University of South Florida, Morsani College of Medicine TAMPA, FL
Yadis Arroyo Martinez, MD1, Harsh Patel, MD1, Fahad Hawk, MD1, Nicole Riddle, MD2, Renee Marchioni, DO1; 1University of South Florida, Morsani College of Medicine, Tampa, FL; 2Tampa General Hospital, Tampa, FL
Introduction: Primary small bowel neoplasms are rare, accounting for 1-5% of all gastrointestinal (GI) tract malignancies. Metastatic small bowel lesions are more common than primary and typically arise from malignant melanoma and adenocarcinomas from the lung, kidney and colon. Distant metastasis from cervical adenocarcinoma is extremely rare, most often seen with advanced stages. We report the case of a young female with known cervical cancer presenting with acute abdominal pain and melena secondary to metastatic ulcerated duodenal mass.
Methods: 43-year-old female with stage IIIB cervical adenocarcinoma status post pelvic radiation, human immunodeficiency virus (HIV) on antiretroviral therapy, and right upper extremity deep vein thrombosis on Eliquis presented with mild diffuse abdominal pain and intermittent melena over four weeks. On admission, she was afebrile and hemodynamically stable. Laboratory findings were significant for acute blood loss anemia with hemoglobin 3.3 g/dL (7.6 g/dL two months prior). Computed tomography abdomen and pelvis showed a heterogenous cervical mass near the sigmoid colon without signs of obstruction or perforation. Three units of packed red blood cells were transfused, proton pump inhibitor drip was initiated, and anticoagulation was held. Esophagogastroduodenoscopy revealed a large, infiltrative, ulcerated and friable mass within the second portion of the duodenum (Figure 1), occupying 50% of the luminal circumference with stigmata of recent bleeding. Duodenal mass biopsies confirmed metastatic cervical adenocarcinoma (Figures 2 and 3). She had no further bleeding throughout her course and was discharged home with palliative oncology care.
Discussion: Cervical cancer is the second most common gynecologic malignancy. Up to half of stage III cervical cancer patients present with distant metastases, most often to liver, lungs and bone marrow; however, only approximately 8% have GI tract metastases, often to the rectosigmoid secondary to local extension. Isolated metastases to the small bowel are exceedingly rare . Clinical presentations include small bowel obstruction, anemia, abdominal pain and, less commonly, overt GI bleeding. Early diagnosis of such an unusual pattern of metastasis related to cervical cancer is vital for optimal therapeutic management and prediction of prognosis.
Ulcerated mass at second portion of the duodenum.
Medium-power view demonstrating reactive duodenal mucosa on the top and poorly-differentiated carcinoma growing up from the submucosa (H&E, 100x).