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Letter to the Editor Ocular Melanoma Recurrence Presenting as Cholestatic Jaundice due to Periampullary Area Metastases
Sotiris Anastasiadis,orcid, Andreas Xanthis, Jannis Kountouras, Panagiotis Katsinelos
Clinical Endoscopy 2018;51(5):500-501.
DOI: https://doi.org/10.5946/ce.2018.061
Published online: August 22, 2018

Section of Gastroenterology, Second Department of Internal Medicine Ippokration Hospital, Thessaloniki, Greece

Correspondence: Sotiris Anastasiadis Section of Gastroenterology, Second Department of Internal Medicine Ippokration Hospital, Papaflessa 26a Pylaia, Thessaloniki 55534, Greece Tel: +30-693-684-3708, Fax: +30-231-093-1345, E-mail: anassot@yahoo.gr
• Received: April 5, 2018   • Revised: April 16, 2018   • Accepted: April 16, 2018

Copyright © 2018 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 76-year-old woman presented with complaints of pruritus and painless jaundice. She had undergone radical resection of a stage IIB retinal melanoma followed by chemotherapy and immunotherapy 5 years before and is free of disease in last 3 years.
On admission, she had a total bilirubin level of 9.6 mg/dL (direct, 6.3 mg/dL) and highly elevated cholestatic enzymes. An abdominal computed tomography revealed dilation of the intrahepatic and extrahepatic biliary systems, as well as the main pancreatic duct up to the level of the major papilla. No evidence of metastases to the liver or other organs were observed. An endoscopic retrograde cholangiopancreatography image demonstrated a swollen major papilla with a blackish hue at the periampullary area and a black volcano-like lesion near the major papilla (Fig. 1). Conventional cannulation of the common bile duct was impossible. Therefore, a suprapapillary sphincterotomy was performed. Many biopsy specimens were taken through sphincterotomy, from the volcano-like lesion. A palliative 10-Fr, 7-cm plastic stent was placed (Fig. 1). Histological examination of the biopsies with hematoxylin-eosin staining revealed spindle-shaped cells with cytoplasmic brightness and nuclear atypia consistent with the diagnosis of melanoma (Fig. 2). Immunohistochemistry was positive for melan-A protein antigen, confirming the diagnosis of metastatic malignant melanoma (Fig. 2). An outpatient positron emission tomography scan showed numerous areas from the chest to the abdomen with hypermetabolic activity indicating neoplasia. She underwent palliative chemotherapy but died 6 months later.
Malignant melanoma is among the most threatening malignancies and a highly metastatic cancer [1]. Gastrointestinal tract metastases involve mostly the small intestine and colon [2]. Cholestatic jaundice due to major papilla or periampullary area metastases is rare [3].
The endoscopic findings of melanomas metastases frequently comprise a black volcano-like lesion or infiltrates in the submucosa and extend for variable depths into the wall [4]. Amelanotic lesions with variable appearance are rare entities [2,4]. The diagnosis of malignancy is established by immunohistochemical analysis of biopsy specimens; the tumor marker S-100 protein positivity ranges from 30% to 100%, melan-A protein antigen has high specificity (100%), and HMB-45 protein displays high specificity (100%) and sensitivity of 80%–90% [1].

Conflicts of Interest: The authors have no financial conflicts of interest.

Fig. 1.
Duodenoscopy image showing a periampullary area with blackish hue, a plastic stent inserted in the common bile duct, and a black volcano-like lesion near the major papilla.
ce-2018-061f1.jpg
Fig. 2.
(A) Stranded proliferation of spindle-shaped cells with cytoplasmic brightness and nuclear atypia (hematoxylin-eosin, original magnification ×200). (B) Immunohistochemical staining showing positivity for melan-A.
ce-2018-061f2.jpg
  • 1. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol 2000;12:181–185.ArticlePubMed
  • 2. Blecker D, Abraham S, Furth EE, Kochman ML. Melanoma in the gastrointestinal tract. Am J Gastroenterol 1999;94:3427–3433.ArticlePubMed
  • 3. Marks JA, Rao AS, Loren D, Witkiewicz A, Mastrangelo MJ, Berger AC. Malignant melanoma presenting as obstructive jaundice secondary to metastasis to the ampulla of Vater. JOP 2010;11:173–175.PubMed
  • 4. Kadakia SC, Parker A, Canales L. Metastatic tumors to the upper gastrointestinal tract: endoscopic experience. Am J Gastroenterol 1992;87:1418–1423.PubMed

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        Ocular Melanoma Recurrence Presenting as Cholestatic Jaundice due to Periampullary Area Metastases
        Clin Endosc. 2018;51(5):500-501.   Published online August 22, 2018
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      Ocular Melanoma Recurrence Presenting as Cholestatic Jaundice due to Periampullary Area Metastases
      Image Image
      Fig. 1. Duodenoscopy image showing a periampullary area with blackish hue, a plastic stent inserted in the common bile duct, and a black volcano-like lesion near the major papilla.
      Fig. 2. (A) Stranded proliferation of spindle-shaped cells with cytoplasmic brightness and nuclear atypia (hematoxylin-eosin, original magnification ×200). (B) Immunohistochemical staining showing positivity for melan-A.

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