Melanoma metastasis in the papilla of vater mimicing pancreatic cancer

Malignant melanoma is a highly unpredictable tumor that can metastasize to any organ. The following is a case report of known malignant melanoma presenting as new onset obstructive jaundice as a result of an uncommon metastasis to the Ampulla of Vater. According to the litterature data, melanoma metastasis in the papilla is very rare. A thorough review of the literature reveals only five such prior reported cases. A 44 year old male presented with 1 week of jaundice, right upper abdominal pain, and general weakness. He had history of melanoma malignum, diagnosed by excision from the left side of the back in 1995. The patient received interferron immunotherapy. At the region of the previous excission a painfull cutaneous node appeared in 2009. The CT examination verified multiplex melanoma propagations in the right axillary, the retroperitoneal regions, many sites of the skin and in the muscles as well. In the pancreatic head a solid mass appeared with bileduct dilatation, that suggested possibility of a second neoplasm as pancreatic tumor. To evaulate the pancreas malformation, and manage the bileduct dilatation, he underwent ERCP, which revealed a huge, approximatly 4–5cm mass in the papilla of Vater. The papillotome passed into a necrotic cavity, which did not have any linkage to the bileduct, or pancreatic duct. Several biopsies have been taken, and two 5F nasocystic drains were implanted for continuous lavage. Histology demonstrated melanoma malignum. At a second attempt of ERCP, we performed an extended precut, and entered to the common bileduct at the suprapapillary region. The biliary tree showed the tipical radiological signs of cholangitis. After bacterial sampling, and dilation, we implanted an 50mm long, fully covered biliary stent (Niti-S Biliary. The bilirubin levels decreased quickly. The oncoteam indicated DITC chemotherapy with planned palliative radiation, but after few days the patient died.

Malignant melanoma metastatic to the gastrointestinal tract is a late manifestation of the disease with an overall poor prognosis. When identified ante-mortem, the heralding sign is usually small intestinal intussusception or obstruction, although GI bleeding is also common. Jaundice is a very rare complication. Optimal therapy remains unclear given the rare incidence of melanoma of the ampulla of Vater. Biliary prostheses seem to offer at least temporary symptomatic palliation with a rapid improvement of cholestasis.