and benign lesions. Melanoma is a malignant neoplasm developing from melanocytes, inhabiting the skin and the alimentary tract, as well. Hereby, we describe a complicate case of recurrent melanoma.

A 56-year old woman was admitted to our hospital with a 3-month history of worsening mesogastric abdominal pain. In 1999 she had undergone to surgery for melanoma of the back skin with axillary lymph nodes dissection; no recurrence was detected during the 10-year follow-up period. Abdominal ultrasound, CT- and MR-enterography had been performed in the previous weeks as first-line examinations, showing the presence of several solid lesions of the small bowel. Suspecting a Peutz-Jeghers, she underwent esophagogastroduodenoscopy (EGD) and PUSH-enteroscopy, which displayed an ulcerated duodenal lesion, occupying 3/4 of the lumen, next to multiple similar polyps. Videocapsule endoscopy confirmed the presence of the main duodenal neoplasm associated with almost 8 growing lesions along the small bowel (video). In the meanwhile, a total-body CT-scan surprisingly showed asymptomatic cerebral lesion with a typical behavior suggestive for metastasis. A consequent specific analysis of histological specimen confirmed the diagnosis of melanoma. Furthermore, intussusception was progressing and a sub-occlusive condition required an early chemotherapy instead of urgent surgical treatment.

This recurrence of metastatic melanoma after more than 20 years highlights we still partially know the natural history of this insidious neoplasm. The diagnosis of growing melanoma during endoscopy of the small bowel can be a diagnostic challenge and sometimes warrants a difficult decision between conservative chemotherapy and urgent surgery.