A review of duodenal metastases from squamous cell carcinoma of the cervix presenting as an upper gastrointestinal bleed

Abstract

Upper gastrointestinal bleeding due to duodenal metastases is extremely uncommon. Extra-pelvic spread of squamous cell carcinoma (SCC) of the cervix to the small bowel is rare with only 6 reported cases in the English literature since 1981(PubMed, Medline).We report the case of a 49-year-old woman who presented with upper-gastrointestinal bleeding two years after the diagnosis of SCC of the cervix. At esophagogastroduodenoscopy, there was a stricture in the second part of the duodenum which was biopsied for a suspected neoplastic lesion. Histologic and immunohistochemical examination showed a malignant lesion with characteristics identical to her original tumor in the cervix confirming the duodenal metastases.The clinical presentation of a 'malignant' upper-gastrointestinal bleed due to duodenal metastases from SCC of the cervix is unusual. Awareness of such infrequent patterns of metastases in cervical cancer confirmed by histopathological diagnosis is important for best practice therapeutic decisions in these patients.

Figure 1

CT Scans of the Abdomen. 1a:. CT scan demonstrates the presence of a soft tissue mass (*) impinging on the duodenum. 1b: CT scan demonstrates the presence of an extensive, abnormal retroperitoneal soft-tissue mass (▲) surrounding the aorta most consistent with metastatic lympadenopathy. 1c: CT scan also shows evidence of some lytic destruction of the left lateral aspect of the L5 vertebral body most likely related to local invasion of the metastatic disease.

Figure 2

Duodenal Biopsy. 2a:. Photomicrograph of haematoxylin and eosin stained slide at low power ( lens objective x2) shows the presence of cohesive sheets of malignant nonkeratinizing squamous cells (*) adjacent to normal duodenal mucosa (#) 2b: Photomicrograph of staining with Cytokeratin 5 shows strong cytoplasmic and membrane staining of the lesional cells (*) with no staining in the adjacent duodenal mucosa (#) 2c: Photomicrograph of staining with P63 shows strong nuclear staining of the lesional cells (*) with no staining in the adjacent duodenal mucosa (#) 2d: Photomicrograph of staining with P16 shows diffuse cytoplasmic and nuclear staining of the lesional cells (*) with no staining in the adjacent duodenal mucosa (#)

Figure 3

Bladder Biopsy. 3a:. Photomicrograph of haematoxylin and eosin stained slide at low power ( lens objective x2) shows the presence of cohesive sheets of malignant nonkeratinizing squamous cells(*) similar to the cells seen in Figure 2a(*). 3b: Photomicrograph of staining with Cytokeratin 5 shows strong cytoplasmic and membrane staining of the lesional cells (*) as seen in Figure 2b. 3c: Photomicrograph of staining with P63 shows strong nuclear staining of the cells (*) as seen in the duodenal biopsy in Figure 2c. 3d: Photomicrograph of staining with P16 shows diffuse cytoplasmic and nuclear staining of the lesional cells (*) similar to those seen in Figure 2d.

Figure 4

Cervix Biopsy. 4a:. Photomicrograph of haematoxylin and eosin stained slide at low power (lens objective x2) shows the presence of cohesive sheets of malignant nonkeratinizing squamous cells(*) similar to the cells seen in Figure 2a (*). 4b: Photomicrograph of staining with Cytokeratin 5 shows strong cytoplasmic and membrane staining of the lesional cells (*) as seen in Figure 2b. 4c: Photomicrograph of staining with P63 shows strong nuclear staining of the cells (*) as seen in the duodenal biopsy in Figure 2c. 4d: Photomicrograph of staining with P16 shows diffuse cytoplasmic and nuclear staining of the lesional cells (*) similar to those seen in Figure 2d.