Gastric Metastasis from Lung Adenocarcinoma: A Case Report

Introduction: Hematogenous metastases to the stomach are rare. Usually, they are submucosal. The macroscopic appearance of these submucosal gastric metastasis in most cases appears radiographically as a “Bull's eye” sign and endoscopically as “volcano-like” or umbilicated on the tip. These metastases are usually asymptomatic. In this report we present a case of upper gastrointestinal bleeding caused by lung cancer metastases to the stomach.Figure 1Figure 3Figure 2Case report: 69-years-old female with a past medical history of stage IV lung adenocarcinoma with brain and pulmonary metastases presented to with melena of 4 days and hypotension.She was diagnosed with lung cancer 1 month prior to this presentation when she presented to with dyspnea and hoarseness of voice. CT scan of chest with contrast showed a large left upper lobe mass with extensive local involvement. Biopsy revealed poorly differentiated tumor cells. Immunohistochemistry demonstrated diffuse positivity for thyroid transcription factor 1, focal positivity for cytokeratin 7 and was negative for cytokeratin 20 which is most consistent with adenocarcinoma of lung origin. The patient received radiotherapy and she was discharged home. On this presentation, she was tachycardic and hypotensive. Laboratory tests showed a hemoglobin of 7.2 g/dL (from a baseline of 11.5-13 g/dl), platelet count of 175 x 103/uL, and creatinine 1.4 mg/dL (baseline of 0.7-0.8 mg/dL). Coagulation studies were normal. The patient was resuscitated with intravenous fluids and packed red blood cells and started on pantoprazole infusion. Esophago-gastro-duodenoscopy was performed and no active bleeding was detected. A red spot which could not be washed and three nodules with overlying mucosa which appeared inflamed and ulcerated where found in the body of the stomach. The nodules where biopsied and pathology revealed poorly differentiated tumor cells with similar morphological and immunohistochemical profile to the tumor from the tracheal biopsy and therefore is consistent with metastatic deposits from her lung adenocarcinoma. The patient was stabilized but she opted for hospice care and finally succumbed to progressive disease two weeks later. Conclusion: We present a rare case of lung adenocarcinoma with gastric metastasis. In general, it should be considered in a patient with known cancer who presents with upper GI bleeding and endoscopy with biopsy is essential for diagnosis.