PMC8263269_01
PET (positron emission tomography) scan with persistent and increasing FDG uptake in distal small bowel (arrow).
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The patient underwent PET-CT scan in the weeks prior to presentation which showed interval increased FDG uptake at the distal small bowel near the ileocolic junction (Figure 1).
(a) Capsule endoscopy image of erythematous, ulcerated, and congested area of mucosa presumed to be localized to the distal ileum at 6 hours, 26 minutes, and 12 seconds. (b) Additional image of the aforementioned area located in distal ileum on capsule endoscopy.
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Given recurrent findings, patient underwent capsule endoscopy which revealed ulcerated, nodular, congested, and erythematous mucosa at 6 hours, 26 minutes, and 12 seconds past swallowing capsule, with location deemed likely in distal ileum (Figures 2(a) and 2(b)).
Ulcerated and inflamed nodular area (15 mm x 20 mm) in distal ileum identified on DBE and measured at 95 cm from the ileal valve. This area was subsequently biopsied and tattooed with carbon black in preparation for resection.
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Given this finding, patient underwent retrograde double-balloon enteroscopy (DBE) which showed ulcerated, edematous mucosa in the distal ileum at 95 cm from ileocecal valve (Figure 3), with biopsies consistent with metastatic melanoma as confirmed by the presence of melanin in tumor biopsy and positive staining.
Surgical specimen from laparoscopic-assisted small bowel resection of the tattooed site (Figure 3).
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Patient underwent surgical resection of this area (Figure 4), which also revealed the second area of ileal metastasis (2.8 cm of the ileum) separate from the tattooed area (2.6 cm), and seven lymph nodes removed were negative for metastatic melanoma.
H&E staining of surgical specimen (Figure 4) with positive stain for HMB45 and Melan-A, suggesting diagnosis of melanoma.
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The surgical resection specimens also demonstrated the presence of melanin and had positive staining for melanoma (Figure 5).