METASTATIC MELANOMA PRESENTING AS AN ILEAL CONDUIT FILLING DEFECT

0022-5347/01/1664-1393/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 166, 1393–1394, October 2001 Printed in U.S.A.

METASTATIC MELANOMA PRESENTING AS AN ILEAL CONDUIT FILLING DEFECT DAN THEODORESCU,* ROBERT A. OLDER

AND

ERIC J. SORENSON

From the Departments of Urology, Molecular Physiology and Biological Physics, and Radiology, University of Virginia Health Sciences Center, Charlottesville and Seven Hills Urology Center Inc., Lynchburg, Virginia KEY WORDS: urinary diversion; melanoma; neoplasm recurrence, local

Urinary diversion filling defects can be due to multiple causes. We report an unusual case of an ileal conduit filling defect resulting from a metastatic lesion of malignant melanoma. We also performed a brief literature review of metastatic melanoma to bowel segments and offer insights into managing such lesions. CASE REPORT

The patient was referred in December 2000 for evaluation of stomal stenosis of an ileal conduit. During the last 3 years the patient underwent multiple abdominal procedures as a result of complications following excision of a tubulovillous adenoma of the colon in 1995. Due to multiple abscesses and other intestinal complications cystectomy and ileal conduit were performed in 1998 and associated with stomal stenosis. Initial examination for this problem involved a loopogram in 1999 which revealed no abnormalities (part A of figure). At referral in December 2000 a repeat loopogram revealed a subtle filling defect in the ileal conduit (part B of figure). At consultation the patient was found to have multiple small lung lesions and hilar adenopathy on chest films (part C of figure). Considering his smoking history, Accepted for publication May 4, 2001. * Requests for reprints: Department of Urology, Box 422, University of Virginia Health Sciences Center, Charlottesville, Virginia, 22908.

wedge excision of 1 small lesion was done with simultaneous endoscopic evaluation of the ileal conduit. Visualization of the conduit lumen revealed a papillary lesion compatible with malignant melanoma (part D of figure). The same histology was found in the lung lesions and a thorough evaluation of the skin was performed but no primary lesion was detected. After oncological consultation the patient was started on immunotherapy. DISCUSSION

Malignant melanoma has an unusual predilection to metastasize to the small intestine,1, 2 and the most common presenting clinical features include anemia and abdominal pain. The most frequently involved portion of the gastrointestinal tract is the small bowel followed by the colon and stomach. Endoscopic studies are diagnostically useful for many of these lesions.2 More than 50% of small bowel metastases are polypoid masses that many times act as leading points for intussusception.2 In a study from Memorial Sloan-Kettering Cancer Center median survival of 68 patients with gastrointestinal metastases from melanoma following operative intervention was 8.2 months with 18% survival at 5 years.1 Multivariate analysis identified complete resection rendering 19 patients free of all identifiable disease (median survival 15 months, 38%

Radiological and histological imaging of metastatic melanoma. A, loopogram before detection of filling defect. B, loopogram at time of filling defect (arrow) diagnosis. C, chest radiograph reveals nodular lesions (arrows) proved surgically to be metastatic melanoma. D, histological appearance of biopsy taken from lesion in ileal conduit. Darker areas indicate cellular melanin accumulation. Reduced from ⫻40. 1393

1394

METASTATIC MELANOMA AS ILEAL CONDUIT FILLING DEFECT

survival at 5 years) and low preoperative serum lactate dehydrogenase in 2 (median survival 14 months, 35% survival at 5 years) as independent favorable prognostic factors for survival. Another large series of 110 patients demonstrated that 90% gained relief of symptoms and overall survival from the time of confirmed small bowel disease averaged 17 months (range 6 months to 9 years).2 In a smaller study of 68 cases from Roswell Park Cancer Institute complete resection of gastrointestinal metastases was accomplished in 47%.3 Median survival after operation was 28 months for patients treated with complete resection of gastrointestinal metastasis and no other disease, 5 months for those treated with resection of involved gastrointestinal tract and other metastases present, and 2 months for those who underwent a bypass procedure only. The 5-year survival of patients treated with complete resection of gastrointestinal metastases and no other evidence of disease was 28%. The other 2 groups had only 1-year survivors. These studies suggest that surgical intervention is justified based on clinical symptoms with extended palliation achieved in patients treated with complete resection of met-

astatic disease. In addition, in the absence of randomized trials this approach may lead to some improvement in survival and occasionally even long-term survival.4 Similar principles should be followed for metastases to urinary diversions. In such cases a multidisciplinary approach should be taken involving a urologist and general surgeon in the hope of eradicating all gross disease. REFERENCES

1. Agrawal, S., Yao, T. J. and Coit, D. G.: Surgery for melanoma metastatic to the gastrointestinal tract. Ann Surg Oncol, 6: 336, 1999 2. Reintgen, D. S., Thompson, W., Garbutt, J. et al: Radiologic, endoscopic, and surgical considerations of melanoma metastatic to the gastrointestinal tract. Surgery, 95: 635, 1984 3. Ricaniadis, N., Konstadoulakis, M. M., Walsh, D. et al: Gastrointestinal metastases from malignant melanoma. Surg Oncol, 4: 105, 1995 4. Wade, T. P., Goodwin, M. N., Countryman, D. M. et al: Small bowel melanoma: extended survival with surgical management. Eur J Surg Oncol, 21: 90, 1995