A 54-year old woman presented to hospital with two days of epigastric pain, nausea and vomiting. Her history was significant for malignant melanoma of the right leg, diagnosed five years earlier, with subsequent endometrial, breast, lung and cerebral metastases. Liver enzyme levels were elevated (aspartate aminotransferase 230 IU/L, alanine aminotransferase 336 IU/L), with a total bilirubin level of 178 μmol/L. Computed tomography scanning demonstrated biliary dilation and a distal common bile duct (CBD) mass.
DIAGNOSIS
Endoscopic retrograde cholangiopancreatography demonstrated an oblong, distal filling defect (Figure 1). Following sphincterotomy and balloon sweep, a soft tissue mass was extracted (Figure 2). This was retrieved with a basket and sent for histological analysis that demonstrated malignant cells consistent with melanoma (Figure 3). The patient’s obstructive jaundice resolved but she unfortunately succumbed to her illness three weeks later.
Figure 1).
Cholangiogram demonstrating distal filling defect causing biliary obstruction
Figure 2).
Gross specimen of mass extracted from the common bile duct
Figure 3).
Histology of mass demonstrating malignant cells consistent with metastatic melanoma. Hematoxylin and eosin stain, original magnification ×20
DISCUSSION
Cases of primary melanoma of the ampulla and CBD have been reported (1), as have cases of metastases to the biliary tree (2,3). The present case is just the second report of metastatic melanoma extracted from the CBD and serves as another example of the unusual behaviour of this particular malignancy (4).
The Canadian Journal of Gastroenterology is now considering a limited number of submissions for IMAGE OF THE MONTH. These are be based on endoscopic, histological, radiological and/or patient images, which must be anonymous with no identifying features visible. The patient must consent to publication and the consent must be submitted with the manuscript. All manuscripts should be practical and relevant to clinical practice, and not simply a case report of an esoteric condition. The text should be brief, structured as CASE PRESENTATION and DISCUSSION, and not more than 700 words in length. A maximum of three images can be submitted and the number of references should not exceed five. The submission may be edited by our editorial team.
REFERENCES
- 1.Agrawal D, Tannous GC, Chak A. Primary malignant melanoma of the hepatic duct: A case report. Gastrointest Endosc. 2010;72:845–6. doi: 10.1016/j.gie.2010.03.1121. [DOI] [PubMed] [Google Scholar]
- 2.van Bokhoven MM, Aarntzen EH, Tan AC. Metastatic melanoma of the common bile duct and ampulla of Vater. Gastrointest Endosc. 2006;63:873–4. doi: 10.1016/j.gie.2005.12.023. [DOI] [PubMed] [Google Scholar]
- 3.Uchikov A, Genova S, Dimitrov I, Entchev A, Dimov R, Stefanov C. A case of melanoma metastatic to the gallbladder and the common bile duct with clinical presentation of obstructive jaundice and bilirubinemia. J BUON. 2004;9:317–9. [PubMed] [Google Scholar]
- 4.Thompson JF, Mathur MN, Coates AS. Common bile duct obstruction due to intraluminal metastatic melanoma. Aust N Z J Surg. 1993;63:502–4. doi: 10.1111/j.1445-2197.1993.tb00438.x. [DOI] [PubMed] [Google Scholar]