Gastrointestinal: Caval tumor thrombus and duodenal metastasis from endometrial carcinoma

Abstract

A woman had a history of endometrial carcinoma treated with hysterectomy, bilateral salpingo-oophorectomy, and pelvic nodal dissection. After 3 years of uneventful postoperative course, the patient complained of a right lower back pain irradiating to the right inguinal region and right proximal lower extremity. Radiographs and magnetic resonance imaging of the lumbar spine and pelvis were negative for osseous lesions. However, the magnetic resonance exam depicted, on the limited field of view of the lumbar spine imaging, a possible right retroperitoneal lesion compressing the inferior vena cava. Subsequent F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and contrast-enhanced CT of the abdomen and pelvis showed a bilobed hypermetabolic mass. The anterior and horizontal component of the mass represented the duodenal involvement, and the posterior and vertical component corresponded to the inferior vena cava invasion with tumor thrombus (Fig. 1). Endoscopic biopsy of the duodenal lesion showed histological evidence of metastasis from the initially resected endometrial carcinoma (Fig. 2). The patient underwent surgical resection of the duodenal and caval metastasis with, unfortunately, short survival outcome due to subsequent widespread tumor dissemination. Endometrial carcinoma, the most common gynecologic malignancy, typically metastasizes locally and into para-aortic and pelvic lymph nodes before disseminating hematogenously throughout the body. Gastrointestinal tract metastasis from gynecologic malignancies, of rare occurrence, mostly originates from melanoma, breast, lung, colon, and renal cell carcinomas. The exact incidence of small bowel metastasis of gynecologic origin is currently unknown due to its rarity and asymptomatic presentation until the advanced stage of the disease. Caval tumor thrombus is also an uncommon complication in patients with gynecologic malignancies. This case highlights the diagnostic value of F-18 FDG positron emission tomography/CT, contrast-enhanced CT, and endoscopic ultrasound in the detection of atypical metastasis from endometrial carcinoma.