Multiple Metastatic Melanoma of the Small Intestines Causing Multiple Intussusceptions in an Adult Patient: a Case Report
Janix M. De Guzman, MD
Edgardo Penserga, MD, FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Objective:
This report is made to create awareness on the clinical presentation of a metastatic malignant melanoma in the small intestines.
Introduction:
Malignant melanoma is a neoplasm of melanocytes or of the cells that originates from melanocytes. Once considered an uncommon disease, accounts for only 4% of all skin cancers, the annual incidence is increasing (1). The incidence of melanoma increases by 3-7% yearly (2,3). Early stage melanoma is curable, but, once the melanoma has metastasized, prognosis is grim, with a median survival of 6-9 months(4,5).
Malignant melanoma has the propensity to metastasize widely. In malignant melanoma the small bowel is involved fairly often (75%) and usually this occurs in a metastatic form (6-10). Small bowel metastatic melanomas are generally clinically undetectable in the early stages. Diagnosis is therefore often delayed and is made only when complications occur. Here we report one case of metastatic malignant melanoma to the small intestines who presented with intestinal obstruction secondary to intussusception.
Adult intussusception is very rare. The incidence of adult intussusception was 0.08% of all abdominal surgeries and 3.0% of all intestinal obstructions (11). Intussusception in adults stresses the point that it may represent an underlying pathology (12). However, it is known that the small bowel excepting the proximal 3 cm of the duodenum is not a common site for disease. Despite comprising 75% of the length and 90% of the surface area of the gastro-intestinal (GI) tract, the small bowel harbors relatively few primary neoplasms and fewer than 2% of GI malignancies (13,14). Metastatic spread from a tumor originating outside the peritoneal cavity also rarely involves the small intestine (15).
Presentation of Case:
A 56-year-old woman was admitted to the hospital because of acute intestinal obstruction.
The patient had been well until 4 days earlier, when she developed abdominal pain, crampy in character associated with nausea and vomiting about 6 episodes per day. She also experienced non-passage of flatus and no bowel movements with gradual enlargement of the abdomen.
Five months before admission, patient underwent Cholecystectomy at Capitol Medical Center.
One year prior to admission, patient developed papular lesions on the heel of the left foot which became infected with abscess formation due to self-manipulation. She was brought to Capitol Medical Center where Incision and Drainage was done and was prescribed oral antibiotics as home medications. Lesion however persisted despite different antibiotics taken and became fungating in character.
Eleven years prior to admission, patient underwent Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy at Lipa City Hospital. Diagnosis then was not known.
The patient has no occupation. She had no history of hypertension, heart disease, diabetes mellitus, asthma, and other systemic disease. She is non-smoker nor alcoholic-beverage drinker.
At the emergency Room, her temperature was 36.8°C, the pulse was 82, and the respirations were 21. The blood pressure was 120/80 mm Hg.
Physical examination centered on abdomen showed globular abdomen, distended, normoactive to hyperactive bowel sounds with occasionally observed hyperperistaltic movements, no tenderness, without masses, no organomegaly. Digital Rectal Examination showed no skin tags, empty rectal vault, collapsed, no tenderness, no blood nor feces on tactating finger.
A 2.5 x 3cm fungating mass with minimal yellowish discharge noted on the heel of left foot. No inguinal lymphadenopathy noted.
Clinical Diagnosis
|
1. |
Certainty |
Treatment |
|
Primary Diagnosis: Intestinal Obstruction secondary to Post-operative Adhesions |
90% |
Conservative/Surgical |
|
Secondary Diagnosis: Intestinal Obstruction secondary to Obstructing Mass |
10% |
Surgical |
|
2. |
Certainty |
Treatment |
|
Primary Diagnosis: Non-healing wound, heel, foot, left Prob Malignant: |
70% |
Surgical |
|
Secondary Diagnosis: Non-healing wound, heel, foot, left Benign |
30% |
Surgical/Medical |
Algorithm:
1. Abdominal Distention
Based on pattern and prevalence recognition, the presenting signs and symptoms of the patient, abdominal pains, abdominal distention, vomiting, no bowel movement, no flatus with collapsed rectal vault on rectal examination we considered mechanical obstruction over non-mechanical obstruction as to the cause of intestinal distention.
2. Non-healing Wound
Using pattern recognition, with the chronic presentation of the lesion which was non-responsive to antibiotics a non-inflammatory condition was highly considered. Since this condition does not warrant immediate attention at that time we planned to do excision biopsy of the mass to establish our diagnosis and focused more our attention on the primary problem.
Paraclinical Diagnostic Procedures:
Plain film of the abdomen showed distal small gut obstruction.
Pre-treatment Diagnosis:
1. Small Intestinal Obstruction secondary to Post-operative Adhesions
Goals of Treatment:
Ø Resolve obstruction
Ø Maintain bowel continuity
Conduct of Treatment:
Conservative management was instituted on this patient. Patient was put on “no per orem” (NPO), nasogastric tube inserted, hydration corrected and monitored by inserting intravenous fluids and inserting an indwelling catheter. Intravenous antibiotics were given to prevent bacterial translocation and anti-secretory agent also given while patient was maintained on NPO. Patient was then observed with improvement of condition within 24 hours; decreased abdominal distention, decreased abdominal pains, good urine output, normal vital signs with no signs of peritonitis. However, on the second hospital stay, we noted recurrence of abdominal distention associated with severe colic abdominal pains and bilious NGT output. Emergent Exploratory laparotomy was then contemplated.
At laparotomy, we noted the small intestines to be dilated caused by multiple intussusceptions, a jejuno-jejunal and an ileo-ileal. Upon manual reductions multiple pigmented intraluminal masses were noted on the segments of jejunum and ileum causing obstructions. Multiple mesenteric lymph nodes were also noted Liver was grossly normal with smooth surface. Surgically absent gallbladder, uterus, and adnexae. We performed segmental resections on jejunum and ileum encompassing tumors and mesenteric lymph nodes.
After the laparotomy procedure, we did an excision biopsy of the fungating lesion located at the heel of the left foot.
Patient clinically improved and went home after 7 days stay at the ward.
Pathologic Discussion:
Histologic sections from jejunal and distal ileal masses show intestinal tissue with infiltration of malignant tumor cells in nests. The individual melanocytes show atypia, pelomorphism and prominent nuclei. Also seen are scattered prominent melanin pigmentation. Histologic section from the lines of resection show a viable intestinal tissue with no evidence of malignant cells. Histologic sections from all seven (7) pericolic and mesenteric lymph nodes show infiltration of tumor cells.
Histologic sections from the foot mass show a tumor composed of large malignant cells that contain large pleomorphic nuclei with irregular contours and prominent nucleoli that forms as nests in the dermis, underneath a squamous epithelium. These nests are also evident in the subcutaneous tissue. All lines of resection are positive for tumor cells.
Histo-Pathologic Diagnosis:
Malignant Melanoma, Clark’s level IV, Foot, Left
Metastatic Malignant Melanoma, Jejunum, distal ileum, pericolic and mesenteric lymph nodes.
Final Diagnosis:
Malignant Melanoma, Stage IV
Malignant Melanoma, Clark’s level IV, Foot, Left
Multiple Intussusceptions secondary to Metastatic Malignant Melanoma, Jejunum, Ileum
Discussion:
The cause of intussusception differs between pediatric and adult populations. In adults, an underlying cause is present 90% of the time, whereas in children a precipitating lesion is found in only 10% of patients (12). The most common presentation of adult intussusception for the patient reported by Eisen et al. (13) was signs and symptoms of intestinal obstruction including abdominal pain and emesis; pediatric patient had a similar presentation. In contrast, with this patient the classic triad of abdominal mass, intermittent abdominal pain and currant jelly stool commonly observed in childhood intussusception was not observed.
The incidence of GI metastatic melanoma presenting in living patients is not unusual. Despite the frequent autopsy findings of gastrointestinal tract involvement by melanoma, the antemortem diagnosis is made in only 1.5% to 4.4% of all patients with melanoma. While most gastrointestinal metastases from melanoma remain undetected, those that become symptomatic can cause life threatening problems, including intestinal haemorrhage, obstruction and perforation.
Conclusion:
Abdominal pain and emesis were the main symptoms of adult intussusception of the small bowels. Intestinal metastasis causing intussusception should be considered in patients with a history of multiple metastatic tumors. However, pre-operative diagnosis of small bowel metastases from malignant melanoma is difficult if diagnosis is not yet established. Careful and thorough physical examination is still our best tool coupled with sound patient management process.
Bibliography: