A 65-year-old man was admitted to the China-Japan Friendship hospital with a chief complaint of progressive dysphagia for 3 mo.
He also complained of a drastic weight loss of 8 kg in the past 2 mo.
He denied a history of smoking, alcohol intake and substance abuse, but had a chronic atrophic gastritis for nearly 10 years.
Also, there was no family history of genetic defect or malignancy.
Physical examination showed no palpable findings.
Admission blood test showed a slight decrease in hemoglobin (106 g/L).
Upper gastrointestinal (GI) examination using barium contrasts showed a large tumor blocking the esophago-gastric junction (Figure ​1).
Computed tomography (CT) scan revealed a soft mass in the esophago-gastric junction with lymph node metastasis in the lesser curvature of the stomach (Figure ​2).
Endoscopic examination showed a black spot in the lower esophagus and a bulky black mass blocking the esophago-gastric junction, as well as two black crater-like ulcers in the fundus of the stomach (Figure ​3).
Biopsy specimens taken from the tumor were identified as poorly differentiated adenocarcinoma.
Preoperative nutrition status of this case was scored 2 based on the Nutrition Risk Screening 2002 (NRS 2002)[6].
Because of the obstructive symptom caused by the tumor, a debulking surgery of distal esophagectomy and proximal gastrectomy was performed.
Esophagogastric anastomosis and reconstruction was then completed with stapling device.
Intraoperatively, the tumor was found located at the esophago-gastric junction and the tumor infiltrated the whole layer with lymph node metastasis at station four.
No ascites or dissemination of the tumor was observed in the peritoneal cavity.
The tumor measured 3 cm × 6 cm in size with black pigmentation (Figure ​4).
There were several pigmented satellite nodules beside the main tumor lesion, the largest one being 1 cm × 1 cm in diameter.
Moreover, two ulceration lesions were found at the fundus of the stomach.
Microscopically, the excised tumor tissue was composed of non-organized and pleomorphic cells exhibiting atypical nuclei, and abundant melanin granules (Figure ​5).
Pathological examination identified this case at a stage of IVA (T4aN1M0).
Immunohistochemical staining showed that the tumor was positive for S-100, HMB-45, mclean-A and Vimentin, but negative for cytokeratin 7 and cytokeratin 20 (Figure ​6).
Based on these results, a diagnosis of primary advanced esophago-gastric melanoma was established.
The postoperative course was smooth and without complications.
The patient gradually recovered and was discharged 14 d after surgery.
As the patient denied a postoperative adjuvant therapy, abdominal recurrence and hepatic metastases were found within one month by a postoperative follow-up CT.
No other effective treatment was administered afterwards.
The patient died of diffuse metastatic disease 2 mo later.