An 83-year-old man with a history of hypertension and coronary artery
disease presented with a 4-day history of mental status changes, slurred speech, and difficulty ambulating. He reported a lack of appetite and weakness of several days.
Drs Abdul M. Swied and
Madhuri Trivedi of the University of
Missouri-Columbia, report that mild
abdominal distention and bilateral
lower extremity pitting edema were
noted. A 3 * 5-cm lesion was also
found on the patient's back (A). Sodium
level was 128 mEq/L; blood urea
nitrogen, 100 mg/dL; creatinine,
2.8 mg/dL; mean corpuscular volume,
79 μm3; and hemoglobin, 8.5 g/dL
(6 months earlier, hemoglobin mea-
sured 14.4 g/dL). A CT scan of the
head, taken when the patient was admitted
to the hospital, was normal.
Because of the anemia, a colonoscopy
and an esophagogastroduodenoscopy
(EGD) were performed.
The EGD revealed a "bull's-eye" ulcer
in the second part of the duodenum
(B); a biopsy of the lesion confirmed
the diagnosis of metastatic melanoma
(C). An abdominal CT scan also
showed metastasis to the liver and
spleen (D, arrows).
Metastases to the GI tract may be difficult to diagnose. These tumors
may appear as a nodule, mass, or ulcer and can lead to obstruction and bleeding. The bull's-eye appearance is typical of melanoma metastases to the stomach or small intestine.
Metastatic melanoma is incurable; treatment with chemotherapeutic
or biologic agents is usually palliative. Typically, patients survive for
less than 1 year.
This patient refused treatment. He relocated to another state and was
lost to follow-up.