Small Bowel Metastasis Research Articles

S3683 Chronic Diarrhea Secondary to a Metastatic Primary Peritoneal Carcinoma

Introduction: We report a case of a patient with chronic diarrhea secondary to a metastatic cancer to small intestine. Causes of diarrhea are multiple including infectious, malabsorption, inflammatory, osmotic and secretory. Diarrhea secondary to metastatic malignancy has been reported mostly in breast cancers with metastasis to the colon. In our case, a metastatic primary peritoneal carcinoma (PCC) was the most likely cause after exclusion of other common etiologies. Case Description/Methods: A 56 year old female with a history of metastatic PCC presented to the hospital with watery diarrhea of two months duration. She reported greater than 10 bowel movement per day. She denied hematochezia, mucus, or fever. In terms of her oncological history, she was diagnosed with PPC 14 years prior to presentation and treated with omentectomy, hysterectomy, and oophorectomy with subsequent adjuvant therapy. Unfortunately, she developed recurrence with metastasis to lymph nodes and liver that failed to respond to chemotherapy and she received only one dose of pembrolizumab 2 months prior to presentation. Her admission vital signs were normal. On exam her mucous membranes were dry and abdominal exam was normal. Laboratory evaluation was significant for white cell count of 24.7 X 103/uL (normal 4.5-11.0 X 103). Stool studies were negative for infection. Upper and lower endoscopy were performed. Colonoscopy revealed normal colonic mucosa and biopsies were negative for microscopic colitis. Upper endoscopy showed a large, infiltrative, ulcerated, and friable mass in second portion of duodenum. Pathology revealed poorly differentiated adenocarcinoma (Figure 1) with ulceration consistent with gynecological origin. Discussion: Diarrhea secondary to metastatic malignancy has been reported mainly in breast cancer patients. Presumably, The pathophysiology in most of these cases is through diffuse colonic invasion and interference with water reabsorption. We presented a rare case of PPC cancer with metastasis to the small bowel and given similarity to epithelial ovarian cancer, it was reported histologically as adenocarcinoma consistent with gynecological origin. The pathophysiology of diarrhea in this situation is presumably malabsorption. Our patient’s prognosis was poor, and she entered hospice care soon after the diagnostic procedures. It is important to consider small bowel metastasis as an etiology of loose stools in patients with a history of cancer and an otherwise negative work up for more common etiologiesFigure 1:: showing normal duodenal mucosa with underlying tumor (A)..

A small bowel metastasis from an achromic melanoma causing intussusception and bowel obstruction – a case presentation

A small bowel metastasis from an achromic melanoma causing intussusception and bowel obstruction – a case presentation

A Case of Recurrent Small Bowel Metastasis from Breast Cancer 24 Years after Surgery that Required Differentiation from Small Bowel Metastasis from Lung Cancer

A Case of Recurrent Small Bowel Metastasis from Breast Cancer 24 Years after Surgery that Required Differentiation from Small Bowel Metastasis from Lung Cancer

Gastrointestinal tract metastasis of lung cancer: The PD-L1 expression and correlated clinicopathological variables.

The gastrointestinal tract is a rare site for metastatic lung cancer. Programmed cell death-ligand 1 (PD-L1) expression in lung cancer is a biomarker for the response to anti-PD-1/PD-L1 therapy. We investigated clinicopathological features and PD-L1 expression in 25 gastrointestinal metastatic tumors from the lung and primary adenocarcinoma of the small bowel. The small bowel was the most common site (16/25; 64%) of gastrointestinal tract lung cancer metastasis. A total of 19 (76%) of the gastrointestinal metastasis showed PD-L1 expression in ≥5% of tumor cells, with 14 (56%) showing high expression levels (≥50%). In contrast, 21 (84%) expressed PD-L1 in ≥5% immune cells, including 4 (16%) showing a high expression levels (≥50%). The PD-L1 expression on tumor cells and immune cells in primary lung cancer and corresponding gastrointestinal metastasis was concordant in 13 (68%) and 11 (58%) of the 19 paired cases, respectively. Small-bowel metastasis of lung cancer was characterized by a higher incidence of perforation (31% vs. 0%), ulcerated mass (83% vs. 60%), and neoplastic PD-L1 expression (75% vs. 0%) compared to primary small-bowel adenocarcinoma. Gastrointestinal metastasis from lung cancer might be a potential target for immune checkpoint inhibitor therapy, given its high expression of PD-L1.

S1852 Retrograde Balloon-Assisted Deep Enteroscopy in the Diagnosis of Metastatic Melanoma

INTRODUCTION: A 74 year old male with past medical history of melanoma, presents to clinic due to persistently abnormal small bowel findings on PET-CT scan. The following case illustrates a unique and unusual case of metastatic gastrointestinal disease, and the utility of both capsule endoscopy and balloon-assisted deep enteroscopy to assist in the diagnosis of metastatic melanoma. CASE DESCRIPTION/METHODS: A 74 year old male with past medical history of previously excised melanoma in remission presented to clinic due to persistently abnormal small bowel findings on surveillance PET-CT scan. Patient reported feeling well. Over the last 2 years, multiple PET scans had shown intense focal FDG uptake in distal small bowel, deemed to be inflammatory in nature although melanoma recurrence remained a possibility. Given recurrent findings, patient underwent capsule endoscopy which revealed ulcerated, nodular, and erythematous mucosa likely in distal ileum. Patient underwent retrograde double balloon enteroscopy which showed ulcerated, edematous mucosa in distal ileum at 95 cm from ileocecal valve, with biopsies consistent with metastatic melanoma as confirmed by the presence of melanin in tumor biopsy and positive staining. The site of the lesion was marked with SPOT Tattoo to allow for intraoperative localization. Patient underwent surgical resection which revealed second area of ileal metastasis, which was safely resected. DISCUSSION: The following case illustrates the utility of capsule endoscopy to identify small bowel metastasis; an atypical use in the current practice of capsule endoscopy. This case details how retrograde double balloon enteroscopy, in combination with diagnostic modalities such as PET scans and capsule endoscopy, can assist in the diagnosis of distal small bowel disease including metastasis. This case also illustrates how SPOT tattoo utilization may assist with intraoperative surgical localization of suspicious lesions. While metastatic melanoma in the small intestine is a well-described phenomenon, small bowel metastasis has been detected clinically in only 2%–5% of patients with malignant melanoma. Although these lesions are typically resected surgically for diagnosis, our case illustrates the role of initial small bowel endoscopic imaging to assist in localization to facilitate intraoperative management, and that the combination of capsule endoscopy and retrograde double balloon enteroscopy is a practical and feasible method to evaluate for metastatic disease in the distal small bowel.Figure 1.: Area of ulcerated, nodular, erythematous and congested mucosa seen on Capsule Endoscopy.Figure 2.: Area of ulcerated, nodular, erythematous and congested mucosa seen on Capsule Endoscopy.Figure 3.: Area of ulcerated, erythematous and congested mucosa identified on Retrograde Deep Balloon Enteroscopy.

INDEPENDENT PERITONEAL CANCER, NEARLY MISSED AS A METASTASIS FROM LUNG CANCER

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung carcinoma is the leading cause of cancer-related mortality and nearly 50% of cases exhibit distal metastasis at the time of diagnosis. The most common sites of metastasis are brain, spine, nerve, adrenal gland, bone, liver, pleura, but rarely involves the peritoneum.[1] Peritoneal involvement in lung cancer is assumed to be due to metastasis from primary lung cancer. The occurrence of primary peritoneal adenocarcinoma and lung cancer together in one person is uncommon and difficult to distinguish from the metastatic spread. [2] CASE PRESENTATION: A 73-year-old female, smoker of 30 pack-year, presented with symptoms of abdominal bloating, distension, and loss of appetite. Computed tomography(CT) chest, abdomen, and pelvis showed moderate abdominal ascites consistent with peritoneal carcinomatosis, along with a 4.3 cm mass in the left lower lobe of the lung and 1.1 cm left-sided mediastinal lymph node. Paracentesis with ascitic fluid analysis was positive for adenocarcinoma. [Picture 1] She underwent endobronchial ultrasound with biopsy with immunohistochemistry staining which showed poorly differentiated squamous cell carcinoma [Picture 2]. Metastatic workup with a magnetic resonance imaging(MRI) of the brain was negative. Positron emission tomography-computed tomography scan showed a Fluorodeoxyglucose avid left lower lobe lung lesion with hilar and subcarinal adenopathy, consistent with primary lung malignancy. Pelvic ultrasound showed enlarged uterus secondary to multiple intramural fibroids. Labs showed Carcinoembryonic antigen level 1.2 and Alpha-fetoprotein 1.6. Oncology planned to start on carboplatin and paclitaxel along with pembrolizumab every 3 weeks for 4 cycles, followed by maintenance therapy with pembrolizumab every 3 weeks. She reported improvement in the abdominal bloating with the removal of 2-3 liter of peritoneal fluid weekly and symptomatic treatment. The patient continued to feel excessively tired and deteriorated within a few weeks. Unfortunately, the patient passed away before the start of the treatment. DISCUSSION: Peritoneal metastasis of primary lung carcinoma is very rare, only present in 2.7–16% of all lung cancer patients.[3] Advanced stage IV non-small cell lung cancer (NSCLC) and peritoneal adenocarcinoma can present in the same patient together, like in our case, which can be easily missed assuming it as metastatic cancer. Management of two separate cancers requires individualized treatment plans dissimilar to standard practices in the setting of a single tumor. A 1-year survival rate after cytotoxic chemotherapy is only 29% in patients with advanced NSCLC hence priority must be given to the treatment regimen that improves symptoms and prolongs survival. CONCLUSIONS: Therefore, one should always be suspicious and more effort should be made to improve the diagnostic approach and management to rule out any other underlying malignancy. Reference #1: McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer. 1987;59:1486–1489. Reference #2: MARÍA SERENO,1. Lung cancer and peritoneal carcinomatosis. Oncol Lett. 2013 Sep; 6(3): 705–708 Reference #3: Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer. 1950;3:74–85. DISCLOSURES: No relevant relationships by Mary Grace Bethala, source=Web Response No relevant relationships by Apurwa Karki, source=Web Response No relevant relationships by Salman Khan, source=Web Response No relevant relationships by Shobha Mandal, source=Web Response

When Lung cancer chokes your bowel: An interesting case

When Lung cancer chokes your bowel: An interesting case - IJMPO- Print ISSN No: - 2581-4699 Online ISSN No:- 2581-4702 Article DOI No:- 10.18231/j.ijmpo.2020.007, IP International Journal of Medical Paediatrics and Oncology-IP Int J Med Paediatr Oncol

Metastatic Lobular Carcinoma of the Breast Presenting with Small Bowel Metastases: Case Report and Literature Review

Introduction: Invasive lobular carcinoma (ILC) is the second most common histologic type of breast cancer, representing 5% to 15% of invasive tumors. ILC tends to spread to bones, lungs, central nervous system, reproductive organs, and the gastrointestinal tract (GI tract). The most commonly affected organs in the GI tract are the stomach, small intestine, followed by colon and rectum. Case presentation: A 78-year-old woman who was referred to our institution after having a bowel obstruction that required a diagnostic laparoscopy where they identified an obstructing ulcerative lesion in the distal ileum that was managed with a segmental bowel resection. Pathology report showed an invasive lobular breast carcinoma that occluded 90% of the bowel lumen. A PET/CT scan revealed a left breast tumor with increased metabolism. The patient was staged as a clinical cT4b, cN0, cM1 left breast invasive lobular carcinoma (ER/PgR positive, HER-2 negative). She was managed with endocrine therapy with Letrozole (an eight-week course). A follow-up PET/CT showed a peritoneal hypermetabolic nodule adjacent to the previous ileal anastomosis. The lesion decreased in size and metabolic activity. In a multidisciplinary fashion, the endocrine therapy was extended for another three months. Another follow-up PET/CT scan was performed three months after the identification of the peritoneal implant that showed that the nodule increased in size and in metabolism. The lesion continued to decrease significantly in size and became metabolically inactivity. Due to the good breast response and the possibility that the ileal nodule could be a granuloma, she underwent an exploratory laparoscopy with excision of the peritoneal nodule, and a modified left radical mastectomy with immediate breast reconstruction (complex wound closure). The final pathology report of the nodule was negative for malignancy. She continued on endocrine therapy and underwent whole breast irradiation four weeks after the operation. Currently, she is free of disease with no evidence of local, regional, or distant recurrence, and she is still on endocrine therapy. Discussion: The time interval between primary breast cancer and gastrointestinal involvement may range from synchronous presentation to as long as 30 years. The clinical manifestations in GI lobular breast cancer metastasis may range from non-specific complaints to acute GI symptoms, such as a bowel obstruction. There are multiple controversies in the management of ILC. Systemic treatment should be initiated as soon as possible. Indications for postmastectomy radiotherapy are also controversial, given the propensity for multifocal/multicentric tumors and late recurrences, sometimes in atypical locations. Five years of postoperative adjuvant hormonal therapy is an option for women with poor prognosis. Remissions are observed in 32% to 53% of patients. Conclusion: Metastatic lobular carcinoma of the breast has a wide range of clinical presentations. Patients with a history of breast cancer who present with new GI tumors should have these lesions evaluated for evidence of metastasis through histopathologic and immunohistochemical analysis, this will allow for appropriate management. Currently, breast cancer management involves a multidisciplinary approach including surgery, radiotherapy, and systemic medical therapy, and the treatment must be tailored to the patient’s needs.

A Case of a Recurrence-free Survival for Eight Years After Surgical Resection of Small Bowel Metastasis of Lung Cancer

A Case of a Recurrence-free Survival for Eight Years After Surgical Resection of Small Bowel Metastasis of Lung Cancer

2654 Metastatic Squamous Cell Carcinoma to the Small Bowel Masquerading as Crohn’s Disease: A Diagnostic Dilemma

INTRODUCTION: Head and neck squamous cell carcinoma (HNSCC) is the sixth most common type of cancer in the world. The presence of distant metastasis after the initial treatment of head and neck cancers is associated with a poor prognosis. The most frequent site for distant metastasis of HNSCC is lung, followed by mediastinal lymph nodes, bone and liver. Metastatic squamous cell carcinoma (SCC) to the small bowel is an extremely rare occurrence. We present a unique case of a patient with HNSCC who presented with small bowel obstruction and concern for Crohn’s disease (CD) but was ultimately diagnosed with metastatic SCC. CASE DESCRIPTION/METHODS: A 67 year old Caucasian male with a history of SCC of the left pinna and epiglottis on cisplatin chemotherapy and radiation therapy, presented with 2 weeks of intractable nausea, vomiting, and peri-umbilical abdominal pain. Lab work revealed leukocytosis with WBC 16,000. CT abdomen and pelvis was notable for dilated small bowel loops and a long segment thickening of the distal ileum causing a partial small bowel obstruction (Figure 1). His symptoms persisted despite nasogastric decompressiontube and antibiotics. An abdominal MRI showed similar findings of long discontinuous segments of diffuse distal small bowel thickening, luminal narrowing and mural enhancement with concern for small bowel CD. Given these findings, an empiric course of steroids was initiated. Patient’s symptoms improved and he was discharged from the hospital..To further evaluate the small bowel, he underwent a retrograde balloon enteroscopy, which showed subtle findings of multiple sub-centimeter distal ileal nodules (Figure 2), but no other abnormalities. Biopsies of the nodules returned as metastatic poorly differentiated squamous cell carcinoma (Figure 3). DISCUSSION: Small bowel metastasis represents less than 10% of malignant tumors of the small bowel. Small bowel metastasis from HNSCC is an unusually rare occurrence and to date, there is minimal literature on it’s occurrence. Clinical presentation is variable with acute or sub-acute intestinal obstruction, ileus, gastrointestinal hemorrhage or bowel perforation. Here, we present an unusual case of small bowel metastasis from HNSCC, which is unique given the initial radiologic findings suggestive of CD. Thus, clinicians must be cognizant of the metastatic potential of squamous cell cancer in order to prevent delayed diagnosis and avoid devastating consequences.

2666 Disseminated Renal Cell Carcinoma Presented as Obscure Gastrointestinal Bleeding

INTRODUCTION: Metastatic disease to the gastrointestinal tract is frequently observed in patient with known disseminated malignancies. Among those, melanoma, breast and lung cancer are commonly reported. Renal cell carcinoma (RCC) metastasis to small bowel is rare and the presentation varies from obstructive symptoms, intussusception, as well as, gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 85 years old male with medical history of pulmonary embolism on apixaban and progressive stage IV RCC despite multiple lines of therapy on lenvatinib, presented with progressive fatigue and melenic stools. Denied abdominal pain, change in bowel habits, prior episodes of bleeding, or NSAIDs use. Vital signs were unremarkable. Physical exam was pertinent for non-tender abdomen, no distention, active bowel sounds, no rebound or guarding, and a rectal exam that revealed melenic stools. Labs: Hemoglobin of 6.8 g/dL (Baseline 10.3 g/dl), electrolytes, kidney and liver function tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed multiple hepatic, retroperitoneal and mesenteric metastases. He received two units of packed red blood cells with appropriate response. Apixaban was held and he was admitted for workup of gastrointestinal bleeding. Esophagogastroduodenoscopy was unrevealing, while colonoscopy showed a few non-bleeding colonic and rectal angioectasias. A subsequent capsule endoscopy demonstrated an actively bleeding jejunal lesion (Figure 1). He continued to have large melenic bowel movements, and his hemoglobin decreased to 5.5 g/dL. A computed tomography angiography showed a blush of contrast in the jejunum, near the site of a tumor implant (Figures 2 and 3). An interventional radiology embolization was performed, with successful hemostasis. DISCUSSION: One autopsy series reported that only 2 out of 44 metastatic tumors to the small intestine were duodenal implants of RCC. In recent years, however, the number of published reports of RCC small bowel metastasis has been increasing. Retrograde venous spread to the paravertebral vessels has been propose as the route of dissemination of RCC to the intestine and solitary, bulky hypervascular lesions might be diagnostic if seen on CT scan. Luminal evaluation may localize the bleeding and offer potential treatment, however, angiography with embolization is the preferred therapeutic approach for small intestine lesions. Small bowel metastases must be considered as an etiology of bleeding when patients with RCC present with melena.

2622 A Case of Metastatic Renal Cell Carcinoma to the Jejunum Presenting as Iron Deficiency Anemia

INTRODUCTION: Small bowel malignancies comprise only 0.35% of all malignancies and small bowel metastases only comprise 2% of malignancies, only 7.1% of which are from a primary renal cell carcinoma (RCC).This case demonstrates a rare metastatic RCC of the small bowel diagnosed through video capsule endoscopy (VCE) prompting an antegrade double-balloon enteroscopy (DBE). CASE DESCRIPTION/METHODS: A 53-year old male with hypertension, diabetes mellitus, and anemia presented with a rapidly worsening, necrotic right lower quadrant abdominal wall lesion. Dermatopathology from a wound edge biopsy demonstrated an ulcer with neutrophils and karyorrhectic debris, consistent with pyoderma gangrenosum (PG). He was found to have iron deficiency anemia (IDA) requiring multiple blood transfusions and iron infusions. Colonoscopy and esophagogastroduodenoscopy were unremarkable. VCE demonstrated markedly abnormal mucosa in the proximal jejunum, occupying at least 75% of the lumen with several satellite lesions. Antegrade DBE revealed a large ulcerated jejunal mass with leakage of serosanguinous fluid. Pathology showed poorly-differentiated carcinoma of unknown etiology. Pan-CT revealed a 5.6 × 5.4 cm solid mass in the right kidney with invasion of the right renal vein with thrombus extending into the inferior vena cava, liver masses, and pulmonary nodules consistent with metastatic renal cell carcinoma. DISCUSSION: This is a rare case of RCC metastatic to the small bowel. Only three other case studies report this in the literature. Approximately 25–30% of patients have metastatic disease at time of RCC diagnosis. The most common sites of metastasis for RCC include lymph nodes, lung, bone, liver and brain. Metastasis to the small bowel often originate from cancers of the breast, lung, esophagus, head and neck, and melanoma. While there have been case reports of jejunal metastases many years status-post nephrectomy, there have only been three reported cases of synchronous jejunal metastases from RCC. Metastatic RCC to the small bowel can present as gastrointestinal bleeding and intussusception. VCE and DBE were useful diagnostic tools in our particular case. CT or MR enterography may have also served as an appropriate diagnostic alternative, and in retrospect may have helped to make the diagnosis sooner. Overall, it is important to consider small bowel malignancy on the differential diagnosis in a patient who presents with IDA.

2033 Gastrointestinal Bleeding: A Rare Manifestation of Renal Cell Carcinoma

INTRODUCTION: We describe a rare cause of gastrointestinal bleeding in a patient with metastatic renal cell carcinoma (RCC) and discuss consideration and workup of this manifestation, as it is becoming more common given improved survival of this patient cohort. CASE DESCRIPTION/METHODS: A 65-year-old male with history of RCC treated with left nephrectomy complicated by local recurrence and pancreatic tail involvement, on nivolumab, presented with melena and dyspnea. Vitals were notable for orthostasis, melena on rectal exam, and labs revealed a Hgb of 5.6 gm/dL. After resuscitation, the patient underwent push enteroscopy and colonoscopy which did not reveal a source. The following day, the patient developed large volume hematochezia with lightheadedness, hypotension, and acute blood loss anemia requiring transfusion. Given his negative endoscopy and known metastatic RCC, CT angiogram was performed demonstrating an enhancing left upper quadrant soft tissue mass invading into the small bowel lumen. Interventional Radiology was consulted and recommended against embolization due to high risk of small bowel necrosis. Subsequently, Surgery was consulted and requested video capsule endoscopy, but the patient deteriorated requiring emergent surgery. An ileal mass, confirmed to be metastatic RCC, was resected. The patient had no further bleeding and was discharged home; he continues to follow closely with Oncology. DISCUSSION: Metastases to the small bowel are a rare cause of GI bleeding, but are often due to malignancies of the breast, cervix, lung, and melanoma. RCC metastatic to the small bowel has only been described in case reports thus far, but may become more common. Advances in targeted chemotherapeutics of the VEGF and mTOR pathways lead to improved survival and thus, more opportunities for metastases. Patients may present with intussusception, bowel obstruction, or GI bleeding alone, with bleeding favored by their vascular nature. Patients will undergo extensive upper and lower endoscopic evaluation without localizing the source, prompting cross-sectional imaging which is more sensitive for confirming the diagnosis. Surgery is often required, as tumors supplied by branches of the mesenteric arteries pose significant risk of small bowel infarction if embolized. In patients with known history of RCC who present with GI bleeding, small bowel metastases should be considered as an etiology if endocscopy is negative, and obtaining CT imaging urgently may lead to timely management of such lesions.

1942 A Rare Source of Gastrointestinal Bleeding Discovered With Capsule Endoscopy

INTRODUCTION: Melanoma accounts for 5% of all skin cancers, with lentigo maligna melanoma (LMM) accounting for 10–15% of melanomas. The LMM variety harbors a risk of invasive progression up to 20%. Studies have shown that the small bowel is a preferred site for melanoma metastasis due to its high vascularity, and approximately 60% of patients diagnosed with melanoma skin cancer will have gastrointestinal (GI) metastasis. The usual time for primary melanoma to GI metastasis is 60–90 months. Metastatic melanoma is a rare cause of GI bleeding but should be considered in all patients with history of cutaneous melanoma. This case report presents a man with history of LMM who presented with melena and capsule endoscopy identified small bowel metastasis of the primary cutaneous melanoma. CASE DESCRIPTION/METHODS: A 78-year-old man with medical history of cutaneous melanoma and Mohs surgical resection 2 years prior presented to the emergency department for melena over a 2-week duration. One year before this admission the patient presented with similar complaints and esophagogastroduodenoscopy (EGD) with colonoscopy did not yield a bleeding source. At admission he was hemodynamically stable with a hemoglobin of 9.7. Hemoccult testing in the emergency department was negative, but the patient was admitted for monitoring. Gastroenterology was consulted and because the patient had a stable hemoglobin during his stay without hemodynamic compromise, and in-light of recent negative EGD and colonoscopy, the decision was made to follow-up outpatient with capsule endoscopy (CE). On review of CE footage, the patient was found to have an ulcerated mass with active bleeding in the small bowel. Biopsy confirmed the mass was metastatic melanoma. The patient was referred to oncology who found multiple boney and liver metastases and started him on Nivolumab and Zometa. DISCUSSION: Metastatic melanoma spreads to the small bowel in 60% of cases. As in this case, metastatic melanoma to the small bowel can cause an occult GI bleed, or even massive bleeding and hematemesis, with some cases of intussusception also reported. Whatever the presentation, one should have a high index of suspicion of metastasis in patients with a history of cutaneous melanoma and new GI bleeding. Negative EGD and colonoscopy should prompt an investigation with CE to rule out metastatic lesions.

An extremely rare primary sarcoma of the lung with peritoneal and small bowel metastases: a case report

BackgroundPrimary sarcoma of the lung is a very rare malignant tumor accounting for less than 0.5% of all lung tumors and presenting diagnostic and treatment challenge. We describe a case of a patient diagnosed with primary lung undifferentiated pleomorphic sarcoma developing subsequent peritoneal and small bowel metastases, which stand for highly unusual disease presentation.Case presentationA 57-year-old male presented with extensive partially necrotic tumor in the left upper lobe (LUL) of the lung that involved LUL bronchus and extended to the visceral pleura. There was no evidence of nodal or visceral dissemination. After initial presentation, the patient was admitted to the hospital’s pulmonology department for further workup. The most likely diagnosis based on biopsy specimen was poorly differentiated sarcoma. Left pneumonectomy with mediastinal lymph node dissection was performed. The final pathohistological diagnosis (PHD) was undifferentiated pleomorphic sarcoma (UPS). Three months after lung surgery, a follow-up CT scan was done which showed a 60-mm obstructive metastatic intraabdominal lesion with small bowel infiltration and further separate peritoneal deposits. Unfortunately, an urgent surgery had to be performed as the patient developed signs of acute abdomen due to bowel perforation. Only 2 months later, the patient passed away at home.ConclusionsTreatment options of UPS are based on algorithms used in treatment of extremity lesions with well-established role of surgery. However, the role of perioperative chemotherapy remains equivocal with no strong evidence-based data due to the rarity of the disease. Small bowel is an unexpected metastatic site, but of significant clinical relevance.

Small bowel metastasis from pulmonary rhabdomyosarcoma causing intussusception: a case report

BackgroundRhabdomyosarcoma (RMS), especially primary pulmonary RMS, is an extremely rare type of soft tissue sarcoma in adults. Small bowel is an uncommon site for metastases.Case presentationThis report described an unusual case of jejunum metastasis from primary pulmonary RMS causing intussusception in a 75-year-old man. The patient consulted for 2 weeks of continuous dyspnea. Chest computed tomography (CT) demonstrated a large mass involving the left lower lobe. Transthoracic biopsy confirmed the existence of pleomorphic RMS. Immunohistochemical studies showed positive findings about desmin and MyoD1. The results of gastroscopy, colonoscopy and abdominal CT were all negative. Positron emission tomography/CT demonstrated a fluorodeoxyglucose-reactive large lesion in the left lower lobe without metastatic lesions. The patient received synchronous chemoradiotherapy. After 9 months, the patient presented with intermittent upper abdominal pain with nausea and vomiting. CT showed small bowel dilatation secondary to intussusception. The patient subsequently received laparotomy, and the intussuscepted small bowel segment was resected. Histological examination revealed pleomorphic RMS involving the mucosa, submucosa, and muscular tissues.ConclusionsRMS is highly aggressive and metastatic. The metastatic disease can rapidly progress to cause subsequent complications. The possibility of small bowel metastasis should be considered, although it is extremely rare.

Emergency Surgery for Small Bowel Metastasis from Melanoma: Report of Three Cases

Emergency Surgery for Small Bowel Metastasis from Melanoma: Report of Three Cases

Clinical time course and CT detection of metastatic disease to the small bowel.

The purpose of this study was to identify the CT characteristics of metastatic disease of the small bowel and define the clinical time course between primary tumor diagnosis and small bowel metastasis detection. A retrospective search of a pathologic database for metastases to small bowel identified 242 cases. Exclusion criteria were cases without CT (N = 49), serosal or mesenteric metastases (N = 114), or cases of direct invasion to small bowel (N = 63). The clinical records and imaging were reviewed for 16 patients. Melanoma was the most common malignancy to metastasize to small bowel (7 of 16 patients). Only one of the 16 cases was detected at the time of initial diagnosis of their primary malignancy. The average time from diagnosis of the primary malignancy or remission to the time of detection of the small bowel metastasis was 7.2 and 8.3years, respectively. The most common symptoms were gastrointestinal bleeding (N = 5) and small bowel obstruction (N = 5). In 3 cases, the masses were not identified on pre-operative CT. Metastases to the small bowel often occur many years after the initial diagnosis of the primary malignancy or entering remission and may be symptomatic. Attention to the small bowel is particularly important in melanoma patients, who may have multiple small bowel metastases, even after many years of being disease free. As oncology patients undergo numerous surveillance scans and improved therapies allow for longer survival, detection of these masses at a small size can facilitate elective resection to avert urgent surgical intervention.

A Case of Superficial Esophageal Cancer Causing Intestinal Obstruction due to Small Bowel Metastasis One Year after Successful Curative Radiation Therapy

A Case of Superficial Esophageal Cancer Causing Intestinal Obstruction due to Small Bowel Metastasis One Year after Successful Curative Radiation Therapy

A Case of Hematogenous Small Bowel Metastasis from Colon Cancer after Colectomy

A Case of Hematogenous Small Bowel Metastasis from Colon Cancer after Colectomy