World J. Surg.
3, 375-379, 1979
Case Reports
Malignant Melanoma Metastatic to the Gastrointestinal Tract
Shamai Giler, M.D., I t a m a r Kott, M.D., and Israel U r c a , M.D.
Department of Surgery, Beilinson Medical Center, Tel Aviv University Medical School, Petah Tiqva, Israel
Five patients with symptomatic metastases of malignant
melanoma to the gastrointestinal tract are presented. The
clinical and pathological findings are reviewed. It seems
that metastases of malignant melanoma to the gastrointesti-
nal tract are more frequent than has previously been as-
sumed. The clinical symptoms are usually variable and in-
clude vague abdominal pain or discomfort, gastrointestinal
bleeding, and intestinal obstruction. Although the progno-
sis is poor, surgical excision is indicated in selected patients.
H e m a t o g e n o u s metastases to the gastrointestinal
tract from malignant tumors are generally rare.
Walther [1] studied 3,584 cases of malignant neo-
plasms and found an incidence of metastases to the
small bowel of 1.14%, a quarter of which were due
to malignant melanoma. Banzet et al. [2] collected
70 cases f r o m the literature of m e l a n o m a in which
small bowel or gastric m e t a s t a s e s were found. Will-
is [3], in a study of 500 autopsies, found gastrointes-
tinal metastatic disease in only 10 cases, of which
only 1 was due to malignant m e l a n o m a . H e also re-
viewed 135 cases of m e t a s t a s e s to the small bowel
and, of these, 45 were malignant melanoma. Das
G u p t a and Brasfield [4], in an analysis of 100 au-
topsies of patients with m e l a n o m a , found that the
disease metastasized to the s t o m a c h and the small
bowel in 26 (58%) of the patients. In m o s t cases, the
primary t u m o r originated in the skin, in some cases
the p r i m a r y site was the eye [4, 6, 8], and in 1 case,
the m e l a n o m a originated in the a n u s [7].
Reprint requests: Shamai Giler, M.D., Department of
Surgery 'B', Beilinson Medical Center, Petah Tiqva,
Israel.
375
Sdrgery
A review of the literature shows that metastatic
m e l a n o m a to the gastrointestinal tract has seldom
been diagnosed during life, and s y m p t o m a t i c metas-
tases are u n c o m m o n . In this report, we present 5
patients with various abdominal s y m p t o m s w h o
p r o v e d to have m e t a s t a s e s of malignant m e l a n o m a
to the gastrointestinal tract.
Case R e p o r t s
Case 1
A 72-year-old w o m a n was admitted to the hospital
complaining of malaise, s o m e vague epigastric dis-
comfort, and several episodes of melena of 3
m o n t h s ' duration. T w o w e e k s prior to admission,
e d e m a of the left thigh developed. T h e r e was a his-
tory of wide excision of a malignant m e l a n o m a of
her left arm 7 years earlier, and of a second excision
in the s a m e area 2 years later b e c a u s e of local recur-
rence. On physical examination, she was found to
be anemic. Signs of deep thrombophlebitis w e r e
noted in her left thigh, and abdominal examination
revealed epigastric tenderness. L a b o r a t o r y investi-
gation was normal except for severe anemia. The
stool was positive for occult blood. A chest x-ray
showed a mass lesion in the l o w e r lobe of the left
lung compatible with a solitary metastasis. Barium
meal x-ray examination revealed a large filling de-
fect in the u p p e r part of the g r e a t e r curvature of the
0364-2313/79/0003-0375 $01.00
9 1979 Socirt6 Internationale de Chirurgie
376
Fig. 1 Case 1. Barium meal x-ray examination showing a
filling defect in the greater curvature of the stomach (ar-
FOWS).
stomach (Fig. 1). Gastroscopy showed a polypoid
mass in the cardia. Biopsy was performed and
showed an undifferentiated malignant tumor. At
laparotomy, a large gastric mass was found, another
tumor was discovered in the jejunum, and a little
black spot was observed in the omentum. Subtotal
gastrectomy, o m e n t e c t o m y , and a local resection of
the jejunum were performed. Histologic examina-
tion confirmed the diagnosis of metastatic mela-
noma. The postoperative course was uneventful.
Case 2
A 67-year-old man was admitted to the hospital with
diffuse abdominal pain and vomiting of 2 weeks' du-
ration. Two months previously, thrombophlebitis of
both thighs was diagnosed and subsided after non-
operative treatment. Physical examination revealed
a pale, ill individual. A large, tender mass was pal-
pated in the upper abdomen. On the right thigh, a
dark mole was observed, and the ipsilateral inguinal
lymph nodes were enlarged. L a b o r a t o r y investiga-
tions revealed a hemoglobin of 7 g/dl and a B U N of
90 mg/dl. Two days later, vomiting developed. Plain
x-rays of the abdomen showed no signs of intestinal
World J. Surg. Voi. 3, No. 3, 1979
Fig. 2 Case 3. Barium x-ray examination of the small bow-
el showing widening of the bowel lumen with a filling de-
fect (arrows).
obstruction, although several loops of jejunum were
dilated. A few hours later, symptoms of an acute
abdomen appeared, and operation was undertaken.
At laparotomy, numerous black tumor masses were
found in the jejunum, ileum, colon, and pancreas,
as well as a small perforation of the jejunum related
to a tumor mass. Because of the widespread dis-
ease, the perforation was sutured and a biopsy per-
formed. At the end of the operation, excision of the
mole on the right thigh was also accomplished.
Twenty-four hours later the patient died. Histologic
examination revealed a primary melanoma of the
skin and metastatic melanoma of the gastrointesti-
nal tract.
Case 3
A 62-year-old male was admitted to the hospital
complaining of malaise, anorexia, and tachycardia
of 10 days' duration. There was a history of a wide
excision of a malignant melanoma of the back 3
years previously. Physical examination was nor-
mal, except for enlarged, nontender left axillary
lymph nodes. A number of hard nonpigmented sub-
cutaneous nodules were noted over the thorax and
abdomen. L a b o r a t o r y investigations showed a he-
moglobin of 8.9 g/dl. The stool contained occult
blood. Chest x-ray was normal. A barium meal x-
ray showed a huge diverticulum of the third portion
S. Giler et al.: Melanoma Metastatic to GI Tract
Fig. 3 Case 4. Surgical specimen of the ileum showing the
melanoma metastasis penetrating through the bowel lu-
men.
of the duodenum and a filling defect in the jejunum,
with moderate widening of the bowel lumen (Fig.
2). At laparotomy, a large black mass was found in
the jejunum causing partial obstruction. Segmental
resection of the jejunum was performed with end-
to-end anastomoses, and the postoperative course
was uneventful. Histologic examination revealed
metastatic melanoma. The patient died 2 years later
of widespread metastatic disease.
Case 4
A 70-year-old man was admitted to the hospital be-
cause of diffuse abdominal pain of 1 week's dura-
377
tion. There was a history of excision of a malignant
melanoma from the lower lobe of the left lung 1 year
previously. Physical examination revealed upper
abdominal tenderness. L a b o r a t o r y investigation
showed a hemoglobin of 10.7 g/dl. A few hours lat-
er, tachycardia and signs of peritoneal irritation ap-
peared, together with a fall in blood pressure. Oper-
ation was undertaken immediately. At laparotomy,
the abdominal cavity contained 2 liters of fresh
blood. A black tumor mass was found in the mid-
ileum with perforation into bowel lumen (Fig. 3).
On the serosal surface of the intestine, several
bleeding blood vessels were observed. Resection of
the involved segment was performed with an end-
to-end anastomosis. Immediately following sur-
gery, the patient died probably due to a myocardial
infarction. Histologic examination of the resected
tumor showed metastatic malignant melanoma.
Case 5
A 62-year-old man was admitted to the hospital
complaining of lower abdominal pain of 7 days' du-
ration. F o u r years previously, a wide excision of a
malignant melanoma of his left thigh had been per-
formed. On physical examination, the abdomen was
distended, and a tender mass was palpated in the
lower abdomen. L a b o r a t o r y investigations were
normal. The patient continued to complain of se-
vere abdominal pain and signs of intestinal obstruc-
tion appeared. L a p a r o t o m y was undertaken and re-
vealed a huge tumor mass in the ileum (Fig. 4).
Segmental resection was performed. Histologic ex-
amination confirmed the diagnosis of metastatic ma-
lignant melanoma. Two years later the patient died
of hepatic and pulmonary metastases.
Fig. 4 Case 5. Cut section through
the surgical specimen showing a
huge black tumor mass in the ileum.
378
Discussion
The small bowel is the most c o m m o n site of gastro-
intestinal metastases from malignant melanoma.
Gastric metastases are less c o m m o n and large bow-
el metastases are quite rare [4, 6, 9], perhaps be-
cause of the scanty vascularization of the large
bowel compared with that of the stomach and the
small bowel [9]. Metastatic melanoma seldom has
been found in the pancreas, spleen, or gallbladder
[4, 6, 10].
Diagnostic difficulties may arise, especially when
the gastrointestinal tract is the only site of metas-
tases. Symptoms and signs are highly variable.
Vague abdominal pain and discomfort, loss of
weight, loss of appetite, and anemia are most com-
mon. N a u s e a and vomiting may occur due to in-
testinal obstruction. It is of interest that obstruction
is usually due to intussusception [4, 7, 11] and very
rarely to metastases alone [12]. Gastrointestinal
bleeding of varying degree may be found, usually
when the metastases involve the mucosa and pro-
duce ulceration. Abdominal tenderness, rigidity, or
other acute abdominal symptoms are less common.
Intestinal metastases rarely b e c o m e large enough to
be palpable [5].
The diagnosis of metastatic melanoma is rarely
considered, usually due to lack of awareness of the
history of a primary melanoma or due to a long dis-
ease-free interval. Radiological studies of the gas-
trointestinal tract usually do not reveal any specific
findings [4], although several radiographic features
have been described. In the stomach and the small
bowel, solitary or multiple filling defects may be
found. Sometimes a central collection of barium
gives rise to the so-called "bull's e y e " lesion [13],
which may be associated with dilatation of the in-
testinal lumen [12]. The differential diagnosis de-
pends on the radiologic appearance and the location
of the lesions. Multiple polypoid lesions involving
the stomach and small bowel may resemble other
malignant tumors, such as lymphoma, leiomyosar-
coma, Kaposi's sarcoma, or carcinoid tumors, as
well as benign lesions, such as adenoma, leiomyo-
ma, lipoma, neurofibromatosis, and hemangioma-
tosis. Other rare conditions in which multiple
polypoid filling defects may o c c u r are Peutz-Jaeger
syndrome, juvenile gastrointestinal polyposis, and
nodular lymphoid hyperplasia. Gastroscopic exami-
nation will sometimes confirm the diagnosis. The
course and prognosis of metastatic malignant mela-
noma are usually unpredictable and metastatic dis-
ease may appear many years after the primary tu-
mor has been excised. H o w e v e r , the prognosis is
poor when visceral metastases are present [14].
World J. Surg. Vol. 3, No. 3, 1979
When a solitary metastasis is found, surgical resec-
tion is practicable, and long-term survival may re-
sult [ 11].
Resume
Pr6sentation de 5 cas de m6tastases digestives de
m61anomes malins, avec symptomes. Les caract6-
ristiques cliniques et histologiques sont revues. Ces
m6tastases digestives paraissent 6tre plus fr6-
quentes q u ' o n ne le pensait. Les symptomes sont
variables: g6ne ou douleur abdominale, h6morragie
digestive, obstruction intestinale. Le pronostic
n'est gu~re favorable. N6anmoins, l'ex6r~se chi-
rurgicale est indiqu6e dans certains cas s61ec-
tionn6s.
References
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Schwabe Co., 1948
2. Banzet, P., Delarue, J., Chapellart, P., Santagostini,
F., Civatte, J.: Un cas de m61anome. A localisations
gastrointestinales multiples apparemment primitive.
Presse M6d. 61:1732, 1958
3. Willis, R.A.: Spread of Tumours in the Human Body,
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4. Das Gupta, T.K., Brasfield, R.D.: Metastatic mela-
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5. Backman, H.: Metastases of malignant melanoma in
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