Jejunal Metastasis From Adenocarcinoma of the Lung

A 59-year-old woman was evaluated for epigastric discomfort and iron deficiency anemia of 2 months' duration. Two years earlier, she had undergone left upper lung lobectomy and adjuvant radiation for T2 N0 M0 poorly differentiated adenocarcinoma of the lung.

Fadi I. Jabr, MD, of Florence, Ore, reports that results of a fecal occult blood test were positive. Esophagogastroduodenoscopy showed gastritis and duodenitis; a Campylobacter-like organism test was positive for Helicobacter pylori. Colonoscopy revealed 3 tubular adenomatous polyps; these were resected. Abdominal and chest CT scans showed only mild hepatomegaly and volume loss in the left lung, consistent with the previous lobectomy.

A proton pump inhibitor and an antibiotic were prescribed. However, the anemia persisted and the abdominal pain increased and was now accompanied by melena. There were no symptoms of obstruction. The image shown here from the upper GI series revealed a filling mass defect in the jejunum.

Segmental resection of the small bowel showed a 4 × 3 × 3-cm tumor, 20 cm from the Treitz ligament and about three fourths the circumference of the small intestine. Microscopic examination revealed a poorly differentiated adenocarcinoma that recapitulated the morphology and pattern of the lung neoplasm resected 2 years earlier. The tumor involved the mucosa, submucosa, and muscularis propria. Adjacent mesenteric lymph nodes and the resection margin were free of tumor. Immunohistochemical studies showed neoplastic cell expression of carcinoembryogenic antigen and cytokeratins. Results of bone scintigraphy were normal.

Although jejunal metastasis from adenocarcinoma of the lung is relatively rare, it must be considered in all lung cancer patients who have abdominal pain, GI bleeding, or a positive fecal occult test result. Since most patients are asymptomatic, fecal occult blood testing may provide an early clue to the diagnosis of GI metastases. If upper and lower endoscopies and CT scans of the abdomen are unremarkable, then a conventional study, such as an upper GI series, may reveal the diagnosis.

Unfortunately, the prognosis remains poor. Surgical resection provides only palliative treatment of the disease. This patient recovered uneventfully and underwent chemotherapy.