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Emergency Surgery for Metastatic Melanoma

Emergency Surgery for Metastatic Melanoma Emergency Surgery for Metastatic Melanoma div.banner_title_bkg div.trangle { border-color: #120603 transparent transparent transparent; opacity:0.7; /*new styles start*/ -ms-filter:"progid:DXImageTransform.Microsoft.Alpha(Opacity=70)" ;filter: alpha(opacity=70); /*new styles end*/ } div.banner_title_bkg_if div.trangle { border-color: transparent transparent #120603 transparent ; opacity:0.7; /*new styles start*/ -ms-filter:"progid:DXImageTransform.Microsoft.Alpha(Opacity=70)" ;filter: alpha(opacity=70); /*new styles end*/ } div.banner_title_bkg div.trangle { width: 394px; } #banner { background-image: url('http://images.hindawi.com/journals/ijso/ijso.banner.jpg'); background-position: 50% 0;} Hindawi Publishing Corporation Home Journals About Us International Journal of Surgical Oncology About this Journal Submit a Manuscript Table of Contents Journal Menu About this Journal · Abstracting and Indexing · Advance Access · Aims and Scope · Article Processing Charges · Articles in Press · Author Guidelines · Bibliographic Information · Citations to this Journal · Contact Information · Editorial Board · Editorial Workflow · Free eTOC Alerts · Publication Ethics · Reviewers Acknowledgment · Submit a Manuscript · Subscription Information · Table of Contents Open Special Issues · Published Special Issues · Special Issue Guidelines Abstract Full-Text PDF Full-Text HTML Full-Text ePUB Linked References How to Cite this Article International Journal of Surgical Oncology Volume 2014 (2014), Article ID 987170, 4 pages http://dx.doi.org/10.1155/2014/987170 Clinical Study Emergency Surgery for Metastatic Melanoma Dimitrios Mantas , 1 Petros Tsaparas , 1 Petros Charalampoudis , 1 Helen Gogas , 2 and Gregory Kouraklis 1 1 2nd Propaedeutic Department of Surgery, Laiko General Hospital, Athens University School of Medicine, 17 Agiou Thoma Street, 11527 Athens, Greece 2 1st Internal Medicine Department, Laiko General Hospital, Athens University School of Medicine, 17 Agiou Thoma Street, 11527 Athens, Greece Received 28 June 2014; Accepted 14 October 2014; Published 28 October 2014 Academic Editor: S. Curley Copyright © 2014 Dimitrios Mantas 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. Abstract Visceral metastases from malignant melanoma (stage M1c) confer a very poor prognosis, as documented on the most recent revised version of the TNM/AJCC staging system. Emergency surgery for intra-abdominal complications from the disease is rare. We report on our 5-year single institution experience with surgical management of metastatic melanoma to the viscera in the emergent setting. From 2009 to 2013, 14 patients with metastatic melanoma were admitted emergently due to an acute abdomen. Clinical manifestations encompassed intestinal obstruction and bleeding. Surgical procedures involved multiple enterectomies with primary anastomoses in 8 patients, and one patient underwent splenectomy, one adrenalectomy, one right colectomy, one gastric wedge resection, one gastrojejunal anastomosis, and one transanal debulking, respectively. The 30-day mortality was 7 percent. Median follow-up was 14 months. Median overall survival was 14 months. Median disease free survival was 7.5 months. One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. Emergency surgery for metastatic melanoma to the viscera is rare. Elective curative surgery combined with novel cytotoxic systemic therapies is under investigation in an attempt to grant survival benefit in melanoma patients with visceral disease. 1. Introduction Metastatic melanoma is an aggressive disease with dismal prognosis despite novel chemotherapeutic agents. M1c disease is defined as the presence of visceral metastases with elevated lactate dehydrogenase (LDH) level in the absence of pulmonary metastasis and carries a median survival of about 6 to 10 months [ 1 ]. Advanced melanoma can disseminate to any organ, with the commonest distant sites of metastasis being the skin, lung, and brain. In cases of visceral involvement, metastatic malignant melanoma most commonly attains the liver and the small bowel. Interestingly, up to 95 percent of patients with metastases to the gastrointestinal tract will not be identified until autopsy [ 1 ]. Intra-abdominal dissemination of melanoma can manifest itself with weight loss, vague abdominal pain, and/or anemia. In some cases, patients can present in the emergency setting with bowel intussusception, obstruction, bleeding, or perforation [ 2 ]. Although an acute abdominal symptomatology can raise the suspicion of intra-abdominal metastasis in any patient with a history of cutaneous melanoma, diagnosis is definitely made at surgery. We report on our five-year, single-center experience in emergency surgery for M1c melanoma. 2. Case Series Between 2009 and 2013, 14 consecutive patients (9 men and 5 women) with M1c melanoma underwent emergency surgical exploration due to acute abdomen by a single senior consultant general surgeon (DM). Clinical characteristics were as follows: all patients were Caucasian with a history of known metastatic melanoma and had previous chemotherapy for palliation. Median age was 61.5 years old (range of 17–87). An elevated serum lactate dehydrogenase (LDH) level was documented in 8 out of 14 patients (LDH mean value 652.6 U/L, range of 251–1567, Table 1 ). A senior consultant oncologist would be following all patients at the time of presentation to the acute setting. Table 1: Clinicopathological characteristics, operative data, and outcomes. 3. Surgery All patients were admitted emergently in the Surgical Department. Acute abdominal pain was reported as the chief complaint. All patients underwent diagnostic abdominal computed tomography preoperatively in order to confirm the clinical suspicion as well as to acquire information on the disease extent and intra-abdominal localization. Intraoperative data were as follows: all patients were operated approximately 3 to 4 hours after admission. Intestinal obstruction was the commonest intraoperative finding (9 cases) followed by intra-abdominal bleeding (5 cases). The type of surgery varied significantly; 8 out of 14 patients underwent multiple enterectomies with primary end-to-end enteroenteral anastomoses (range of 2–5 resections); one patient underwent a right hemicolectomy with primary ileotransverse anastomosis due to ileocecal valve involvement by the disease; one patient underwent splenectomy for splenic rupture due to splenic metastasis; one patient underwent wedge resection of a gastric lesion; one patient underwent a gastrojejunal bypass procedure for gastrointestinal bleeding; one patient underwent laparoscopic exploration with left adrenalectomy due to adrenal rupture; one patient who presented with bleeding per rectum and rectal perforation underwent a transanal rectal tumor debulking; in this latter case, we opted for limited palliative surgery over formal abdominoperineal resection due to high intraoperative morbidity. 4. Outcomes Following surgery, two patients developed early intestinal obstruction and underwent reoperation and one patient was admitted with late obstruction in another tertiary center. One of them died in the immediate postoperative period; the 30-day mortality was 7.14 percent. We documented a 14.28 percent cumulative operative morbidity in the form of intestinal obstruction. All histopathology reports were consistent with metastatic melanoma. Median follow-up was 14 months (range of 0.5–26). Recurrence events pertained mainly to peritoneum, brain, and lung. Median disease free survival was 7.5 months (range of 0–26). One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. 5. Discussion Metastatic melanoma carries a very dismal prognosis. The American Joint Committee on Cancer (AJCC, 2007 Revision) has divided patients with systemic disease into three groups: M1a (distant skin, subcutaneous, or nodal metastases), M1b (lung metastases), and M1c (absence of pulmonary lesion with any visceral or distant metastases and an elevated LDH level). Cumulative evidence suggests that M1a disease has the best survival rates, while M1c has the worst [ 1 , 3 ]. In Europe melanoma shows some significant geographical heterogeneity, with the highest rates being reported in Scandinavia (15 cases/100,000 per year) and the lowest in the Mediterranean basin (7 cases/100,000 per year) [ 4 ]. About 20 percent of patients with melanoma will ultimately develop distant metastases; prognosis remains poor despite novel treatment modalities; single-agent or multiple-agent chemotherapy, biological therapy (interferon-alpha, interleukin-2), radiotherapy, and biochemotherapy have failed to demonstrate a consistent survival benefit in advanced systemic disease [ 5 ]. Surgery for stage IV melanoma has demonstrated debatable results. In carefully selected patients, elective surgery can improve quality of life albeit it grants no survival benefit [ 6 – 11 ]. Conversely, Wasif and coworkers compared surgery with no surgery for metastatic melanoma on 4229 patients. They concluded that patients who underwent metastasectomy (33.6 percent) showed improved median and 5-year overall survival rates compared to patients who were ineligible for resection [ 12 ]; notably, metastasectomy was found to be an independent predictor of survival in this study. Emergency surgery on the small bowel can be employed for a variety of reasons. Most commonly, intestinal obstruction, perforation, and intractable bleeding can lead urgently a patient to the operating theatre. Adhesions, tumors, diverticulosis, neoplasia, inflammatory bowel disease, and acute ischemia account for the majority of emergency surgical admissions pertaining to the small bowel [ 13 – 17 ]. Cutaneous melanoma exhibits an unusual predilection for metastasizing to the small intestine causing vague abdominal pain and weight loss. At autopsy, metastatic deposits are reportedly present in 50 to 60 percent of patients with melanoma; however less than 4 percent of patients are found to have gastrointestinal metastasis during the course of their disease; moreover, in up to 9 percent of cases of gastrointestinal melanoma the primary site is unidentifiable. Nevertheless, gastrointestinal melanoma rarely manifests itself with acute abdominal symptoms and emergency surgery has scarcely been reported [ 16 , 18 , 19 ]. Bleeding, obstruction, perforation, and intussusception are the leading causes that prompt emergency surgical management. Generally, intestinal metastasis of melanoma is difficult to diagnose and when encountered it reflects advanced disease and dismal outcome [ 16 , 19 , 20 ]. Spontaneous splenic rupture is a rare cause of major nontraumatic hemorrhage and usually occurs in cases that are infectious insults to the spleen [ 21 ]. Acute abdomen during the course of treatment for melanoma has been rarely attributed to pharmacologic agents [ 22 , 23 ]. Next to the spleen, the adrenal can also represent a site of solitary metastasis from melanoma [ 24 ]. Complete adrenal resection and adjuvant treatment have been advocated in such cases. Rare reports of metastatic melanoma to the stomach, colon, and rectum/anal canal have been also reported [ 2 , 25 , 26 ]. A rigorous approach by a multidisciplinary team is crucial in an attempt to deliver the best of care in cases of metastatic melanoma. Metastatic melanoma to the gastrointestinal tract or to another solid organ should be suspected in any patient with a history of cutaneous melanoma and a new onset of abdominal symptoms. Recently, new biological therapies such as vemurafenib and ipilimumab have shown promising results in IV melanoma [ 27 ]. 6. Conclusion Surgery with a curative intent for stage IV melanoma remains debatable. A combination of modern systemic therapies and surgical resection is currently under investigation. A better understanding of tumor biology is essential in designing new strategies. Surgery for M1c disease could possibly gain ground in the future by debulking a significant load of disease and therefore by giving way to more aggressive and efficient systemic treatments. Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper. References A. M. Leung, D. M. Hari, and D. L. Morton, “Surgery for distant melanoma metastasis,” Cancer Journal , vol. 18, no. 2, pp. 176–184, 2012. View at Publisher · View at Google Scholar S. Shenoy and R. Cassim, “Metastatic melanoma to the gastrointestinal tract: role of surgery as palliative treatment,” The West Virginia Medical Journal , vol. 109, no. 1, pp. 30–33, 2013. View at Scopus C. M. Balch, A. N. Houghton, A. J. Sober, et al., Eds., Cutaneous Melanoma , Quality Medical Publishing, St. Louis, Mo, USA, 2009. M. Maio, P. Ascierto, A. Testori, et al., “The cost of unresectable stage III or stage IV melanoma in Italy,” Journal of Experimental & Clinical Cancer Research , vol. 31, p. 91, 2012. View at Publisher · View at Google Scholar C. Bedane, M.-T. Leccia, B. Sassolas, B. Bregman, and C. Lebbé, “Treatment patterns and outcomes in patients with advanced melanoma in France,” Current Medical Research and Opinion , vol. 29, no. 10, pp. 1297–1305, 2013. View at Publisher · View at Google Scholar · View at Scopus K. P. Wevers and H. J. Hoekstra, “Stage IV melanoma: completely resectable patients are scarce,” Annals of Surgical Oncology , vol. 20, no. 7, pp. 2352–2356, 2013. View at Publisher · View at Google Scholar · View at Scopus T. C. Chua, A. Saxena, and D. L. Morris, “Surgical metastasectomy in AJCC stage IV M1c melanoma patients with gastrointestinal and liver metastases,” Annals of the Academy of Medicine , vol. 39, no. 8, pp. 634–639, 2010. View at Scopus S. R. Martinez and S. E. Young, “A rational surgical approach to the treatment of distant melanoma metastases,” Cancer Treatment Reviews , vol. 34, no. 7, pp. 614–620, 2008. View at Publisher · View at Google Scholar · View at Scopus T. Tomov, R. Siegel, and A. Bembenek, “Long-term survival in stage IV melanoma after repetitive surgical therapy,” Onkologie , vol. 31, no. 5, pp. 259–261, 2008. View at Publisher · View at Google Scholar · View at Scopus P. J. Mosca, E. Teicher, S. P. Nair, and B. A. Pockaj, “Can surgeons improve survival in stage IV melanoma?” Journal of Surgical Oncology , vol. 97, no. 5, pp. 462–468, 2008. View at Publisher · View at Google Scholar · View at Scopus S. E. Young, S. R. Martinez, and R. Essner, “The role of surgery in treatment of stage IV melanoma,” Journal of Surgical Oncology , vol. 94, no. 4, pp. 344–351, 2006. View at Publisher · View at Google Scholar · View at Scopus N. Wasif, S. P. Bagaria, P. Ray, and D. L. Morton, “Does metastasectomy improve survival in patients with stage IV melanoma? A cancer registry analysis of outcomes,” Journal of Surgical Oncology , vol. 104, no. 2, pp. 111–115, 2011. View at Publisher · View at Google Scholar · View at Scopus C. Vallicelli, F. Coccolini, F. Catena, et al., “Small bowel emergency surgery: literature's review,” World Journal of Emergency Surgery , vol. 6, article 1, 2011. View at Publisher · View at Google Scholar · View at Scopus M. C. Wyers, “Acute mesenteric ischemia: diagnostic approach and surgical treatment,” Seminars in Vascular Surgery , vol. 23, no. 1, pp. 9–20, 2010. View at Publisher · View at Google Scholar · View at Scopus K. Woods, E. Williams, W. Melvin, and K. Sharp, “Acquired jejunoileal diverticulosis and its complications: a review of the literature,” The American Surgeon , vol. 74, no. 9, pp. 849–854, 2008. View at Scopus F. Catena, L. Ansaloni, F. Gazzotti, et al., “Small bowel tumours in emergency surgery: specificity of clinical presentation,” ANZ Journal of Surgery , vol. 75, no. 11, pp. 997–999, 2005. View at Publisher · View at Google Scholar · View at Scopus S. B. Williams, J. Greenspon, H. A. Young, and B. A. Orkin, “Small bowel obstruction: conservative vs. surgical management,” Diseases of the Colon & Rectum , vol. 48, no. 6, pp. 1140–1146, 2005. View at Publisher · View at Google Scholar · View at Scopus B. Szynglarewicz, M. Ekiert, J. Forgacz, A. Halon, R. Skalik, and R. Matkowski, “The role of surgery in the treatment of colorectal metastases from primary skin melanoma,” Colorectal Disease , vol. 14, no. 6, pp. e305–e311, 2012. View at Publisher · View at Google Scholar · View at Scopus B. Shpitz, Z. Kaufman, A. Gildor, and A. Dinbar, “Metastatic malignant melanoma of the small bowel as a surgical emergency,” Harefuah , vol. 119, no. 11, pp. 364–365, 1990. View at Scopus A. Giacobbe, D. Facciorusso, G. Modola, and A. Andriulli, “Metastatic melanoma: endoscopy as aid to earlier in vivo diagnosis of gastrointestinal involvement. A case report,” Minerva Gastroenterologica e Dietologica , vol. 42, no. 3, pp. 169–171, 1996. View at Scopus R. H. Richter, B. Reingruber, C. Grüneis, A. Altendorf-Hofmann, and H. Rupprecht, “Spontaneous splenic rupture in metastatic malignant melanoma,” Zentralblatt fur Chirurgie , vol. 126, no. 8, pp. 630–631, 2001. View at Publisher · View at Google Scholar · View at Scopus E. Castellani, P. Covarelli, C. Boselli et al., “Spontaneous splenic rupture in patient with metastatic melanoma treated with vemurafenib,” World Journal of Surgical Oncology , vol. 10, article 155, 2012. View at Publisher · View at Google Scholar · View at Scopus T. Frieling, J. Heise, and S. W. Wassilew, “Multiple colon ulcerations, perforation and death during treatment of malignant melanoma with sorafenib,” Deutsche medizinische Wochenschrift , vol. 134, no. 28-29, pp. 1464–1466, 2009. View at Scopus M. Wantz, F. Antonicelli, C. Derancourt, P. Bernard, M. F. Avril, and F. Grange, “Long-term survival and spontaneous tumor regression in stage IV melanoma: possible role of adrenalectomy and massive tumor antigen release,” Annales de Dermatologie et de Venereologie , vol. 137, pp. 464–467, 2010. View at Publisher · View at Google Scholar T. Namikawa and K. Hanazaki, “Clinicopathological features and treatment outcomes of metastatic tumors in the stomach,” Surgery Today , vol. 44, no. 8, pp. 1392–1399, 2014. View at Publisher · View at Google Scholar N. Mourra, A. Jouret-Mourin, T. Lazure, et al., “Metastatic tumors to the colon and rectum: a multi-institutional study,” Archives of Pathology & Laboratory Medicine , vol. 136, no. 11, pp. 1397–1401, 2012. View at Publisher · View at Google Scholar · View at Scopus M. C. Fox, C. D. Lao, J. L. Schwartz, M. L. Frohm, C. K. Bichakjian, and T. M. Johnson, “Management options for metastatic melanoma in the era of novel therapies: a primer for the practicing dermatologist: part II: management of stage IV disease,” Journal of the American Academy of Dermatology , vol. 68, no. 1, pp. 13.e1–13.e13, 2013. View at Publisher · View at Google Scholar var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-8578054-2']); _gaq.push(['_trackPageview']); (function () { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Surgical Oncology Hindawi Publishing Corporation

Emergency Surgery for Metastatic Melanoma

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Emergency Surgery for Metastatic Melanoma div.banner_title_bkg div.trangle { border-color: #120603 transparent transparent transparent; opacity:0.7; /*new styles start*/ -ms-filter:"progid:DXImageTransform.Microsoft.Alpha(Opacity=70)" ;filter: alpha(opacity=70); /*new styles end*/ } div.banner_title_bkg_if div.trangle { border-color: transparent transparent #120603 transparent ; opacity:0.7; /*new styles start*/ -ms-filter:"progid:DXImageTransform.Microsoft.Alpha(Opacity=70)" ;filter: alpha(opacity=70); /*new styles end*/ } div.banner_title_bkg div.trangle { width: 394px; } #banner { background-image: url('http://images.hindawi.com/journals/ijso/ijso.banner.jpg'); background-position: 50% 0;} Hindawi Publishing Corporation Home Journals About Us International Journal of Surgical Oncology About this Journal Submit a Manuscript Table of Contents Journal Menu About this Journal · Abstracting and Indexing · Advance Access · Aims and Scope · Article Processing Charges · Articles in Press · Author Guidelines · Bibliographic Information · Citations to this Journal · Contact Information · Editorial Board · Editorial Workflow · Free eTOC Alerts · Publication Ethics · Reviewers Acknowledgment · Submit a Manuscript · Subscription Information · Table of Contents Open Special Issues · Published Special Issues · Special Issue Guidelines Abstract Full-Text PDF Full-Text HTML Full-Text ePUB Linked References How to Cite this Article International Journal of Surgical Oncology Volume 2014 (2014), Article ID 987170, 4 pages http://dx.doi.org/10.1155/2014/987170 Clinical Study Emergency Surgery for Metastatic Melanoma Dimitrios Mantas , 1 Petros Tsaparas , 1 Petros Charalampoudis , 1 Helen Gogas , 2 and Gregory Kouraklis 1 1 2nd Propaedeutic Department of Surgery, Laiko General Hospital, Athens University School of Medicine, 17 Agiou Thoma Street, 11527 Athens, Greece 2 1st Internal Medicine Department, Laiko General Hospital, Athens University School of Medicine, 17 Agiou Thoma Street, 11527 Athens, Greece Received 28 June 2014; Accepted 14 October 2014; Published 28 October 2014 Academic Editor: S. Curley Copyright © 2014 Dimitrios Mantas 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. Abstract Visceral metastases from malignant melanoma (stage M1c) confer a very poor prognosis, as documented on the most recent revised version of the TNM/AJCC staging system. Emergency surgery for intra-abdominal complications from the disease is rare. We report on our 5-year single institution experience with surgical management of metastatic melanoma to the viscera in the emergent setting. From 2009 to 2013, 14 patients with metastatic melanoma were admitted emergently due to an acute abdomen. Clinical manifestations encompassed intestinal obstruction and bleeding. Surgical procedures involved multiple enterectomies with primary anastomoses in 8 patients, and one patient underwent splenectomy, one adrenalectomy, one right colectomy, one gastric wedge resection, one gastrojejunal anastomosis, and one transanal debulking, respectively. The 30-day mortality was 7 percent. Median follow-up was 14 months. Median overall survival was 14 months. Median disease free survival was 7.5 months. One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. Emergency surgery for metastatic melanoma to the viscera is rare. Elective curative surgery combined with novel cytotoxic systemic therapies is under investigation in an attempt to grant survival benefit in melanoma patients with visceral disease. 1. Introduction Metastatic melanoma is an aggressive disease with dismal prognosis despite novel chemotherapeutic agents. M1c disease is defined as the presence of visceral metastases with elevated lactate dehydrogenase (LDH) level in the absence of pulmonary metastasis and carries a median survival of about 6 to 10 months [ 1 ]. Advanced melanoma can disseminate to any organ, with the commonest distant sites of metastasis being the skin, lung, and brain. In cases of visceral involvement, metastatic malignant melanoma most commonly attains the liver and the small bowel. Interestingly, up to 95 percent of patients with metastases to the gastrointestinal tract will not be identified until autopsy [ 1 ]. Intra-abdominal dissemination of melanoma can manifest itself with weight loss, vague abdominal pain, and/or anemia. In some cases, patients can present in the emergency setting with bowel intussusception, obstruction, bleeding, or perforation [ 2 ]. Although an acute abdominal symptomatology can raise the suspicion of intra-abdominal metastasis in any patient with a history of cutaneous melanoma, diagnosis is definitely made at surgery. We report on our five-year, single-center experience in emergency surgery for M1c melanoma. 2. Case Series Between 2009 and 2013, 14 consecutive patients (9 men and 5 women) with M1c melanoma underwent emergency surgical exploration due to acute abdomen by a single senior consultant general surgeon (DM). Clinical characteristics were as follows: all patients were Caucasian with a history of known metastatic melanoma and had previous chemotherapy for palliation. Median age was 61.5 years old (range of 17–87). An elevated serum lactate dehydrogenase (LDH) level was documented in 8 out of 14 patients (LDH mean value 652.6 U/L, range of 251–1567, Table 1 ). A senior consultant oncologist would be following all patients at the time of presentation to the acute setting. Table 1: Clinicopathological characteristics, operative data, and outcomes. 3. Surgery All patients were admitted emergently in the Surgical Department. Acute abdominal pain was reported as the chief complaint. All patients underwent diagnostic abdominal computed tomography preoperatively in order to confirm the clinical suspicion as well as to acquire information on the disease extent and intra-abdominal localization. Intraoperative data were as follows: all patients were operated approximately 3 to 4 hours after admission. Intestinal obstruction was the commonest intraoperative finding (9 cases) followed by intra-abdominal bleeding (5 cases). The type of surgery varied significantly; 8 out of 14 patients underwent multiple enterectomies with primary end-to-end enteroenteral anastomoses (range of 2–5 resections); one patient underwent a right hemicolectomy with primary ileotransverse anastomosis due to ileocecal valve involvement by the disease; one patient underwent splenectomy for splenic rupture due to splenic metastasis; one patient underwent wedge resection of a gastric lesion; one patient underwent a gastrojejunal bypass procedure for gastrointestinal bleeding; one patient underwent laparoscopic exploration with left adrenalectomy due to adrenal rupture; one patient who presented with bleeding per rectum and rectal perforation underwent a transanal rectal tumor debulking; in this latter case, we opted for limited palliative surgery over formal abdominoperineal resection due to high intraoperative morbidity. 4. Outcomes Following surgery, two patients developed early intestinal obstruction and underwent reoperation and one patient was admitted with late obstruction in another tertiary center. One of them died in the immediate postoperative period; the 30-day mortality was 7.14 percent. We documented a 14.28 percent cumulative operative morbidity in the form of intestinal obstruction. All histopathology reports were consistent with metastatic melanoma. Median follow-up was 14 months (range of 0.5–26). Recurrence events pertained mainly to peritoneum, brain, and lung. Median disease free survival was 7.5 months (range of 0–26). One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. 5. Discussion Metastatic melanoma carries a very dismal prognosis. The American Joint Committee on Cancer (AJCC, 2007 Revision) has divided patients with systemic disease into three groups: M1a (distant skin, subcutaneous, or nodal metastases), M1b (lung metastases), and M1c (absence of pulmonary lesion with any visceral or distant metastases and an elevated LDH level). Cumulative evidence suggests that M1a disease has the best survival rates, while M1c has the worst [ 1 , 3 ]. In Europe melanoma shows some significant geographical heterogeneity, with the highest rates being reported in Scandinavia (15 cases/100,000 per year) and the lowest in the Mediterranean basin (7 cases/100,000 per year) [ 4 ]. About 20 percent of patients with melanoma will ultimately develop distant metastases; prognosis remains poor despite novel treatment modalities; single-agent or multiple-agent chemotherapy, biological therapy (interferon-alpha, interleukin-2), radiotherapy, and biochemotherapy have failed to demonstrate a consistent survival benefit in advanced systemic disease [ 5 ]. Surgery for stage IV melanoma has demonstrated debatable results. In carefully selected patients, elective surgery can improve quality of life albeit it grants no survival benefit [ 6 – 11 ]. Conversely, Wasif and coworkers compared surgery with no surgery for metastatic melanoma on 4229 patients. They concluded that patients who underwent metastasectomy (33.6 percent) showed improved median and 5-year overall survival rates compared to patients who were ineligible for resection [ 12 ]; notably, metastasectomy was found to be an independent predictor of survival in this study. Emergency surgery on the small bowel can be employed for a variety of reasons. Most commonly, intestinal obstruction, perforation, and intractable bleeding can lead urgently a patient to the operating theatre. Adhesions, tumors, diverticulosis, neoplasia, inflammatory bowel disease, and acute ischemia account for the majority of emergency surgical admissions pertaining to the small bowel [ 13 – 17 ]. Cutaneous melanoma exhibits an unusual predilection for metastasizing to the small intestine causing vague abdominal pain and weight loss. At autopsy, metastatic deposits are reportedly present in 50 to 60 percent of patients with melanoma; however less than 4 percent of patients are found to have gastrointestinal metastasis during the course of their disease; moreover, in up to 9 percent of cases of gastrointestinal melanoma the primary site is unidentifiable. Nevertheless, gastrointestinal melanoma rarely manifests itself with acute abdominal symptoms and emergency surgery has scarcely been reported [ 16 , 18 , 19 ]. Bleeding, obstruction, perforation, and intussusception are the leading causes that prompt emergency surgical management. Generally, intestinal metastasis of melanoma is difficult to diagnose and when encountered it reflects advanced disease and dismal outcome [ 16 , 19 , 20 ]. Spontaneous splenic rupture is a rare cause of major nontraumatic hemorrhage and usually occurs in cases that are infectious insults to the spleen [ 21 ]. Acute abdomen during the course of treatment for melanoma has been rarely attributed to pharmacologic agents [ 22 , 23 ]. Next to the spleen, the adrenal can also represent a site of solitary metastasis from melanoma [ 24 ]. Complete adrenal resection and adjuvant treatment have been advocated in such cases. Rare reports of metastatic melanoma to the stomach, colon, and rectum/anal canal have been also reported [ 2 , 25 , 26 ]. A rigorous approach by a multidisciplinary team is crucial in an attempt to deliver the best of care in cases of metastatic melanoma. Metastatic melanoma to the gastrointestinal tract or to another solid organ should be suspected in any patient with a history of cutaneous melanoma and a new onset of abdominal symptoms. Recently, new biological therapies such as vemurafenib and ipilimumab have shown promising results in IV melanoma [ 27 ]. 6. Conclusion Surgery with a curative intent for stage IV melanoma remains debatable. A combination of modern systemic therapies and surgical resection is currently under investigation. A better understanding of tumor biology is essential in designing new strategies. Surgery for M1c disease could possibly gain ground in the future by debulking a significant load of disease and therefore by giving way to more aggressive and efficient systemic treatments. Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper. References A. M. Leung, D. M. Hari, and D. L. Morton, “Surgery for distant melanoma metastasis,” Cancer Journal , vol. 18, no. 2, pp. 176–184, 2012. View at Publisher · View at Google Scholar S. Shenoy and R. Cassim, “Metastatic melanoma to the gastrointestinal tract: role of surgery as palliative treatment,” The West Virginia Medical Journal , vol. 109, no. 1, pp. 30–33, 2013. View at Scopus C. M. Balch, A. N. Houghton, A. J. Sober, et al., Eds., Cutaneous Melanoma , Quality Medical Publishing, St. Louis, Mo, USA, 2009. M. Maio, P. Ascierto, A. Testori, et al., “The cost of unresectable stage III or stage IV melanoma in Italy,” Journal of Experimental & Clinical Cancer Research , vol. 31, p. 91, 2012. View at Publisher · View at Google Scholar C. Bedane, M.-T. Leccia, B. Sassolas, B. Bregman, and C. Lebbé, “Treatment patterns and outcomes in patients with advanced melanoma in France,” Current Medical Research and Opinion , vol. 29, no. 10, pp. 1297–1305, 2013. View at Publisher · View at Google Scholar · View at Scopus K. P. Wevers and H. J. Hoekstra, “Stage IV melanoma: completely resectable patients are scarce,” Annals of Surgical Oncology , vol. 20, no. 7, pp. 2352–2356, 2013. View at Publisher · View at Google Scholar · View at Scopus T. C. Chua, A. Saxena, and D. L. Morris, “Surgical metastasectomy in AJCC stage IV M1c melanoma patients with gastrointestinal and liver metastases,” Annals of the Academy of Medicine , vol. 39, no. 8, pp. 634–639, 2010. View at Scopus S. R. Martinez and S. E. 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International Journal of Surgical Oncology – Hindawi Publishing Corporation

Published: Oct 28, 2014

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