Volcano Ulcers in Stomach – an Unusual Presentation of Metastatic Non Pigmented Melanoma

Abstract

Purpose: Malignant melanoma is one of the most common malignancies to metastasize to the gastrointestinal (GI) tract. Metastases to GI tract can present at time of primary diagnosis or decades later as first sign of recurrence. Metastatic melanoma to GI tract is found during diagnostic workup in 1%-4% of patients with cutaneous primary and up to 60% of melanoma patients in autopsy. Methods: Our patient is a 45 year old white male with history of primary non-pigmented urinary bladder melanoma who presented with complaint of dyspepsia for 2 months. Patient had received full course of chemotherapy with Tamodar for 5 months with good response. He denied any nausea, vomiting, dysphagia or bleeding. He had no primary skin lesion found on extensive detailed physical exam. Whole body PET scan showed markedly thickened stomach walls with multiple omental lesions in the perigastric region. Upper endoscopy revealed two large, non-pigmented ulcerating masses in body of stomach on the greater curvature. These masses had “volcano appearance” with heaped up edges and central crater. Multiple biopsies were taken which were consistent with non pigmented metastatic melanoma confirmed by immunohistochemical stains. Patient was subsequently started on carboplatin and has had mild improvement in symptoms. Results: Conclusion: Gastrointestinal invasion by melanoma is a rare condition and is often associated with invasion of other visceral organs. The endoscopic classification of the gastric metastases comprises three main types: (a) melanotic nodules, often ulcerated at the tip; most common (b) submucosal mass, melanotic or not, elevated and ulcerated at apex; typical aspect of “bull's eye” lesion and (c) mass lesions with varying incidence of necrosis and melanosis. Gastric metastases may appear even as a simple ulcer. Majority of gastric metastases are reported to occur in body and fundus, most often on the greater curvature. Most frequent sites of melanoma metastases include small bowel, stomach, colon, and anorectum in decreasing order. Symptoms may include abdominal pain, dysphagia, small bowel obstruction and GI bleed. Diagnosis requires careful inspection of mucosa and biopsy with special immunohistochemical stains. Management may include surgical resection, chemotherapy, immunotherapy, observation, or enrollment in clinical trials. Surgery seems to be of limited value and should be performed in carefully selected patients and in patients with complications. Prognosis is poor, with median survival time in patients presenting with GI invasion being less than 1 year. Endoscopic “Volcano ulcers” in the stomach have been reported in many secondary neoplasms of the stomach and their presence should always raise suspicion for an underlying malignancy.