Metastatic malignant melanoma of duodenum: the tip of the iceberg.

A47-year-old male patient was referred to our gastroenterology department, to investigate multiple and large conglomerate mediastinal adenopathies. He reported a 6-month history of anorexia, weight loss, hoarseness, decrease in visual acuity, and several pigmented skin nodules scattered over the whole body with an average size of 2 cm. More recently, he presented with diffuse abdominal pain, nausea and vomiting. Upper endoscopy showed at the duodenal bulb and second part of duodenum, several sessile erythematous polyps, between 5 and 15 mm with central ulceration (Fig. 1). The biopsy specimen revealed metastatic malignant melanoma. Immunohistochemistry stains showed neoplastic cells positive for S-100 protein (Fig. 2). Cutaneous investigation confirmed a very aggressive malignant melanoma (Fig. 3), with disseminated metastasis, including intra-orbital, thyroid, bronchial, lymphatic, heart, pancreatic, peritoneal and bone metastasis. Clinical management relied on symptomatic therapy only. PICTURES IN DIGESTIVE PATHOLOGY