Incidental Finding of Late Metastasizing Melanoma to the Duodenum by PET-CT: About a Case Report

Authors: Matei OA*, Matei L, Lamade W

DOI: 10.23880/ghij-16000204

Volume 8, Issue 1

Abstract

Three years later after primary resection from skin melanoma with right inguinal lymphadenectomy, a Caucasian 62-year old female patient underwent at Helios Hospital Pforzheim investigations because of persistent high grade fever episodes. A very high suspicious mass of tumor was incidental identified and described in the descending duodenum and head of pancreas after PET-CT scan. Upper endoscopic examination with ultrasonography showed a 30 mm tumor mass arising from the descending part of the duodenum, which had invaded the head of pancreas and caused loop obstruction. Endoscopic biopsy revealed neoplastic cells with melanin granules and positive for Melan-A/SOX10 staining, indicating the presence of a metastatic malignant melanoma. It showed no BRAF-Mutation. These additional staining’s were evaluated after surgery. The colonoscopy showed not tumor finding. After tumor board procedure we strongly recommended surgical resection, and the patient accepted surgery. She underwent in Department of General Surgery at Helios Hospital Pforzheim the pylorus preserving pancreatico-duodenectomy. In the surgically resected Whipple specimen, the mass was 5x4 cm large, solid and ulcerated. Histologically the tumor infiltrated all duodenal layers and the tissue around them. Immunocytochemistry and electronic microscopy findings confirmed the diagnosis of malignant melanoma; similar to the skin specimen from the right thigh; therefore, the duodenal lesion was considered to be a metastasizing skin melanoma from the right thigh. The post operatory evolution was good, and was released from the hospital after 13 days. She underwent immunotherapy with Ipilimumab and Nivoluma. No recur was registrated during 5 months close follow-up. The history of the patient began three years earlier. She underwent a resection of skin melanoma. The initial skin melanoma was localized on anterior side of the right thigh (lower limb). At that time pathological specimen confirmed as malignant melanoma Clark level IV, pT2aN1bM0 as TNM-Staging, positive for BRAF-Wild-type by Mutation Analysis. Our patient also underwent another removal of skin melanoma from the back area just a couple of months after the first surgery. Pathological results from the second specimen confirmed as skin melanoma Clark level II, pT1a as TNM-Staging. She received chemotherapy and heavy particle radiotherapy after surgery. No suspect mass was identified on regular follow-up during 12 months after primary operation. Recurrence was registrated in the scar on the right thigh (lower limb) and right inguinal site, two years later. No suspect mass was identified on follow-up CT-Scan’s from head, lung and abdomen. She received immunotherapy and no additional chemotherapy or radiotherapy.

Keywords: Duodenal Metastasis; Pancreas Invasion; PET-CT Scan; Skin Melanoma

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