Oosting et al. Journal of Medical Case Reports 2010, 4:10 http://www.jmedicalcasereports.com/content/4/1/10 Page 3 of 4 Figure 4 Chest X-ray showing free intraperitoneal air. in nature. The primary lesion can be discrete, especially when, as in this case, regression has occurred. In patients with end stage melanoma, gastric metastases and small bowel metastases are quite common. In two large autopsy series, gastric metastases were found in about 20% of the patients studied, and small bowel metastases in 35.6% and 58% of the patients [6,7]. Differentiation between a primary gastrointestinal tract lesion and metastasis from an occult cutaneous mela- noma can be difficult in cases with solitary gastrointest- inal localization. However, due to the lack of convincingly effective adjuvant regimens for melanoma, the clinical consequences are marginal. Surgery for melanoma lesions that are metastatic to the gastrointestinal tract is quite effective for controlling symptoms but it rarely leads to long-term survival [8,9]. The systemic treatment of metastatic disease has been met with limited success. Over the decades, single-agent treatment with dacarbazin has remained the standard of care. An incentive for using this drug even in the end stage of the disease is its limited toxicity, with easily controllable nausea as its main clinical side effect. The generally mild hematological toxicity of dacarbazine compares favorably to that of drugs used in other advanced stages of cancer [10]. Although the response rate is low, prolonged remissions are sometimes achieved, which makes treatment worthwhile. Perforation of a gastrointestinal tumor as a result of che- motherapy is rare, as remissions are usually partial and occur gradually. An exception in this regard is intra- abdominal lymphoma. This tumor is highly sensitive to cytotoxic therapy and responds with rapid necrosis. Abdominal non-Hodgkin’s lymphoma in children, with otherwise favorable prognosis, is associated with a very poor outcome if gastrointestinal perforation occurs [11,12]. We could only identify one other case of fatal gastro- intestinal perforation in a patient with metastatic mela- noma during treatment with dacarbazine, but bowel perforation was not attributed to chemotherapy by the authors [10]. In our patient, perforation was ascribed to responding gastrointestinal metastases. A recent gastro- intestinal endoscopy had revealed multiple metastases and no peptic ulcers. Our patient had not been using non-steroidal anti-inflammatory drugs (NSAIDs), which makes perforation of a gastric or duodenal ulcer unli- kely. Furthermore, his LDH level had fallen dramatically, thus indicating his fast response to chemotherapy. Conclusion Chemotherapy in end stage melanoma is aimed at a rarely achievable goal of prolonged remission in the context of limited toxicity. In the presence of extensive digestive tract involvement, a remission could lead to perforation, resulting in excess toxicity and probably death. When perforation is recognized as a possible threat, a prolonged administration of the drug in its oral formulation might be advisable. This does not seem to compromise treatment efficacy [10]. Consent Written informed consent was obtained from the part- ner of the patient for publication of this case report and any accompanying images. A copy of the written con- sent is available for review by the Editor-in-Chief of this journal. Author details 1Department of Medical Oncology, University Medical Center Groningen and University of Groningen, 9700 RB, Groningen, The Netherlands. 2Department of Gastroenterology, University Medical Center Groningen and University of Groningen, 9700 RB, Groningen, The Netherlands. Authors’ contributions SO treated the patient with chemotherapy and drafted the manuscript. FP performed the endoscopy and made the diagnosis of metastatic melanoma. GH conceived of the manuscript and participated in its design. NM supervised this patients treatment and drafted the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 16 November 2009 Accepted: 15 January 2010 Published: 15 January 2010 References 1. Hamm C, Verma S, Petrella T, Bak K, Charette M: Melanoma Disease Site Group of Cancer Care Ontario’s Program in Evidence-based Care. Biochemotherapy for the treatment of metastatic malignant melanoma: a systematic review. Cancer Treat Rev 2008, 34:145-156. 2. Chapman PB, Einhorn LH, Meyers ML, Saxman S, Destro AN, Panageas KS, Begg CB, Agarwala SS, Schuchter LM, Ernstoff MS, Houghton AN, Kirkwood JM: Phase III multicenter randomized trial of the Dartmouth regimen versus dacarbazine in patients with metastatic melanoma. J Clin Oncol 1999, 17:2745-2751.