Learning points: Metastatic melanoma can present with non-cutaneous symptoms even after several years of remission.Although poor prognosis, surgical resection and arterial embolisation can provide effective symptom palliation. Medical image: A 73-year-old man presented to hospital with melaena. He had a previous history of cutaneous melanoma with left axillary nodal metastases, treated with axillary lymph node dissection and radiotherapy 2 years previously. Clinical examination and laboratory investigations suggested upper gastrointestinal haemorrhage. On this admission, there was no evidence of recurrent cutaneous or nodal disease.Endoscopy was performed to investigate his melaena. It showed multiple large gastric polypoid lesions up to 60 mm in diameter, some of which were oozing blood (Figure 1). Biopsies were taken and histology was consistent with metastatic melanoma (Figure 2). Computed tomography of the abdomen showed multiple large pedunculated gastric polyps (Figure 3).The patient received blood transfusions, and also palliative radiation with a view to preventing further bleeding from the gastric lesions, but this was unsuccessful and the patient died 3 days later. Figure 1. Endoscopic view of the gastric polypoid lesions Figure 2. Biopsy histology from the gastric polypoid lesions Note: 40× magnification of melan-A red chromogen stain. Metastatic melanoma is histologically confirmed by positive S100, melan-A and CD117 staining. Figure 3. Large pedunculated gastric polyps on computed tomography DiscussionPrimary malignant melanoma in the gastrointestinal tract is extremely rare, but primary cutaneous malignant melanoma is one of the most common malignancies which metastases to the gastrointestinal tract. Symptoms may include gastrointestinal bleeding, abdominal pain, and small bowel obstruction or perforation. Prognosis is poor with a median survival of 4 to 6 months.1,2Surgical resection for bleeding provides effective symptom palliation and in some cases improves mortality.3 Medical adjuvant therapies including chemotherapy, and also radiotherapy, have not demonstrated survival benefit.2 Arterial embolisation has been used effectively as a palliative measure to control bleeding in gastrointestinal malignancies, but less invasive measures are generally preferable in the first instance.4,5Metastatic melanoma can present with non-cutaneous symptoms after several years of remission. Metastatic melanoma of the gastrointestinal tract should be considered in patients with a history of cutaneous melanoma who present with gastrointestinal symptoms.Author information: Judy Huang, Gastroenterology Registrar; Robert Cunliffe, Gastroenterologist; Gastroenterology Department, Tauranga Hospital, Bay of Plenty District Health Board, TaurangaCorrespondence: Dr Judy Huang. Email: Ju2c@hotmail.comReferences:1.Dasgupta TK, Brasfield RD. Metastatic melanoma of the gastrointestinal tract. Arch Surg. 1964;88:969–73.2.Liang KV, et al. Metastatic malignant melanoma of the gastrointestinal tract. Mayo Clin Proc. 2006;81(4):511–6.3.Ollila DW, et al. Surgical resection for melanoma metastatic to the gastrointestinal tract. Arch Surg. 1996;131(9):975–80.4.Thacker PG, et al. Embolization of nonliver visceral tumors. Semin Intervent Radiol. 2009;26(3):262–9.5.Broadley KE, et al. The role of embolization in palliative care. Palliat Med. 1995;9(4):331–5.

Learning points: Metastatic melanoma can present with non-cutaneous symptoms even after several years of remission.Although poor prognosis, surgical resection and arterial embolisation can provide effective symptom palliation. Medical image: A 73-year-old man presented to hospital with melaena. He had a previous history of cutaneous melanoma with left axillary nodal metastases, treated with axillary lymph node dissection and radiotherapy 2 years previously. Clinical examination and laboratory investigations suggested upper gastrointestinal haemorrhage. On this admission, there was no evidence of recurrent cutaneous or nodal disease.Endoscopy was performed to investigate his melaena. It showed multiple large gastric polypoid lesions up to 60 mm in diameter, some of which were oozing blood (Figure 1). Biopsies were taken and histology was consistent with metastatic melanoma (Figure 2). Computed tomography of the abdomen showed multiple large pedunculated gastric polyps (Figure 3).The patient received blood transfusions, and also palliative radiation with a view to preventing further bleeding from the gastric lesions, but this was unsuccessful and the patient died 3 days later. Figure 1. Endoscopic view of the gastric polypoid lesions Figure 2. Biopsy histology from the gastric polypoid lesions Note: 40× magnification of melan-A red chromogen stain. Metastatic melanoma is histologically confirmed by positive S100, melan-A and CD117 staining. Figure 3. Large pedunculated gastric polyps on computed tomography DiscussionPrimary malignant melanoma in the gastrointestinal tract is extremely rare, but primary cutaneous malignant melanoma is one of the most common malignancies which metastases to the gastrointestinal tract. Symptoms may include gastrointestinal bleeding, abdominal pain, and small bowel obstruction or perforation. Prognosis is poor with a median survival of 4 to 6 months.1,2Surgical resection for bleeding provides effective symptom palliation and in some cases improves mortality.3 Medical adjuvant therapies including chemotherapy, and also radiotherapy, have not demonstrated survival benefit.2 Arterial embolisation has been used effectively as a palliative measure to control bleeding in gastrointestinal malignancies, but less invasive measures are generally preferable in the first instance.4,5Metastatic melanoma can present with non-cutaneous symptoms after several years of remission. Metastatic melanoma of the gastrointestinal tract should be considered in patients with a history of cutaneous melanoma who present with gastrointestinal symptoms.Author information: Judy Huang, Gastroenterology Registrar; Robert Cunliffe, Gastroenterologist; Gastroenterology Department, Tauranga Hospital, Bay of Plenty District Health Board, TaurangaCorrespondence: Dr Judy Huang. Email: Ju2c@hotmail.comReferences:1.Dasgupta TK, Brasfield RD. Metastatic melanoma of the gastrointestinal tract. Arch Surg. 1964;88:969–73.2.Liang KV, et al. Metastatic malignant melanoma of the gastrointestinal tract. Mayo Clin Proc. 2006;81(4):511–6.3.Ollila DW, et al. Surgical resection for melanoma metastatic to the gastrointestinal tract. Arch Surg. 1996;131(9):975–80.4.Thacker PG, et al. Embolization of nonliver visceral tumors. Semin Intervent Radiol. 2009;26(3):262–9.5.Broadley KE, et al. The role of embolization in palliative care. Palliat Med. 1995;9(4):331–5.