Case Presentation:

A 42‐year‐old man presented with 4 months of intractable nausea, vomiting, and a twenty‐pound weight loss. He noted no recent travel, and he had no tuberculosis risk factors. Outpatient attempts at antiemetic therapy were unsuccessful. The nausea and vomiting slowly progressed, and on the day of admission, he was unable to keep or ingest any food or liquid without vomiting. He appeared weak, and he was wheelchair bound because of this weakness. His physical examination was otherwise normal. He had only mild abdominal tenderness to palpation, and there was no guarding or rebound tenderness. The liver measured 8 cm below the right costal margin. The skin examination was unremarkable for any nevi or suspicious rashes. Esophagogastroduodenoscopy revealed multiple black lesions dispersed throughout the esophagus leading down into the stomach. A PET/CT showed multiple hepatic lesions, bilateral lung lesions, splenic lesions, left femur lytic lesions, and a left parietal skull lesion all suspicious for metastasis. Biopsy of one of the dark esophageal lesions revealed mitotic clusters of malignant cells which stained positive for melanin. On further questioning, he noted that he had had a “mole” removed from his posterior neck 9 years earlier.


Although malignant melanoma accounts for only 4% of the 4 types of skin‐related cancers, it accounts for 80% of skin cancer‐related deaths. As such, melanoma is the most common skin malignancy encountered by a hospitalist. Thus, it is important for the hospitalist to identify and ask about the risk factors for melanoma in patients with unexplained metastatic disease. Melanoma is associated with intermittent periods of intense sunlight exposure rather than consistent moderate UV damage. The resultant DNA damage secondary to extreme UV exposure is the initiating event of malignant melanoma. Contrary to widespread belief, sunscreen has not been proven to decrease the incidence of melanoma in any population. Areas of cell turnover result in characteristic lesions that follow the ABCDE morphology; asymmetric, border irregularity, color variation, diameter > 6 cm, and evolving or enlarging lesions. Prognosis is directly related to depth of the lesion rather than superficial spread. Importantly, 45% of metastatic melanoma cases arise from dysplastic nevi with superficial spreading.


Melanoma is among The deadliest of skin cancers, as microinvasion is a major feature. Therefore, complete resection is not assuring for prevention of recurrence. Because of its vascular invasion, melanoma, unlike other malignancies, follows no regular pattern of metastatic spread, and can recur at any point in the future. The only FDA approved chemotherapy for treatment of malignant melanoma is decarbazine, usually in conjunction with other therapies. Wide excision was previously recommended but has not been shown to prevent recurrence.

Author Disclosure:

H. Toliver, none.