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“A 72-year-old man presented with dysphagia and was investigated with an endoscopy. An ulcerated blackish tumor was found in the mid esophagus (Figure 1A). Some shallow ulcers were present in the stomach (Figure 1B). Biopsies of the tumor revealed melanoma (Figure 2). He was treated with chemotherapy and readmitted 3 months later due to an episode of upper GI bleeding. Repeat endoscopy revealed slight shrinkage of the esophageal tumor but numerous ulcerated nodules were now present in the stomach (Figure 1C). Biopsies of these

nodules revealed melanoma cells. The patient died 4 months after the diagnosis. Primary malignant melanoma of the esophagus (PMME) is an extremely rare neoplasm representing 0.1% find more to 0.2% of all primary esophageal cancers. To date, there are fewer than 300 cases reported in the CAL-101 mouse published literature. These tumors seem to be more common in men and are located primarily in

the mid- and lower- esophagus. The incidence of PMME is highest in the sixth and seventh decades of life. PMME usually presents with dysphagia (73%), weight loss (72%), pain (44%), and melena (10%). PMME is an aggressive neoplasm with a poor prognosis. At the time of diagnosis, approximately 50% of patients already have metastatic disease. The mean survival after diagnosis of PMME is 13.4 months. The pathogenesis of PMME is not entirely clear but it presumably develops from malignant degeneration of preexisting melanocytes in the esophagus. Differentiation from metastatic

melanoma where the primary lesion has involuted, may not be possible. The treatment of choice for PMME is surgical resection, with dissection of the lymph nodes. The utility of other treatment such as chemotherapy, radiotherapy, and immunotherapy remain unproven. Contributed by “
“Prolonged ambulatory reflux monitoring is an important tool in evaluating patients with gastroesophageal reflux (GERD) symptoms. While current clinical practice guidelines favor empiric trials of proton pump inhibitors (PPI) before pH testing or endoscopy to diagnose GERD, esophageal pH testing is recommended in patients with persistent symptoms despite acid-suppressive therapy and in patients who are considering antireflux surgery. In many circumstances the decision ifenprodil to test the patient on or off therapy is problematic and one of debate amongst experts. Off-therapy testing allows for a diagnosis of abnormal esophageal acid exposure and assessment of relationship of symptoms and acid reflux. On therapy testing can assess the effect of therapy, the relationship of reflux and the remaining symptoms and if impedance is added to pH the presence of non acid reflux. This chapter will review the options available for ambulatory reflux monitoring, as well as the potential benefits in the clinical arena.