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+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.