Rapidly Growing Urothelial Carcinoma Masquerading as a Duodenal Mass

Abstract

Introduction: A 78-year-old female presented to her primary care physician with nausea, vomiting and right-sided abdominal pain worsened after eating. A CT scan of her abdomen showed a large, right-sided abdominal mass spanning from duodenum to bladder, causing obstruction and mild hydronephrosis. A CT scan 3 months prior showed no signs of abdominal mass but noted slight ureteral stricturing of unknown significance. Her exam showed right-sided abdominal tenderness but no palpable mass. Initial work-up re-demonstrated the obstructive mass and urinary analysis showed no blood or RBCs. Initial creatinine was 1.61 with an estimated GFR of 31. CEA and CA19-9 were 0.5 and <15.0, respectively. She underwent an upper endoscopy and the mass was seen in the second part of the duodenum. Duodenal biopsies were consistent with reactive duodenopathy. Urinary cytology showed atypical cells, which prompted cystourethroscopy. A tumor emanating from the distal ureteral orifice was biopsied showing a high grade papillary urothelial carcinoma/transition cell carcinoma (TCC). At that time, a ureteral stent was placed to relieve the hydronephrosis and she received a gastrojejunostomy to divert the obstruction. She was discharged with outpatient oncology follow-up and was started on a chemotherapy trial for advanced transition cell carcinoma. Discussion: This case offers a unique presentation of a rapidly progressing, urothelial cell carcinoma presenting with duodenal obstruction. The most common presenting symptom of TCC is hematuria (intermittent, gross, painless and present entirely throughout micturition) as well as pain, usually with advanced disease. Other symptoms include weight loss, fatigue, anorexia and renal failure in rare cases. There is 1 report of a duodenal mass causing obstruction that once biopsied showed recurrence of a formerly resected TCC of the bladder but no report of primary TCC being diagnosed presenting with gastrointestinal obstructive symptoms. Other pelvic carcinomas have been described in rare cases to present with gastrointestinal obstructive symptoms. New techniques/tools in EUS and biopsy have increased sensitivity/specificity in abdominal mass evaluations (80-90% and >95%, respectively) with low complication rates. Because of this, EUS and biopsy remains a reasonable initial approach at obtaining tissue for diagnosis. Conclusion: Abdominal masses can present with a variety of symptoms, which may or may not involve the organ of origin. Large, duodenal masses that appear to have involvement of kidneys, ureter and/or bladder on CT should have thorough TCC work-up with urinalysis +/- cystoscopic evaluation to go along with intestinal carcinoma evaluation with esophagogastroduodenoscopy.