Wandering Mucosal Melanoma Presenting as Occult Gastrointestinal Blood Loss Anemia

Malignant melanoma is a highly aggressive cancer arising from the skin, retina, and mucosal lining of the respiratory, gastrointestinal (GI), or genitourinary tracts, all of which contain melanocytes. Mucosal or extracutaneous melanomas (ECMs) are rare accounting for 1% of all melanomas. We herein report a case of a metastatic mucosal melanoma presenting as occult blood loss anemia. A 58-year-old male presented with generalized weakness, anorexia, weight loss, and intermittent melena for one year. On exam, he was tachycardic, borderline hypotensive, and pale without epigastric tenderness. Labs showed severe anemia [hemoglobin, Hgb 3.8 mg/dL, mean corpuscular volume (MCV) 72 fl] for which he received two units of red cells. Endoscopy revealed an 8 mm non-bleeding, gastric ulcer with a raised border and a clean base on the wall of the gastric body. Histologic analysis was consistent with malignant melanoma displaying strong positivity for S-100, Melan A, and HMB 45 stains. The CT of the abdomen revealed multifocal metastatic disease with subcutaneous, intramuscular, and perinephric implants with suspicion of small bowel carcinomatosis. The patient underwent an excisional biopsy for the abdominal wall mass and surgical pathology confirmed melanoma. The patient is planned to be started on immunotherapy for advanced disease. Most melanomas found in the GI tract are metastatic. Mucosal melanoma presenting as a gastric ulcer is extremely rare. As a result, metastasis from other sites must be ruled out before making a diagnosis of primary gastric melanoma (PGM). In our case, a widespread disease with unknown primary elucidated the diagnosis but post-operative inspection failed to find any potential lesion on the skin, genitals, or other organs, suggesting the possible diagnosis of metastatic gastric melanoma. However, follow-up is still required to confirm the diagnosis according to the established criteria. Pathologic diagnosis of melanoma requires the identification of melanin in the cytoplasm and immunohistochemistry with specific markers such as S-100, Melan A, and HMB-45. Although the pathologic diagnosis of PGM is similar to cutaneous melanoma, preoperative diagnosis is difficult due to the extremely low incidence, lack of obvious melanin pigmentation, similar microscopic patterns as more common gastric cancers, and lack of awareness among physicians and pathologists. The prognosis of mucosal melanoma is poor, with a five-year survival rate of 25% versus 80% for cutaneous melanoma. Advanced age, surgically unresectable disease, and lymph node involvement are all poor prognostic markers. There is no standard protocol for treatment. Surgery is the only curative treatment for the resectable disease. Adjuvant chemotherapy, radiation, and immunotherapy have an established role in cutaneous melanoma but there is only limited data on adjuvant systemic therapy with mucosal melanoma. Further research is imperative to establish proper management guidelines for this rare disease entity.