Leonard J. Chabert Medical Center Houma, Louisiana
Introduction: Adenocarcinoma (NSCLC) is the most common primary lung cancer in the United States, making up 30% of all lung cancers and accounting for nearly 25% of all cancer mortality. Lung cancer metastasis occurs in many organs, including the adrenal glands, bone, lymph nodes, brain and liver. More commonly associated with small cell lung carcinoma, metastasis of non-small cell lung carcinoma to the stomach and small bowel have been rarely reported, many of which were found incidentally or during autopsy. We present a case of a patient with NSCLC who developed metastasis to the duodenum almost four months after diagnosis.
Case Description/Methods: The patient is a 43 year old female with a medical history of NSCLC and recent pulmonary embolism treated with eliquis presented with intermittent episodes of hematemesis and hemoptysis for three weeks. She described medium sized blood clots during episodic coughing and vomiting. On exam, she was afebrile, BP was 187/78, pulse 140, RR 26, and SpO2 94% on room air. She was ill appearing exhibiting epigastric tenderness without guarding. Lab studies revealed a Hg of 9.3, ALK 296, AST 67, ALT 56 and an elevated lactic acid at 4.4. All other lab tests were normal. Two large bore IVs were placed, initiated PPI, type and screened. Eliquis was stopped and the patient was transferred to the ICU for further monitoring. An EGD revealed a 2.5 cm fungating mass in the first portion of the duodenum, which did not require cauterization or clipping. Pathology reported a malignant mass and cells consistent with metastatic carcinoma from the lung primary. After discussing the pathology results with the patient, a decision was made to discontinue anticoagulation as the risk of bleeding outweigh the risk of pulmonary embolism.
Discussion: Common primary tumors that metastasize to the duodenum are renal cell carcinoma, melanoma, breast cancer and small cell carcinoma of the lung. Metastasis to the small intestine may be indolent and a challenge to diagnosis given vague symptoms like nausea, vomiting, abdominal pain and lack of overt bleeding, which can lead to a delay in endoscopy and diagnosis. In this case, anticoagulation likely exacerbated bleeding resulting in a need for an EGD. Duodenal metastasis is a grim prognosis with a survival rate less than 12 months. The case displays that distant metastasis from a primary malignancy can present with vague gastrointestinal symptoms and should not be discarded in certain clinical settings.
