A 64-year-old presenting with abdominal pain and vomiting. History of a lesion in the left heel for 2 years and left inguinal region swelling for 6 months.

A 64-year-old presenting with abdominal pain and vomiting. History of a lesion in the left heel for 2 years and left inguinal region swelling for 6 months.

A 64-year-old presents with abdominal pain and vomiting. History of a lesion in the left heel for 2 years and left inguinal region swelling for 6 months.

  • CECT Abdomen and Pelvis demonstrates dilated stomach and small bowel loops with air-fluid levels and positive small bowel faeces sign. An endophytic lesion along the lesser curvature of stomach. Transition point in right lower quadrant, where there is ileo-ileal intussusception with a small bowel metastatic lesion acting as lead point.
  • CECT Chest, Abdomen and Pelvis demonstrates widespread metastatic lesions in left inguinal nodal mass, chest wall lesion, multiple pulmonary nodules and intramuscular lesion in right adductor magnus.
  •  Topogram demonstrates multiple cannon ball metastatic lesions and central dilated bowel loops.
  •  Biopsy of left inguinal mass suggestive of metastatic lesion of malignant melanoma.
  • Malignant melanoma of left foot with extensive metastases and acute small bowel obstruction secondary to ileo-ileal intussusception with a small bowel metastatic deposit as a lead point.

DISCUSSION:

  • Malignant melanoma is an aggressive neoplasm that arises from
    melanocytes, which predominantly occur in the basal layer of the
    the epidermis of the skin.
  • The thorax is the most common site of metastases in malignant
    melanoma.
  •  The small bowel is the most common site of the gastrointestinal tract
    involvement by metastatic melanoma, hence are a risk factor for
    intussusception.
  •  Metastases to skeletal muscle are uncommon.

Differential diagnosis:

  1. Primary neural tumours such as schwannomas.
  2. Invasive fungal infections such as aspergillosis or mucormysosis (in severely immunocompromised individuals).
  3. Meningeal inflammatory disorders such as sarcoidosis or histiocytosis.

REFERENCES:

  1. Fishman EK, Kuhlman JE, Schuchter LM, Miller JA et al. CT of malignant melanoma in the chest, abdomen, and musculoskeletal system. Published Online Jul 1 1990. doi.org/10.1148/radiographics.10.4.2198632
  2. Patnana M, Bronstein Y, Szklaruk J, Gershenwald JE. Multimethod imaging, staging, and spectrum of manifestations of metastatic melanoma. Published January 11, 2011. doi.org/10.1016/j.crad.2010.10.014
  3. Keraliya AR, Krajewski KM, Braschi-Amirfarzan M, et al. Extracutaneous melanomas: a primer for the radiologist. Insights Imaging. 2015;6(6):707-717. doi:10.1007/s13244-015-0427-8

Case contributed by:

Dr. Diwakar C
Radiology Resident,
Manipal Hospitals Radiology Group

Dr. Anita Nagadi
MD, MRCPCH (UK), FRCR (UK), CCT (UK)
Senior Consultant Radiologist
Manipal Hospitals Radiology Group.