Abstract
A 44-year-old man with a background of metastatic colorectal cancer presented with haematemesis. An oesophago-gastroduodenoscopy was performed and revealed five focally haemorrhagic grey mucosal lesions in the body and fundus regions of the stomach between 5 mm and 4 mm in diameter. The biopsies of the gastric mucosal lesions showed invasive poorly differentiated adenocarcinoma in which signet ring cells were a prominent component, thus related to the primary cancer. The background mucosa showed no dysplasia.
BACKGROUND
Patients with longstanding ulcerative colitis and colonic Crohn’s disease have an increased risk of colorectal cancer compared with the general population.1,2 Colorectal cancer is a major cause of morbidity and mortality in industrialised countries. It is the third most common cause of cancer related deaths in North America.3 Colorectal cancer is known to spread in a more or less predictable manner and is one of the most serious complications of inflammatory bowel disease.4 In this case report we would like to present an atypical presentation of colorectal metastasis and highlight the need to be vigilant in patients with metastatic disease.
In this report, we describe a patient with an aggressive rectal carcinoma, which led to expected and unexpected sites of metastases. His presentation with haematemesis did not raise the clinical suspicion of metastatic disease until endoscopy. Metastatic deposits from colorectal carcinoma are well recognised in gastric serosa, but have not previously been reported in gastric mucosa. Although rare, the possibility of bleeding from mucosal secondaries should be considered in similar scenarios.
CASE PRESENTATION
A 44-year-old man with a background of metastatic colorectal cancer presented with haemetemesis. His past medical history included ulcerative colitis diagnosed at the age of 13 years requiring initially a sub-total followed by a total colectomy with ileorectal anastomosis 2 years later. In July 1998, he developed Duke’s C adenocarcinoma of the rectum which required proctectomy with adjuvant chemotherapy. In September 2004, metastatic involvement of blood vessels and lymph nodes of the left groin was detected and treated with chemotherapy and radiotherapy. In March 2006, a further metastatic deposit on the wall of the urinary bladder was found and treated with endoscopic resection.
On presenting to us with haematemesis, an oesophago-gastroduodenoscopy revealed five focally haemorrhagic grey mucosal lesions in the body and fundus regions between 5 mm and 4 mm in diameter (figs 1 and 2).
Figure 1.
Naked eye of the gastric mucosa.
Figure 2.
Close up of the grey haemorrhagic lesions.
INVESTIGATIONS
The biopsies of the gastric mucosal lesions showed invasive poorly differentiated adenocarcinoma (fig 3) in which signet ring cells were a prominent component; the background mucosa showed no dysplasia. The histological appearances of the malignancy were indistinguishable from those of the primary rectal carcinoma. The primary cancer and the metastatic deposits revealed strong cytoplasmic expression of cytokeratin 20 and focal weak cytoplasmic expression of cytokeratin 7, the phenotype of which is typical of primary large bowel adenocarcinoma. Primary gastric adenocarcinomas typically show the reverse of this phenotype—that is, strong expression of cytokeratin 7 and weak or absent expression of cytokeratin 20. This strongly supports the fact that the gastric and bladder malignancies were metastases from the rectal carcinoma.
Figure 3.
Histology slide showing poorly differentiated adenocarcinoma.
OUTCOME AND FOLLOW-UP
The bleeding was brought under control spontaneously and the patient continued to be managed for his disease.
DISCUSSION
There are no similar published cases in respect to this case report and for that reason we find the report fascinating and a useful learning tool in respect to metastatic lesions that can arise from colorectal carcinoma.
LEARNING POINTS
Aggressive rectal carcinoma can lead to expected and unexpected sites of metastases.
The histological report provides a vital role in diagnosing disease.
Metastatic deposits from colorectal carcinoma are well recognised in gastric serosa, but have not previously been reported in gastric mucosa.
Although rare, the possibility of bleeding from gastric mucosal secondaries should be considered in similar scenarios.
Acknowledgments
Mr Tim Wheatley provided the case and discussion for this case report, Mr Ahmed Soliman and Mr Abhi Valliattu reviewed literature and were responsible for writing up and preparing the manuscript, and Dr Neil Robertson contributed in writing of the histopathology section. All authors read and approved the final manuscript.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
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