1. Metastatic cancer of Unknown Origin in the Stomach Asan Medical Center Ahn Ji Yong

2. Present Illness 56 year-old male 20 days ago : RUQ discomfort  Large liver mass on the CT and US Transfer to ASAN hospital Past Medical History 20 YA : medication due to pulmonary tuberculosis Family History / Social History None

3. Review of Systems General General weakness(+) Wt. loss(+) : 4kg / 2months Respiratory Dyspnea(+) Gastrointestinal Dyspepsia(-) Anorexia(+) Nausea(+) Vomiting(+) Physical Examination HEENT Icteric sclerae Abdomen Palpable mass (+) : RUQ Back & Extremities Both pretibial pitting edema (+)

4. CBC 4600 /mm3 - 12.9 g/dL - 201K /mm3 Electrolyte 134 – 4.3 – 103 mEq/L PT 75.4 % (1.17 INR) aPTT 35.7 sec BUN 23 mg/dL Cr 1.0 mg/dL Protein 5.3 g/dL Albumin 2.5 g/dL AST/ALT 82/91 IU/L ALP/rGT 256/296 IU/L TB/DB 3.1/1.6 mg/dL AFP : 1.9 ng/mlPIVKA II : 36 mAU/mL HBV/HCV (-/-) Initial Lab Data

5. #1. Liver mass  r/o HCC w/u #2. Nausea/Vomiting  EGD Initial Problem List / Plan

6. AP-CT & Chest CT

7. EGD

8. Low body, LC

9. S100HMB45 Malignant neoplasm producing melanin pigments  suggestive of Malignant Melanoma

10. US-guided liver biopsy HD #4

11. Liver (Seg. IV)

12. HD #2 – HD #10 Metastatic melanoma from unknown primary site Stage IV (TxNxM1, liver, stomach, lung)  Conservative management

13. Conclusion Metastatic melanoma from unknown primary site Stage IV (TxNxM1, liver, stomach, lung)

14. Brief review Metastatic Melanoma of Stomach

15. Melanoma Metastatic melanoma of unknown primary : histologically confirm  LN, visceral site & other unusual site without history or evidence of primary cutaneous, mucosal or ocular melanoma : 2-5% of all melanoma : 22% in autopsy (high tropism for GI tract)

16. Melanoma Metastatic > Primary : multifocality of the lesion, umbilicated appearance of polyps, absence of pagetoid & in situ change in the overlying epithelium No systemic therapies & Poor prognosis : median survival of 6 months