2645 Small Bowel Bleeding Due to Solitary Metastatic Ovarian Clear Cell Carcinoma: A Case Report and Review of the Literature

Abstract

INTRODUCTION: Small bowel bleeding (SBB) accounts for 5–10% of gastrointestinal bleeding cases. Common causes of SBB are inflammatory bowel disease, angioectasias, ulcers, & primary & metastatic neoplasms. The aim of this case report & literature review is to present ovarian clear cell carcinoma (CCC) as a rare cause of SBB. CASE DESCRIPTION/METHODS: A 51 year old woman with dual primary stage IIB CCC of bilateral ovaries & uterus, & stage IA, grade 1 endometrioid adenocarcinoma underwent total laparoscopic hysterectomy, bilateral salphingo-oophorectomy, bilateral pelvic lymph node dissection, & omentectomy. Pathology from the right pelvic side wall peritoneum was positive for CCC involving fibroadipose tissue. She completed 6 cycles of chemotherapy with paclitaxel & carboplatin. Following treatment, she achieved clinical remission for 14 months until computed tomography (CT) scan performed for new abdominal pain & constipation showed a 6.3 × 4.6 cm heterogeneously enhancing lobular mass lesion within the pelvis in close contact with the sigmoid colon without definite invasion. A month later, she was admitted with lower abdominal pain & bloody stools. Colonoscopy showed blood in the entire colon & terminal ileum (TI), without active source of bleeding identified. CT Angiography showed no evidence of active bleeding, but revealed increasing pelvic mass size (6.5 × 6.4 cm). No lymphadenopathy was noted on CT scan. Upper endoscopy was unrevealing. Video capsule endoscopy (VCE) showed an actively bleeding mass likely in the distal small bowel, without VCE passage beyond the mass or cecal intubation. Exploratory laparotomy revealed an 8cm mass arising from the distal TI adherent to the epiploica of the rectosigmoid, not involving the vaginal cuff or prior resection sites. A portion of distal TI was resected with a side-to-side ileo-ascending colon anastomosis. TI pathology was positive for CCC, with negative omental & lymph node pathology. Chemotherapy with carboplatin & doxorubicin was initiated without further bleeding. DISCUSSION: Ovarian cancer is thought to metastasize via direct invasion, lymphatic or hematogenous infiltration, or peritoneal dissemination. Solitary metastasis of ovarian CCC to the small bowel without peritoneal carcinomatosis or lymphatic involvement is a rare phenomenon. Our literature review revealed only one other published case report describing this entity. Solitary CCC metastases should be added to the list of potential neoplastic causes of SBB.