An elderly female presented with a chief complaint of severe right shoulder pain with a "burning sensation" down her arm. In addition she had nausea and vague abdominal
discomfort.

Her past medical history was relatively unremarkable aside from a stage 1A melanoma that had been removed from her left calf about 8 months prior. She had had 2 follow up surveillance visits with her Dermatologist since then and was told that "everything looked good".

Here at our facility she underwent a CT abdomen and pelvis. The image is above. This showed probable diffuse metastatic disease involving the liver, both adrenals and the omentum. There were also two suspicious pulmonary nodules and there was destruction of the right shoulder likely due to metastatic disease.

Malignant melanoma is a potentially devastating disease. The ten year survival rates are as follows: stage 1: 84%, stage 2: 54%, stage 3: 35% and stage IV: 7%. My patient had stage IA disease which has the best survival rate. Having said that, it is well documented that melanoma metastasizes to skin, lymph nodes, the liver, the brain, the lungs and visceral organs. My patient had involvement of all of these areas (aside from skin) on her CT scan.

The patient underwent a liver biopsy of one her lesions. The pathology came back as poorly differentiated adenocarcinoma. This was quite a surprise. The sample was re-stained and evaluated and the conclusion was the same. This then prompted me to do a literature search to see if melanoma is associated with any secondary malignancies. I did not find any literature to suggest that.

The patient has been discharged and is following up with Oncology. Her mammogram, pap smear and colonoscopy were normal.

I question…are we now dealing with an adenocarcinoma of unknown primary on top of a known diagnosis of recent melanoma? Perhaps we are. This is quite an unfortunate outcome for this patient.