S3519 A Rare Case of Epigastric Pain Caused by Duodenal Metastatic Cervical Cancer

Abstract

Introduction: Cervical cancer was previously one of the most common causes of death for women in the United States but survival has since improved with the use of screening and the HPV vaccine. Metastatic cervical cancer spread to the duodenum is rare and presents a diagnostic challenge due to vague symptoms. We present a case of epigastric pain caused by invasive squamous cell cervical cancer with duodenal metastasis. Case Description/Methods: A 59-year-old female with a history of GERD and treated cervical cancer (2 years prior) and currently on pembrolizumab presented to clinic for 3 months of progressive upper abdominal pain and dyspepsia. Last upper endoscopy a year ago was normal. Physical exam was notable for epigastric tenderness without guarding. Laboratory data was remarkable for downtrending hemoglobin, normal liver function tests, normal lipase, and negative stool H pylori antigen. She was referred for EGD. A contrasted CT of the abdomen and pelvis performed revealed multiple enlarged lymph nodes of the mesentery. Upper endoscopy revealed thickened folds of the second portion of the duodenum and multiple biopsies taken of this site. It was an otherwise normal upper endoscopy. The duodenal biopsies were positive for metastatic squamous cancer of the cervix. The patient was transitioned to treatment with gemcitabine and carboplatin due to progressive disease on pembrolizumab. She unfortunately succumbed to her disease six months later. (Figure) Discussion: There is an estimated 7.5 per 100,000 new cases of cervical cancer per year with death rate of 2.2 per 100,000 in the United States. Cervical cancer is usually locally invasive and spreads by lymphatics or hematogenously with most common metastatic sites of lungs, liver, and bone. In a previous review, liver metastases was in up to 12.5% of patients but did not mention a single case of luminal disease. It is very rare for most cancers to metastasize to the gastrointestinal tract, but when present, metastasis has a predilection for the stomach and duodenum. Few case reports are available for cervical cancer metastasis to the GI tract specifically, with about 16 identified. These patients generally presented with gastrointestinal bleeding, bowel perforation, nonspecific abdominal pain or obstructive symptoms. In conclusion, duodenal metastasis of cervical cancer is rare and can be frequently missed. A high degree of suspicion can expedite referral for upper endoscopy to diagnose and allow for treatment to extend patients’ quality of life.Figure 1.: Thickened folds in the second portion of duodenum.