PICTURES IN DIGESTIVE PATHOLOGY

 

Severe gastrointestinal bleeding secondary to duodenal metastasis from a choriocarcinoma

Hemorragia digestiva grave por metástasis duodenal de coriocarcinoma

 

 

J. Iglesias García^1,2, E. López García³, F. Macías García^1,2, J. Castro Castro⁴, J. Iglesias Canle^1,2, C. Beiras⁵, J. Lariño Noia^1,2, B. Cigarrán^2,6, J. Forteza Vila⁷ and J. E. Domínguez Muñoz^1,2

¹Department of Gastroenterology.
²Foundation for Research in Digestive Diseases.
³Department of Neurosurgery. University Hospital Xeral-Calde. Lugo.
⁴Department of Neurosurgery and
⁵Department of General Surgery. University Hospital of Santiago de Compostela. A Coruña, Spain.
⁶Department of Internal Medicine. Hospital Virxe da Xunqueira. Cee. A Coruña, Spain.
⁷Department of Pathology. University Hospital of Santiago de Compostela. A Coruña, Spain

 

 

Case report

A 23-year-old man, operated on March 2004 for a malignant mixed germ-cell tumor in a testicle, was admitted in December 2004 at the Department of Neurosurgery after presenting with a left frontal hematoma, initially related to a left frontal arterio-venous malformation (AVM) (Spetzler grade I). The patient underwent a left fronto-temporal craniotomy, and a total evacuation of the hematoma (Fig. 1). Afterwards, the patient presented with severe gastrointestinal bleeding. A gastroscopy was performed, which identified an ulcerated subepithelial lesion at the 3^rd portion of the duodenum with active bleeding (Fig. 2). Hemostasis was achieved after a local injection of adrenalin. After 4 days the patient had signs suggesting rebleeding. At this point, the patient underwent an abdominal arteriogram, which did not show any alterations. A second gastroscopy was then performed, which demonstrated the same duodenal lesion with active bleeding. Hemostasis was again achieved with the injection of adrenalin and argon plasma coagulation. Due to the high risk of rebleeding and the uncertain etiology of the lesion, the patient was scheduled for surgery after endoscopically marking the lesion with hemoclips. The surgical resection was performed with no complications. The patient evolved favorably without signs of rebleeding. Final histology showed an infiltration of the duodenal wall by a choriocarcinoma (syncitiotrophoblastic cells showed positivity for HCG, CK-AE1, CK-CAM 5.2, CK-, and were negative for alkaline phosphatase, vimentin and C-KIT). The study was completed with a thoracic and abdominal CT scan. These identified metastatic disease with lesions at pleural, lung, mediastinum, liver, kidney and intraabdominal lymph node levels (Fig. 3). The patient is now under oncological treatment.

 

Discussion

Non-gestational choriocarcinoma is a trophoblastic germ-cell tumor that spreads through the lymph and blood from the retroperitoneal space, mediastinum and gonads. Metastatic lesions produce beta-human chorionic gonadotropin. These lesions have hemorrhagic tendency, and thus usually present with bleeding at the implant site. Most characteristic locations include the lung, brain, liver, bones and lymph nodes, affecting the gut in less than 5% of cases (1,2). In our case, the first clinical manifestation was a left frontal hematoma in the brain.

Related to the gut, the stomach is the organ most commonly affected (mainly fundus and upper body), although there are few cases published in the literature of metastasis affecting the small intestine and colon (2-5). Characteristically, tumor cells cannot pass the capillary barrier of the muscularis mucosae, so implantation takes place in the submucosa. For this reason, gastrointestinal metastasis corresponds to subepithelial lesions and/or ulcerated polypoid masses (3).

Our patient presented with a case of severe gastrointestinal bleeding related to a duodenal subepithelial lesion, a location not previously reported in the literature. In this context, the specific treatment of gastrointestinal metastases remains controversial. There are few communications about surgical resection for isolated lesions (4,6) or of angiographic embolization (5). In our case urgent surgical treatment was needed because of our inability to control bleeding either endoscopically or radiologically. Finally, a histological analysis of the surgical specimen was essential to reach the diagnosis. In this context, the brain hematoma was related to the same pathology.

 

References

1. Sheinfeld J. Nonseminomatous germ cell tumors of the testis: current concepts and controversias. Urology 1994; 44: 2-14.        [ Links ]

2. Molina Infante J, Beceiro Pedreño I, Ripoll Noiseux C, Marín Jiménez I, González Asanza C, Menchén Fernández-Pacheco P. Gastrointestinal hemorrhage due to metastatic choriocarcinoma with gastric and colonic involvement. Rev Esp Enferm Dig 2004; 96: 77-80.        [ Links ]

3. Hsu C, Chen J, Changchien S. Endoscopic features of metastatic tumors in the upper gastrointestinal tract. Endoscopy 1996; 28: 249-53.        [ Links ]

4. Zerbib P, Prieur E, Khory-Helou A, Catala P, Pruvot FR, Chambor JP. Hemorrhagic digestive metastases from testicular choriocarcionoma. Ann Chir 2002; 127: 300-1.        [ Links ]

5. Rosenblatt GS, Walsh CJ, Chung S. Metastatic testis tumor presenting as gastrointestinal hemorrhage. J Urol 2000; 164: 1655.        [ Links ]

6. Galloway SW, Yeung EC, Lau JY, Cheng CS. Laparoscopic gastric resection for bleeding metastatic choriocarcinoma. Surg Endosc 2001; 15: 100.        [ Links ]