|Year : 2015 | Volume
| Issue : 3 | Page : 648
Metastatic tumors in the duodenum: A report of two cases
Masaya Iwamuro1, Hirokazu Uetsuka2, Kiyoshi Makihata3, Kazuhide Yamamoto4
1 Department of Gastroenterology, Onomichi Municipal Hospital, Onomichi 722-8503; Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700 8558, Japan
2 Department of Surgery, Onomichi Municipal Hospital, Onomichi 722-8503, Japan
3 Takuma Makihata Clinic, Onomichi 722 2324, Japan
4 Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
|Date of Web Publication||9-Oct-2015|
2-5-1 Shikata-cho, Kita-Ku, Okayama 700-8558
Source of Support: None, Conflict of Interest: None
Two cases are presented involving a 71-year-old male with adenocarcinoma of the lung and a 57-year-old male with adenocarcinoma of the sigmoid colon, each with metastatic lesions located in the duodenal bulb. Each lesion appeared as a submucosal tumor with an ulcer at the center. Lymph node swelling in the hepatoduodenal ligament was also found to precede the emergence of each duodenal metastasis. These cases indicate that involvement of the lymph node in the hepatoduodenal ligament may be a forerunner of duodenal metastasis.
Keywords: Duodenal neoplasm, gastrointestinal endoscopy, lymphatic metastasis, metastasis
|How to cite this article:|
Iwamuro M, Uetsuka H, Makihata K, Yamamoto K. Metastatic tumors in the duodenum: A report of two cases. J Can Res Ther 2015;11:648
| > Introduction|| |
Direct invasion of the duodenum by pancreatic or bile duct cancer is frequently encountered. However, distant metastasis to the duodenum by malignancies originating in other organs is rare. In two recent cases, patients presented with metastatic tumors of the duodenum. In one case, the duodenal metastasis appeared soon after the diagnosis of primary lung cancer. In the second case, the duodenal tumor represented a recurrence of colon cancer following surgery. In both cases, swelling of the lymph node in the hepatoduodenal ligament preceded each duodenal metastasis. These cases suggest that metastasis to the lymph node of the hepatoduodenal ligament is a possible predictor of duodenal metastasis. To the best of our knowledge, this is the first report to examine signs preceding the occurrence of metastatic tumors in the duodenum.
| > Case Reports|| |
The chest X-ray examination revealed that a 71-year-old Japanese male had primary lung cancer. The patient had no previous history of gastrointestinal diseases. A computed tomography (CT) scan revealed a pulmonary tumor with a diameter of 3.5 cm in the right middle lobe of the lung that had directly invaded the pericardial sac [Figure 1]a. Adrenal gland metastases and multiple lymph node metastases were also detected in the mediastinum, right pulmonary hilum, and hepatoduodenal ligament [Figure 1]b. A cytologic examination of bronchial lavage fluid revealed the presence of atypical cells exhibiting anisokaryosis, hyperchromasia, and nuclear enlargement [Figure 1]c. The patient was diagnosed with clinical stage IV (T3, N2, M1b) adenocarcinoma of the lung. Combination chemotherapy involving cisplatin and irinotecan was administered.
|Figure 1: A CT scan revealed the presence of a pulmonary tumor in the right lobe of the lung (a, indicated with arrow). Lymph node swelling in the hepatoduodenal ligament was also detected (b, indicated with arrow). (c) A diagnosis of adenocarcinoma of the lung was confirmed based on a cytologic examination|
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After one cycle of treatment, melena occurred and the patient developed anemia. An esophagogastroduodenoscopy revealed a huge ulcerative lesion in the duodenal bulb [Figure 2] a and b. The periphery of the ulcer was elevated and covered with intact duodenal mucosa. A CT scan confirmed the presence of a tumorous lesion in the duodenum [Figure 2]c. Histological examination of biopsy samples obtained from the duodenal tumor revealed diffuse proliferation of atypical cells with prominent nucleoli and a high nuclear-cytoplasmic ratio [Figure 3]a. These cells were also positive for expression of thyroid transcription factor-1 [Figure 3]b, weakly positive for cytokeratin 7 expression [Figure 3]c, and negative for cytokeratin 20 expression [Figure 3]d. Based on these histological and immunohistochemical features, the patient was diagnosed with duodenal metastasis of lung adenocarcinoma. After another cycle of cisplatin plus irinotecan and one cycle of carboplatin plus pemetrexed sodium hydrate, peritoneal dissemination was observed to progress. Subsequently, the patient's condition deteriorated and he died 5 months after the diagnosis of lung cancer.
|Figure 2: (a and b) Images of the metastatic tumor present in the duodenum of Patient 1. An esophagogastroduodenoscopy detected a large ulcerative lesion in the duodenal bulb. (c) A CT scan also detected the presence of a tumor (c, indicated with arrow)|
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|Figure 3: Biopsy samples from the duodenal tumor contained atypical cells (a; H and E staining; magnification, ×20). Tumor cells were positive for thyroid transcription factor-1 (b; magnification, ×40), weakly positive for cytokeratin 7 (c; magnification, ×40), and negative for cytokeratin 20 (d; magnification, ×40)|
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A 57-year-old Japanese male underwent a colonoscopy due to chronic constipation and anemia. He was diagnosed with sigmoid colon cancer and was referred to our hospital for further investigation and treatment. A CT scan revealed two metastatic liver tumors measuring 6 and 2 cm in diameter, as well as abnormal mucosal thickening of the sigmoid colon. Laparoscopy-assisted resection of the sigmoid colon and conventional partial resection of the liver were performed separately. The postoperative diagnosis was adenocarcinoma of the sigmoid colon, type 2, 64 x 20 mm, tub2, SS, N1, P0, H1, M0, stage IV. The patient refused administration of adjuvant chemotherapy. Eight months after surgery, tumor recurrence in the liver and lymph node metastases in the hepatoduodenal ligament were detected by magnetic resonance imaging [Figure 4]. An exploratory laparotomy revealed that the recurrent tumors were unresectable since the tumor cells had directly invaded the portal vein and stromal tissue of the hepatoduodenal ligament from the lymph node.
|Figure 4: (a) T1-weighted image and (b) enhanced T1-weighted image of Patient 2. Tumor recurrence was detected in the caudate lobe of the liver (indicated with arrowhead), and showed ring enhancement on contrast enhanced T1-weighted images. A flat-shaped lymph node adjacent to the liver was also detected (indicated with arrow)|
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Nine cycles of chemotherapy with capecitabine, oxaliplatin, and bevacizumab, followed by five cycles of panitumumab monotherapy, were administered. Despite this, the recurrent liver tumor increased in size and a duodenal tumor appeared. An esophagogastroduodenoscopy revealed an irregular-shaped tumor with an ulcer at its center in the duodenal bulb [Figure 5]. An analysis of the biopsy samples obtained showed the presence of a well to moderately differentiated adenocarcinoma [Figure 6]a. Moreover, these specimens were similar to those resected from the primary colon cancer [Figure 6]b. The patient died 33 months after the diagnosis of colon cancer.
|Figure 5: An irregularly shaped, ulcerated tumor was detected in the duodenal bulb during the esophagogastroduodenoscopy performed for Patient 2|
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|Figure 6: Histological images of the biopsy samples from Patient 2. The duodenal tumor presented as a well to moderately differentiated adenocarcinoma (A; magnification, ×20) that was similar to the colon cancer resected from the same patient (B; magnification, ×20)|
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| > Discussion|| |
Metastasis involving the duodenum is associated with various malignancies, including melanoma, lung cancer, cervical cancer, renal cell carcinoma, thyroid cancer, hepatocellular carcinoma, and Merkel cell carcinoma.  In particular, postmortem studies of patients with lung cancer have found metastasis to the gastrointestinal tract. For example, Antler et al. reported that 58/423 (13.7%) autopsy cases of primary lung cancer had gastrointestinal involvement.  Among them, 20 (4.7%) patients had metastasis to the small bowel. Stenbygaard et al. reported a similar incidence of 4.6% (10/218 patients),  while McNeill et al. found 46/431 (10.7%) patients with lung cancer had small intestinal metastasis at the time of autopsy.  However, metastatic lesions in the duodenum are rarely encountered in clinical settings. For example, in a histopathology study of 615 consecutive duodenal specimens conducted by Terada, there were no cases involving metastatic lesions in the duodenum.  This discrepancy between clinical and postmortem findings can be explained by the observation that metastatic lesions in the duodenum rarely give rise to symptoms or complications. , In addition, the populations studied in postmortem studies have been limited to patients with malignancies. However, the majority of subjects undergoing an esophagogastroduodenoscopy do not have a malignant disease.
For the two patients examined in the present study, both metastatic lesions were observed in the duodenal bulb. Moreover, macroscopically, each lesion had an ulcer at the center and appeared as a submucosal mass with intact mucosa at its periphery. These features are consistent with the morphology commonly observed for duodenal metastases. Furthermore, metastatic tumors of the duodenum are most frequently seen in the duodenal bulb or in the periampullary region of the duodenal second portion. , Endoscopically, a lesion can form a submucosal tumor with or without ulceration, it can have multiple nodules that vary in size, or it can have raised plaques. ,,, Of these characteristics, a submucosal tumor mass that is elevated and ulcerated at the apex is specifically referred to as a 'volcano-like' lesion, and this is a well-known feature of metastatic tumors in the gastrointestinal tract. , In addition, patients with this type of mass generally present with gastrointestinal bleeding or intestinal obstruction, as observed for Patient 1. ,,,,
It was noteworthy that lymph node swelling of the hepatoduodenal ligament was found to precede the emergence of a metastatic lesion in the duodenum in both patients examined. In the posterior case, an exploratory laparotomy also revealed invasion of tumor cells into the stromal tissue of the hepatoduodenal ligament and portal vein. Based on these observations, we hypothesize that the tumor cells primarily metastasized to the lymph node of the hepatoduodenal ligament via a lymphatic route, then invaded the duodenum to form a tumor. Although such involvement of the lymph node in relation to the hepatoduodenal ligament is infrequent, except in cases involving pancreatobiliary and periampullary carcinomas, physicians should be aware of the possible emergence of metastasis in the duodenum.
In conclusion, two cases involving the development of a metastatic lesion in the duodenum were presented, and both patients exhibited lymph node swelling of the hepatoduodenal ligament prior to detection of each metastasis. Based on these results, it is recommended that physicians be aware of the possibility that involvement of the lymph node in the hepatoduodenal ligament may indicate duodenal metastasis.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]