Duodenal metastasis from endometrial cancer: A rare metastatic site, a case report and literature review

Abstract

Duodenal metastasis from endometrial cancer is exceedingly rare, with only seven cases reported in the literature. While endometrial cancer typically spreads to lymph nodes, lungs, and the peritoneum, gastrointestinal involvement, particularly in the duodenum, is an uncommon and diagnostically challenging occurrence. We report the case of a 49-year-old woman initially treated for a stage IIIC2, grade 2 endometrioid adenocarcinoma via total hysterectomy, lymphadenectomy, and adjuvant radiochemotherapy. After 1 year of complete remission, she presented with epigastric pain and hematuria. Imaging revealed circumferential thickening of the third portion of the duodenum, complicated by a rare duodenopyelic fistula and right renal obstruction. Endoscopic biopsy confirmed a poorly differentiated carcinoma of endometrial origin. Palliative management involved duodenal stenting, ureteral JJ stent placement, and systemic chemotherapy. This case highlights that duodenal metastasis from endometrial adenocarcinoma is often diagnosed late and carries a poor prognosis, necessitating a multimodal palliative approach aimed at symptom control.

Introduction

Endometrial cancer represents an increasing concern in Western societies, with incidence rising in parallel with obesity, the leading risk factor for this malignancy. In the absence of Lynch syndrome, the average age at diagnosis is typically in the sixth decade of life. ¹ Molecular and hormonal profiling has become crucial in the management of advanced disease, enabling the use of targeted systemic therapies and improving overall survival. ² Approximately 64% of recurrences occur within 2 years of initial treatment. Common sites of dissemination include the pelvic and para-aortic lymph nodes, vagina, peritoneum, and lungs. ³ Metastasis to the duodenum is exceptionally rare, with only seven cases reported to date in the literature. Here, we present the eighth case.

The reporting of this study conforms to the CARE guidelines. ⁴

Case presentation

We present the case of a 49-year-old woman followed since April 2023 for a grade 2 endometrioid adenocarcinoma of the endometrium, stage IIIC2. Initial staging included an abdominopelvic Magnetic Resonance Imaging (MRI), which revealed an enlarged uterus containing a heterogeneous endometrial mass with low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. The lesion shows deep myometrial invasion (>50%) with extension to the uterine serosa. Multiple enlarged pelvic lymph nodes along the internal and external iliac chains and para-aortic suggestive of metastatic disease. No distant abdominal metastases are observed. Serum CA-125 level was 8.5 U/mL. The patient underwent total hysterectomy with bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and para-aortic lymph node dissection. The postoperative course was uneventful. Histopathological examination revealed a papillary serous adenocarcinoma of the endometrium infiltrating more than half of the myometrium, the endocervix, and the parametria, with the presence of vascular emboli. Surgical margins were tumor-free. Lymph node involvement was confirmed in both pelvic and para-aortic stations. Immunohistochemistry showed hormone receptor positivity. The multidisciplinary committee of our institute recommended adjuvant chemotherapy with paclitaxel and carboplatin, followed by external beam radiotherapy and brachytherapy. She remained under regular follow-up.

One year after achieving complete remission, the patient presented with epigastric pain and hematuria. Evaluation revealed signs of urinary obstruction. Chest, abdomen, and pelvis CT scan showed a circumferential thickening of the third portion of the duodenum (42 mm), an atrophic right kidney, dilated pyelocaliceal cavities, and a large right duodeno-ureteral fistula (14 mm). This carcinomatous mass compressed the gastric antrum and extended into the right renal pelvis, causing a duodeno-ureteral fistula. No other metastatic sites were identified (Figure 1). Serum CA-125 was measured and found to be within normal limits (10.23 U/mL). Upper gastrointestinal endoscopy was performed, including duodenal biopsies and placement of a self-expandable metallic stent. Histopathological analysis revealed a poorly differentiated carcinoma. Immunohistochemical staining showed positivity for p63 and PAX8, while CK7 and WT1 were negative. This immunoprofile is consistent with an endometrial origin (Figures 2 and 3). To relieve the urinary obstruction, a right ureteral double-J stent was placed to allow urine drainage from the kidney to the bladder. The multidisciplinary committee of our institute recommended systemic chemotherapy combining carboplatin (AUC 5) and paclitaxel (175 mg/m²) for six cycles to treat the metastatic disease. During follow-up, 1 week after the placement of the JJ stent, the patient presented with abdominal pain, dysuria, and dark-colored urine. A CT scan was performed to evaluate the placement of the two prostheses. It revealed the double-J stent in the ureter, with the distal end positioned in the bladder, with the proximal end of the JJ probe in the duodenal prosthesis (Figure 4). This finding suggested a rare migration of the proximal end of the stent. The complication was managed successfully by repositioning the stent, ensuring continued effective urinary drainage. The patient was referred again for palliative chemotherapy combining Carboplatin and Paclitaxel. However, due to her poor general condition, she received only two cycles and passed away 1 week later. The cause of death was attributed to septic complications arising from the duodeno-ureteral fistula in the context of advanced metastatic disease.

Figure 1.

CT-enhancing axial section shows: Carcinomatous mass pushing back into the gastric antrum (curved arrow) in addition to duodenal right pyelic metastases with duodeno-ureteral fistula (arrow).

CT: Computed tomography.

Figure 2.

(a) Tumor cells were negative for WT1 (IHCx100), (b) Tumor cells were negative for CK7 (IHCx200), (c) PAX8 was positive in tumor cells.

Figure 3.

(a) Poorly differentiated carcinoma in a background of tumor necrosis (HEx40), (b) Proliferation of poorly differentiated and cohesive tumor cells arranged in sheets, trabeculaes and tubules (HEx200).

Figure 4.

CT-enhancing coronal oblique section (a), MIP (b) and 3D rendering volume (c) showing: Double-J stent inserted into the ureter to relieve obstruction and allow urine to drain from the kidney to the bladder.

Proximal end of the JJ probe in the duodenal prosthesis. CT: Computed tomography; MIP: Maximum intensity projection.

Discussion

Recurrence of endometrial cancer is most often local, involving the vagina or the pelvic and para-aortic lymph nodes, and is frequently observed in patients treated with chemotherapy alone. ¹ Extra-nodal disease at the time of recurrence is uncommon. Peritoneal carcinomatosis occurs in approximately 28% of relapses. Recurrence within intra-abdominal organs is rare and is usually associated with aggressive histological subtypes such as clear cell and serous carcinoma. The liver is the most frequently affected intra-abdominal organ, with secondary lesions reported in about 7% of cases. ⁵ Metastatic spread to the duodenum is exceptionally rare, with only seven cases reported in the literature to date (Table 1). The pathway of metastatic spread to the duodenum remains uncertain. In such cases, retrograde lymphatic dissemination from the para-aortic lymph nodes may represent a possible mechanism. ¹² Patients with duodenal metastasis from endometrial cancer typically present with nonspecific symptoms, including gastrointestinal bleeding, melena, duodenal obstruction, or abdominal pain, which was the case with our patient. ⁷

Table 1.

Reported cases of duodenal metastasis from endometrial cancer.

Author, year	Age	Histological type	Clinical presentation	Synchronous/metachronous	Treatment strategies for the duodenal metastasis
Leitão et al. 2017 6	72	Squamous cell carcinoma	Melena	Metachronous	Chemotherapy
Huynh et al. 2018 7	NA	NA	A right lower back pain	Metachronous	Surgery: Resection of the duodenal mass
Ji Son et al. 2020 8	63	Serous and endometrioid carcinoma	Asymptomatic	Synchronous	Chemotherapy
Oluwadunni Emiloju et al. 2020 9	60	Clear cell endometrial carcinoma	Melena	Metachronous	Pancreaticoduodenectomy
João L Pinheiro et al. 2021 3	76	Endometrioid adenocarcinoma	Melena and left upper quadrant discomfort	Metachronous	Chemotherapy
Lipshutz Seth et al. 2023 10	68	Serous carcinoma	Painless jaundice	Metachronous	Palliative care
Xiao and Sun 2024 11	56	Carcinosarcoma	Epigastric pain	Metachronous	Palliative surgery
The present case	49	Endometrioid adenocarcinoma	Epigastric pain	Metachronous	Chemotherapy

NA: Not available.

Owing to the rarity and atypical presentation of this metastatic site, diagnosis is often delayed. While imaging modalities such as CT, PET/CT, and MRI, along with endoscopic evaluation, are essential for detection, definitive diagnosis depends on histopathological and immunohistochemical confirmation of endometrial origin. ³ In our case, the immunohistochemical profile was consistent with a poorly differentiated endometrioid carcinoma. The tumor showed positivity for PAX8 (confirming Müllerian origin) and p63 (suggesting squamous differentiation). The absence of WT1 expression helped exclude a serous subtype. While endometrioid carcinomas are typically CK7 positive, the loss of CK7 expression in this case may be attributed to tumor dedifferentiation and high-grade histology common in metastatic settings

Reported cases encompass various histological subtypes, including endometrioid adenocarcinoma, clear cell carcinoma, squamous cell carcinoma, and carcinosarcoma, as highlighted in the above-mentioned literature review. Duodenal involvement is often associated with aggressive or high-grade tumors. ¹¹ In our patient’s case, the diagnosis was endometrioid adenocarcinoma, grade 2, stage IIIC2.

Treatment is primarily palliative, aiming at symptom management. Surgical procedures such as segmental duodenectomy or pancreaticoduodenectomy may be considered in cases of bleeding or obstruction. Nonetheless, surgery would be extensive and could worsen the prognosis in a patient who is already metastatic. In our case, despite the metastasis being isolated, surgery was not performed due to the patient’s deteriorating general condition. Furthermore, it was considered that this type of surgery could further compromise her condition. The overall prognosis remains poor due to advanced disease and rapid progression. ⁹ Chemotherapy can offer symptomatic relief but is seldom curative. ⁸

Also, we reported a rare complication of a double-J stent, which was the migration of the proximal end of the stent into the duodenal prosthesis. To the best of our knowledge, this specific complication has not been reported in the literature. In a 2021 study by Geavlete et al., which analyzed complications associated with double-J ureteral stents in over 50,000 procedures performed between 1996 and 2021, a total of 41,369 complications were reported.

Stent proximal migration was reported in 427 cases (0.9%) among the short-term stenting (less than 6 weeks), which is a relatively low rate. No cases of migration into adjacent organs, including the duodenum, were documented in this series. ¹³ This complication requires management by endoscopic replacement via a ureteroscopic approach or percutaneous nephrostomy. According to the literature, many reason for migration such as: increased stone diameter and severity of hydronephrosis, the lack of size of the double-J stent affects stent migration, also if stent is too short for the ureter or with prolonged indwelling time and the placement of the proximal stent in fact the upper calyx rather than in the renal pelvis appears to be a significant factor responsible for proximal migration of the stent.^13,14

In our case, the primary cause of stent migration was the presence of a duodeno-ureteral fistula. Secondary factors included the low placement of the stent in the renal pelvis and the absence of an optimally sized stent. To prevent this complication, regular stent replacements are essential to avoid issues related to prolonged indwelling times. These complications should also be avoided, as they can be severe and potentially fatal in patients who already have a compromised general condition.

Conclusion

The duodenum is an exceptionally rare site of metastasis for endometrial adenocarcinoma. Due to its rarity and atypical presentation, diagnosis is frequently delayed. Once extrapelvic dissemination occurs, endometrial cancer is regarded as incurable, and management is therefore palliative. Chemotherapy may provide symptomatic improvement but rarely achieves a cure.