A 72–year–old male admitted for progressive shortness of breath with pleuritic chest pain for 2 days. He noted weight loss of 25 lbs in the past 6 months. Past medical history includes hypertension and COPD with a 15 pack year smoking history. Chest exam was normal.
Chest X–ray had air space pneumonia in the right upper lobe. He was started on antibiotics for community acquired pneumonia. Further tests showed iron deficiency anemia which prompted investigation. Endoscopy showed multiple ulcerated nodules in the stomach and duodenum suspicious of possible metastatic carcinoma. Biopsy of nodules turned out to be undifferentiated large cell carcinoma positive for CK7 and negative for CK20 ,TTF1, mucicarmine & AB/PAS. CT of the chest, abdomen & pelvis showed a 5– cm necrotic mass at right hilum with right upper lobe post obstructive pneumonitis, non–specific 3–mm liver hypodensity and fullness at the tail of the pancreas without any discrete mass. Transbronchial biopsies of lung mass & bronchial washings were done which revealed anaplastic large cells also consistent with large cell carcinoma.
Hematogenous spread to the GI tract by any cancer is thought to be a rare entity. In our review of literature, presentation of stomach and duodenal metastasis from the lungs are mostly asymptomatic and in those who aren’t, symptoms range from abdominal pain, melena to bowel perforation. Some cases of lung cancer were diagnosed through abdominal symptoms before any pulmonary disease was considered. In our case, iron deficiency anemia was the initiating event that led to the final diagnosis of lung cancer. Gastric metastatic lesions also have a particular endoscopic picture, appearing as umbilicated on the tip or “volcano–like”. Other reported appearances include multiple nodules of variable size with a central ulcer, raised areas without a central ulcer, and polyps or raised plaques. Gastric metastasis occur more commonly in the fundus and cardia, as in our case where in lesions were found in the fundus and body of the stomach and additionally at the second portion of the duodenum. There is the possibility that GI metastasis from primary lung cancer may not be as rare as we once thought it was. As such it would be advantageous to search for gastric metastasis in patients who are diagnosed with lung cancer particularly with squamous, large cell and adenocarcinoma where in most case reports have noted GI metastasis.
Figure 1CT Scan of Chest showing 5 cm necrotic mass at the right hilum.
Figure 21.25 cm nodule with raised, erythematous, irregular rim with central ulceration at Fundus.