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Metastatic Malignant Melanoma Presenting as an Appendiceal Mucocele

Metastatic Malignant Melanoma Presenting as an Appendiceal Mucocele Hindawi Publishing Corporation Journal of Oncology Volume 2011, Article ID 546570, 4 pages doi:10.1155/2011/546570 Case Report Metastatic Malignant Melanoma Presenting as an Appendiceal Mucocele 1 1 2 3 A. A. Alduaij, M. B. Resnick, M. Kawata, and V. E. Pricolo Department of Pathology, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02908, USA Division of Colon and Rectal Surgery, Robert Wood Johnson Medical School, Cooper University Hospital, University of Medicine and Dentistry of New Jersey, Camden, NJ 07103, USA Division of Colorectal Surgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02908, USA Correspondence should be addressed to A. A. Alduaij, dralduaij@gmail.com Received 25 September 2010; Revised 18 December 2010; Accepted 27 January 2011 Academic Editor: V. Valentini Copyright © 2011 A. A. Alduaij et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Melanoma metastatic to the appendix is extremely rare. Here we describe a case of a 31-year-old female from Bolivia with a remote history of metastatic malignant melanoma first diagnosed as a cutaneous malignant melanoma ten years prior to this presentation. The patient was being followed for a mucocele which on resection was found to be metastatic melanoma. “Mucocele” is a generic diagnosis that warrants further characterization and treatment. 1. Introduction with edema and displacement of the midline structures. The patient then underwent surgical resection of brain Malignant melanoma involving the gastrointestinal (GI) tumor which was interpreted as metastatic melanoma. tract is a rare condition although it is one of the most After receiving palliative therapy, the patient enrolled in a common malignancies having the potential to metastasize to chemotherapy trial, Temozolomide along with Sorafenib, at the GI tract [1–4]. GI metastasis are frequently found during the University of Pennsylvania. Later in 2008, she developed autopsy (50%–60% of cases), but only a small proportion of a new 4 mm lesion in right frontal brain lobe. She had living melanoma patients are diagnosed with GI metastasis no evidence of other metastases. While the patient was (2%–5% of patients) [5, 6]. The most common sites of mela- being followed by serial CAT scans, a slow growing mass noma metastasis to the GI tract are the stomach and small was noted in the appendix approximately one year prior to intestine [7, 8]. this presentation, which was interpreted as a mucocele and We report a case of malignant melanoma metastatic to managed conservatively. In April of 2010, she presented to the appendix presenting as acute appendicitis in the back- our institution with symptoms of acute appendicitis. A ground of a mucocele. CT scan of the abdomen and pelvis revealed inflammatory changes and gas in the wall of the distended appendix (Figure 1). The mucocele extended to the base of the cecum; 2. Case Presentation she underwent an appendectomy with partial cecectomy the same day to achieve adequate resection margins. The patient is a 31-year-old female from Bolivia with a Cloudy peritoneal fluid was noted intraoperatively, and history of melanoma removed from her back ten years prior to this presentation. The pathology report was not the postoperative diagnosis was gangrenous appendicitis superimposed on a mucocele. She recovered uneventfully. available. In November 2005, the patient, now living in the USA, developed increasing headaches, vomiting, and blurred On gross examination, the appendix was 8.0 cm in length vision. CT scan showed a large left frontal cerebral mass and 1.5 to 3.2 cm in diameter attached to a partial cecectomy. 2 Journal of Oncology Spin: 0 Tilt: 0 Figure 1: CT scan (coronal view) of the abdomen and pelvis showing an appendiceal mucocele with intraluminal gas and wall edema. The serosal surface was smooth with areas of hyperemia, and a focal disruption measured 1.5 cm was located in mid Figure 2: Gross examination: cross-section of appendix, lobulated appendix. Sectioning revealed an 7.5 cm in length with 1.4– green/brown partially hemorrhagic, and pigmented tumor occupy 3.0 cm in diameter tumor occupying more than 80% of the proximal portion of the appendiceal lumen. the appendix. The tumor was soft, pink/tan in the distal aspect, and lobulated green/brown in the proximal portion (Figure 2) . No perforation was grossly appreciated. On microscopic examination, tumor cells replaced most the skin (cutaneous melanoma), melanomas can occur in any of the appendiceal mucosa and muscularis with no extension organ in which melanin-containing cells are present [7]. to the serosa. The lesional cells formed nests and cords and Melanocytes are normal residents of the mucous mem- had an abundant eosinophilic cytoplasm with mildly pleo- branes of the upper aerodigestive tract, gastrointestinal, and morphic nuclei and prominent nucleoli, some of which had urogenital tracts [7]. These cells give rise to malignant mela- intranuclear inclusions (Figures 3(a) and 3(b)). The tumor nomas of the mucous membranes lining the GI tract. Malig- cells were positive for the melanoma markers Melanoma nant melanomas involving the GI tract may be primary (i.e., Antigen (M; HMB45; Enzo; New York), Melan-A (M; A103; anorectum, esophagus, and gallbladder) or metastatic lesions Cell Marque;California),and S-100 (P;DAKO; California) (i.e., stomach and liver) [7]. Mucosal melanomas of the (Figures 3(c) and 3(d)). Acute appendicitis and periappen- gastrointestinal tract are rare tumors that represent about dicitis were also present. The cecum was free of disease. The 1.5%–2.0% of all melanomas [1, 7, 10]. The overwhelming diagnosis of metastatic malignant melanoma was made. The majority of malignant melanomas involving the GI tract patient is doing well at the present time. She is alive with are secondary to metastatic disease [11]. The interval time the disease. Plan for followup is to continue to monitor between diagnosis of the primary and metastatic disease is her metastatic melanoma and to enter patient in melanoma variable (average, 7.0 years) [7]. Patients with GI metastasis vaccine trials. may present with bleeding, anemia, obstruction, abdominal discomfort, pain, and intestinal perforation [7]. GI metas- tases usually appear as multiple polypoid lesions and can 3. Discussion be either pigmented or amelanotic and often ulcerated [2]. Malignant melanoma represents 1–3% of all cancer in the Less commonly the presentation is of a solitary melanotic USA [9]. Malignant melanomas develop from melanocytes tumor. Metastases to the GI tract can present both at which are derived from neural crest cells. The neural crest the time ofprimary diagnosis oryears laterasthe first cells migrate during embryologic development and may be sign of recurrence. Diagnosis of metastatic melanoma is found in noncutaneous sites. Although they usually occur in generally made by radiographic contrast studies, including Journal of Oncology 3 (a) (b) (c) (d) Figure 3: Microscopic examination: (a) solid cords and nests of tumor cells fill the appendiceal lumen and replace the appendiceal mucosa and submucosa with partial extension to the muscularis, no involvement of the serosa; (b) tumor cells with abundant eosinophilic cytoplasm, some of which are vacuolated, with pleomorphic nuclei, prominent nucleoli, and atypical mitosis (Hematoxylin and eosin staining, (a) x200; (b) x400). (c) Tumor cells strongly express HMB45, and (d) S-100 (HMB45 and S-100 immunostaining, x400). CT, ultrasonography, PET scan and barium studies, and find documented appendiceal involvement by metastatic endoscopic evaluation. The sensitivity of CT for detecting melanoma. metastases is only 60% to 70% [2, 12]. We found one reported case describing a malignant Metastatic melanoma has been observed in almost all melanoma in the vicinity of the appendix. The reported regions of the human body. The most common sites of case was that of a 55-year-old Caucasian woman with no metastases were the lymph nodes (74%) and lungs (71%), available medical history who presented with abdominal followed by the liver (58%), brain (55%), bone (49%), pain. Ultrasound suggested a periappendicular abscess or a adrenal glands (47%), and GI tract (44%), but only 1% to 4% tumor, but no other intraabdominal lesion was identified. of them are diagnosed antemortem [3]. Two large autopsy The tumor cells in that case were positive for Melan-A, S-100, studies which looked at the distribution of metastases in the HMB45, and vimentin. No primary source of melanoma in GI tract are from the Roswell Park Memorial Institute and this case was evident [13]. Memorial Sloan Kettering Cancer Center. The distribution The prognosis of metastatic GI malignant melanoma is of GI organ metastases in both series was as follows: liver, very poor with a 5-year survival of less than 10% [2, 14]. 58–60%; peritoneum, 43%; pancreas, 38%; small bowel, However, with surgical resection there may be a possibility 36–58%; spleen, 31%; colon, 22–28%; stomach, 20–23%; of long-term, disease-free survival. Surgical resection of duodenum, 12%; rectum, 5%; esophagus, 4%; biliary tract, distance metastasis is still the mainstay of treatment. Studies 9% [3, 5]. None of these studies or any others that we could have shown that surgical resection for melanoma metastatic 4 Journal of Oncology to the GI tract may be effective for palliation and may also [14] K. M. Bullard, T. M. Tuttle, D. A. Rothenberger et al., “Surgical therapy for anorectal melanoma,” Journal of the American result in long-term survival in selected patients [4]. College of Surgeons, vol. 196, no. 2, pp. 206–211, 2003. 4. Conclusion Preoperative diagnosis of appendiceal metastases from ma- lignant melanoma is difficult but should be considered in any patient with a history of melanoma who develops GI symptoms, even in the absence of radiographic findings. Mucocele of the appendix should be managed with resection to ascertain its pathologic features and prevent pseudomyx- oma peritonei or other complications. References [1] G. Serin,B.Doga ˇ navs¸argil, C. C¸alis¸kan, T. Akalin, M. Sezak, and M. Tunc¸yu ¨rek, “Colonic malignant melanoma, primary or metastatic? Case report,” Turkish Journal of Gastroenterol- ogy, vol. 21, no. 1, pp. 45–49, 2010. [2] L.M.Schuchter, R.Green, and D. Fraker,“Primary and metastatic diseases in malignant melanoma of the gastroin- testinal tract,” Current Opinion in Oncology,vol.12, no.2,pp. 181–185, 2000. [3] J. K. Patel,M.S.Didolkar, J. W. Pickren, and R. H.Moore, “Metastatic pattern of malignant melanoma. A study of 216 autopsy cases,” American Journal of Surgery, vol. 135, no. 6, pp. 807–810, 1978. [4] K.V.Liang, S.O.Sanderson, G.S.Nowakowski, and A.S. Arora, “Metastatic malignant melanoma of the gastrointesti- nal tract,” Mayo Clinic Proceedings, vol. 81, no. 4, pp. 511–516, [5] T. DasGupta and R. Brasfield, “Metastatic melanoma. A clini- copathological study,” Cancer, vol. 17, pp. 1323–1339, 1964. [6]B.Cagir,M.H.Whiteford,A. Topham, J. Rakinic, and R. D. Fry, “Changing epidemiology of anorectal melanoma,” Diseases of the Colon and Rectum, vol. 42, no. 9, pp. 1203–1208, [7] M. R. Hussein, “Extracutaneous malignant melanomas,” Can- cer Investigation, vol. 26, no. 5, pp. 516–534, 2008. [8] T. Akaraviputh, S. Arunakul, V. Lohsiriwat, C. Iramaneerat, and A. Trakarnsanga, “Surgery for gastrointestinal malignant melanoma: experience from surgical training center,” World Journal of Gastroenterology, vol. 16, no. 6, pp. 745–748, 2010. [9] A.M.Elsayed,M.Albahra,U.C.Nzeako, and L.H.Sobin, “Malignant melanomas in the small intestine: a study of 103 patients,” American Journal of Gastroenterology, vol. 91, no. 5, pp. 1001–1006, 1996. [10] D. Blecker, S. Abraham, E. E. Furth, and M. L. Kochman, “Melanoma in the gastrointestinal tract,” American Journal of Gastroenterology, vol. 94, no. 12, pp. 3427–3433, 1999. [11] M. Gutman, J. M. Klausner, M. Inbar, S. Chaitchik, and R. R. Rozin, “Surgical approach to malignant melanoma in the gastrointestinal tract,” Journal of Surgical Oncology, vol. 36, no. 1, pp. 16–20, 1987. [12] M. O. Meyers,D.J. Frey, and E.A. Levine, “Pancreaticoduo- denectomy for melanoma metastatic to the duodenum: a case report and review of the literature,” American Surgeon,vol.64, no. 12, pp. 1174–1176, 1998. [13] I. Letovanec, M. Vionnet, and H. Bouzourene, “Primary ap- pendiceal melanoma: fiction or reality?” Human Pathology, vol. 35, no. 5, pp. 627–629, 2004. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Oncology Hindawi Publishing Corporation

Metastatic Malignant Melanoma Presenting as an Appendiceal Mucocele

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Abstract

Hindawi Publishing Corporation Journal of Oncology Volume 2011, Article ID 546570, 4 pages doi:10.1155/2011/546570 Case Report Metastatic Malignant Melanoma Presenting as an Appendiceal Mucocele 1 1 2 3 A. A. Alduaij, M. B. Resnick, M. Kawata, and V. E. Pricolo Department of Pathology, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02908, USA Division of Colon and Rectal Surgery, Robert Wood Johnson Medical School, Cooper University Hospital, University of Medicine and Dentistry of New Jersey, Camden, NJ 07103, USA Division of Colorectal Surgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02908, USA Correspondence should be addressed to A. A. Alduaij, dralduaij@gmail.com Received 25 September 2010; Revised 18 December 2010; Accepted 27 January 2011 Academic Editor: V. Valentini Copyright © 2011 A. A. Alduaij et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Melanoma metastatic to the appendix is extremely rare. Here we describe a case of a 31-year-old female from Bolivia with a remote history of metastatic malignant melanoma first diagnosed as a cutaneous malignant melanoma ten years prior to this presentation. The patient was being followed for a mucocele which on resection was found to be metastatic melanoma. “Mucocele” is a generic diagnosis that warrants further characterization and treatment. 1. Introduction with edema and displacement of the midline structures. The patient then underwent surgical resection of brain Malignant melanoma involving the gastrointestinal (GI) tumor which was interpreted as metastatic melanoma. tract is a rare condition although it is one of the most After receiving palliative therapy, the patient enrolled in a common malignancies having the potential to metastasize to chemotherapy trial, Temozolomide along with Sorafenib, at the GI tract [1–4]. GI metastasis are frequently found during the University of Pennsylvania. Later in 2008, she developed autopsy (50%–60% of cases), but only a small proportion of a new 4 mm lesion in right frontal brain lobe. She had living melanoma patients are diagnosed with GI metastasis no evidence of other metastases. While the patient was (2%–5% of patients) [5, 6]. The most common sites of mela- being followed by serial CAT scans, a slow growing mass noma metastasis to the GI tract are the stomach and small was noted in the appendix approximately one year prior to intestine [7, 8]. this presentation, which was interpreted as a mucocele and We report a case of malignant melanoma metastatic to managed conservatively. In April of 2010, she presented to the appendix presenting as acute appendicitis in the back- our institution with symptoms of acute appendicitis. A ground of a mucocele. CT scan of the abdomen and pelvis revealed inflammatory changes and gas in the wall of the distended appendix (Figure 1). The mucocele extended to the base of the cecum; 2. Case Presentation she underwent an appendectomy with partial cecectomy the same day to achieve adequate resection margins. The patient is a 31-year-old female from Bolivia with a Cloudy peritoneal fluid was noted intraoperatively, and history of melanoma removed from her back ten years prior to this presentation. The pathology report was not the postoperative diagnosis was gangrenous appendicitis superimposed on a mucocele. She recovered uneventfully. available. In November 2005, the patient, now living in the USA, developed increasing headaches, vomiting, and blurred On gross examination, the appendix was 8.0 cm in length vision. CT scan showed a large left frontal cerebral mass and 1.5 to 3.2 cm in diameter attached to a partial cecectomy. 2 Journal of Oncology Spin: 0 Tilt: 0 Figure 1: CT scan (coronal view) of the abdomen and pelvis showing an appendiceal mucocele with intraluminal gas and wall edema. The serosal surface was smooth with areas of hyperemia, and a focal disruption measured 1.5 cm was located in mid Figure 2: Gross examination: cross-section of appendix, lobulated appendix. Sectioning revealed an 7.5 cm in length with 1.4– green/brown partially hemorrhagic, and pigmented tumor occupy 3.0 cm in diameter tumor occupying more than 80% of the proximal portion of the appendiceal lumen. the appendix. The tumor was soft, pink/tan in the distal aspect, and lobulated green/brown in the proximal portion (Figure 2) . No perforation was grossly appreciated. On microscopic examination, tumor cells replaced most the skin (cutaneous melanoma), melanomas can occur in any of the appendiceal mucosa and muscularis with no extension organ in which melanin-containing cells are present [7]. to the serosa. The lesional cells formed nests and cords and Melanocytes are normal residents of the mucous mem- had an abundant eosinophilic cytoplasm with mildly pleo- branes of the upper aerodigestive tract, gastrointestinal, and morphic nuclei and prominent nucleoli, some of which had urogenital tracts [7]. These cells give rise to malignant mela- intranuclear inclusions (Figures 3(a) and 3(b)). The tumor nomas of the mucous membranes lining the GI tract. Malig- cells were positive for the melanoma markers Melanoma nant melanomas involving the GI tract may be primary (i.e., Antigen (M; HMB45; Enzo; New York), Melan-A (M; A103; anorectum, esophagus, and gallbladder) or metastatic lesions Cell Marque;California),and S-100 (P;DAKO; California) (i.e., stomach and liver) [7]. Mucosal melanomas of the (Figures 3(c) and 3(d)). Acute appendicitis and periappen- gastrointestinal tract are rare tumors that represent about dicitis were also present. The cecum was free of disease. The 1.5%–2.0% of all melanomas [1, 7, 10]. The overwhelming diagnosis of metastatic malignant melanoma was made. The majority of malignant melanomas involving the GI tract patient is doing well at the present time. She is alive with are secondary to metastatic disease [11]. The interval time the disease. Plan for followup is to continue to monitor between diagnosis of the primary and metastatic disease is her metastatic melanoma and to enter patient in melanoma variable (average, 7.0 years) [7]. Patients with GI metastasis vaccine trials. may present with bleeding, anemia, obstruction, abdominal discomfort, pain, and intestinal perforation [7]. GI metas- tases usually appear as multiple polypoid lesions and can 3. Discussion be either pigmented or amelanotic and often ulcerated [2]. Malignant melanoma represents 1–3% of all cancer in the Less commonly the presentation is of a solitary melanotic USA [9]. Malignant melanomas develop from melanocytes tumor. Metastases to the GI tract can present both at which are derived from neural crest cells. The neural crest the time ofprimary diagnosis oryears laterasthe first cells migrate during embryologic development and may be sign of recurrence. Diagnosis of metastatic melanoma is found in noncutaneous sites. Although they usually occur in generally made by radiographic contrast studies, including Journal of Oncology 3 (a) (b) (c) (d) Figure 3: Microscopic examination: (a) solid cords and nests of tumor cells fill the appendiceal lumen and replace the appendiceal mucosa and submucosa with partial extension to the muscularis, no involvement of the serosa; (b) tumor cells with abundant eosinophilic cytoplasm, some of which are vacuolated, with pleomorphic nuclei, prominent nucleoli, and atypical mitosis (Hematoxylin and eosin staining, (a) x200; (b) x400). (c) Tumor cells strongly express HMB45, and (d) S-100 (HMB45 and S-100 immunostaining, x400). CT, ultrasonography, PET scan and barium studies, and find documented appendiceal involvement by metastatic endoscopic evaluation. The sensitivity of CT for detecting melanoma. metastases is only 60% to 70% [2, 12]. We found one reported case describing a malignant Metastatic melanoma has been observed in almost all melanoma in the vicinity of the appendix. The reported regions of the human body. The most common sites of case was that of a 55-year-old Caucasian woman with no metastases were the lymph nodes (74%) and lungs (71%), available medical history who presented with abdominal followed by the liver (58%), brain (55%), bone (49%), pain. Ultrasound suggested a periappendicular abscess or a adrenal glands (47%), and GI tract (44%), but only 1% to 4% tumor, but no other intraabdominal lesion was identified. of them are diagnosed antemortem [3]. Two large autopsy The tumor cells in that case were positive for Melan-A, S-100, studies which looked at the distribution of metastases in the HMB45, and vimentin. No primary source of melanoma in GI tract are from the Roswell Park Memorial Institute and this case was evident [13]. Memorial Sloan Kettering Cancer Center. The distribution The prognosis of metastatic GI malignant melanoma is of GI organ metastases in both series was as follows: liver, very poor with a 5-year survival of less than 10% [2, 14]. 58–60%; peritoneum, 43%; pancreas, 38%; small bowel, However, with surgical resection there may be a possibility 36–58%; spleen, 31%; colon, 22–28%; stomach, 20–23%; of long-term, disease-free survival. Surgical resection of duodenum, 12%; rectum, 5%; esophagus, 4%; biliary tract, distance metastasis is still the mainstay of treatment. Studies 9% [3, 5]. None of these studies or any others that we could have shown that surgical resection for melanoma metastatic 4 Journal of Oncology to the GI tract may be effective for palliation and may also [14] K. M. Bullard, T. M. Tuttle, D. A. Rothenberger et al., “Surgical therapy for anorectal melanoma,” Journal of the American result in long-term survival in selected patients [4]. College of Surgeons, vol. 196, no. 2, pp. 206–211, 2003. 4. Conclusion Preoperative diagnosis of appendiceal metastases from ma- lignant melanoma is difficult but should be considered in any patient with a history of melanoma who develops GI symptoms, even in the absence of radiographic findings. Mucocele of the appendix should be managed with resection to ascertain its pathologic features and prevent pseudomyx- oma peritonei or other complications. References [1] G. Serin,B.Doga ˇ navs¸argil, C. C¸alis¸kan, T. Akalin, M. Sezak, and M. Tunc¸yu ¨rek, “Colonic malignant melanoma, primary or metastatic? Case report,” Turkish Journal of Gastroenterol- ogy, vol. 21, no. 1, pp. 45–49, 2010. [2] L.M.Schuchter, R.Green, and D. Fraker,“Primary and metastatic diseases in malignant melanoma of the gastroin- testinal tract,” Current Opinion in Oncology,vol.12, no.2,pp. 181–185, 2000. [3] J. K. Patel,M.S.Didolkar, J. W. Pickren, and R. H.Moore, “Metastatic pattern of malignant melanoma. A study of 216 autopsy cases,” American Journal of Surgery, vol. 135, no. 6, pp. 807–810, 1978. [4] K.V.Liang, S.O.Sanderson, G.S.Nowakowski, and A.S. Arora, “Metastatic malignant melanoma of the gastrointesti- nal tract,” Mayo Clinic Proceedings, vol. 81, no. 4, pp. 511–516, [5] T. DasGupta and R. Brasfield, “Metastatic melanoma. A clini- copathological study,” Cancer, vol. 17, pp. 1323–1339, 1964. [6]B.Cagir,M.H.Whiteford,A. Topham, J. Rakinic, and R. D. Fry, “Changing epidemiology of anorectal melanoma,” Diseases of the Colon and Rectum, vol. 42, no. 9, pp. 1203–1208, [7] M. R. Hussein, “Extracutaneous malignant melanomas,” Can- cer Investigation, vol. 26, no. 5, pp. 516–534, 2008. [8] T. Akaraviputh, S. Arunakul, V. Lohsiriwat, C. Iramaneerat, and A. Trakarnsanga, “Surgery for gastrointestinal malignant melanoma: experience from surgical training center,” World Journal of Gastroenterology, vol. 16, no. 6, pp. 745–748, 2010. [9] A.M.Elsayed,M.Albahra,U.C.Nzeako, and L.H.Sobin, “Malignant melanomas in the small intestine: a study of 103 patients,” American Journal of Gastroenterology, vol. 91, no. 5, pp. 1001–1006, 1996. [10] D. Blecker, S. Abraham, E. E. Furth, and M. L. Kochman, “Melanoma in the gastrointestinal tract,” American Journal of Gastroenterology, vol. 94, no. 12, pp. 3427–3433, 1999. [11] M. Gutman, J. M. Klausner, M. Inbar, S. Chaitchik, and R. R. Rozin, “Surgical approach to malignant melanoma in the gastrointestinal tract,” Journal of Surgical Oncology, vol. 36, no. 1, pp. 16–20, 1987. [12] M. O. Meyers,D.J. Frey, and E.A. Levine, “Pancreaticoduo- denectomy for melanoma metastatic to the duodenum: a case report and review of the literature,” American Surgeon,vol.64, no. 12, pp. 1174–1176, 1998. [13] I. Letovanec, M. Vionnet, and H. Bouzourene, “Primary ap- pendiceal melanoma: fiction or reality?” Human Pathology, vol. 35, no. 5, pp. 627–629, 2004. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Journal of OncologyHindawi Publishing Corporation

Published: Mar 30, 2011

References