Unexpected Finding on Endoscopy Done for Evaluation of Dyspepsia—GI Melanoma

Background: Malignant melanoma (MM) is the most common carcinoma to metastasize to the gastrointestinal (GI) tract and it carries a poor prognosis.¹ The primary is usually the skin [extremities (15–57%) followed by the trunk (13–54%) and head and neck (5–33%)],² and metastases within the GI tract commonly occur in the liver, small intestine, colon, and stomach in decreasing order of incidence. Incidence of symptomatic GI involvement is rare (1–5%).³

Aim: To present a case that is unique in terms of presentation and the rarity of encountering such cases in our clinical practice.

Methods: A 42-year-old male, farmer, without known comorbid illness with a history of intermittent upper abdominal pain for 6 months, presented to us for further evaluation and management. He had no alarm features, but he underwent endoscopy as there was no symptom improvement with OTC PPI and prokinetic medication.

Results: Upper GI endoscopy showed the presence of a large exophytic ulceroproliferative lesion of size 1 × 1 cm with a necrotic base in the second part of the duodenum just beyond the papilla. Biopsies taken from the edges of the growth showed atypical cells arranged in sheets with cytoplasm showing brown-colored melanin pigment with a desmoplastic inflammatory background suggestive of MM ([Fig. 1]). Upon detailed history taking and examination, patient states that he had a history of trivial trauma to the right middle finger 1 year ago and then he developed an ulcerated lesion over the tip of the finger which was occasionally painful. Physical examination revealed the presence of tender black ulcerated growth of size 2 × 2 cm over the tip of the right middle finger and right axillary lymphadenopathy. A wedge biopsy of the lesion on the finger suggested the presence of MM. The patient is currently on follow-up with the oncologist at our institute and is planned for initiation on Nivolumab therapy.

Fig. 1 Image depicting the endoscopic picture in our case and the histopathology of the duodenal biopsy specimen.

Conclusion: Our case highlights the unusual presentation of the disease and the importance of history taking and physical examination. The management and prognosis of this disease have been revolutionized by the current options of diagnostic endoscopy tools and the invention of targeted systemic treatment, including immune checkpoint inhibitors and BRAF/MEK inhibitors.

Publication History

Article published online:
22 April 2024