Elmer Press

Case Report

World J Oncol 2013;4(2):102-106

Recurrent Adenocarcinoma of Colon Presenting as Duodenal Metastasis With Partial Gastric Outlet Obstruction:
A Case Report With Review of Literature
Parag Brahmbhatta, Jason Rossa, Atif Saleemb, c, Jason McKinneyb, Pranav Patela,
Sarah Khana, Chakradhar M. Reddyb, Mark Youngb

Abstract
Colorectal cancer is one of the leading causes of cancer related
deaths in western world. While most common site for metastasis for
colon cancer is liver, lung, and the peritoneum, metastasis to various other organs such as brain, bones and thyroid has been reported.
Metastatic lesions to the small bowel are more common than primary lesions and most common primary neoplasms that metastasize to
the duodenum are lung cancer, renal cell carcinoma, breast cancer,
and malignant melanoma. We report a very rare case of recurrent
adenocarcinoma of colon metastasizing to duodenum after 2 years
of curative resection of primary cancer. Surgical resection for curative intent as well as palliative management is recommended.
Keywords: Recurrent adenocarcinoma of colon; Duodenal metastasis; Gastric outlet obstruction

gastrointestinal malignancies [1, 2]. In United States, demographically, black population is the predominantly affected
group with higher incidence as well as higher mortality rate
[3]. Metastatic lesions to the small bowel are more common
than primary lesions and most common primary neoplasms
that metastasize to the duodenum are lung cancer, renal cell
carcinoma, breast cancer, and malignant melanoma [4, 5].
It is estimated that about 15 to 20 % of patients with
colorectal cancer present with metastasis and about 50 to 60
% of patients develops metastasis during the course of their
disease [6]. The most common sites of metastasis from colon cancer are the regional lymph nodes, the liver, the lung,
and the peritoneum. Occasional cases of metastasis to bone,
brain, thyroid and adrenals have been reported in literatures
[7, 8]. We report a very rare case of recurrent adenocarcinoma of colon metastasizing to duodenum after 2 years of
curative resection of primary cancer.

Introduction

Case Report

Although small intestine is the longest part of the digestive

tract involving about 75% of total length, incidence of cancer
involving it is very low. With the global incidence of about
1.0 per 100,000 populations, malignant neoplasm of small
bowel is rare. Adenocarcinoma consists of about 30-40% of
all cancers of small bowel and most of the tumors located in
duodenum and duodeno-jejunal junction.
According to a study, small intestinal malignancy accounts for only 1-2% of all malignancy of the gastrointestinal tract and accounts for only 1% deaths related to

A 54-year-old woman presented with one week duration of

persistent nausea and vomiting in March 2012. Prior to current presentation, patient has experienced ongoing nausea,
lasting more than a month with associated symptoms of early
satiety and 10 pound weight loss.
Patients significant past medical history includes diagnosis of stage IIIC ileocecal adenocarcinoma in December
2009, after being presented with intermittent bowel obstruction. Staging at the time of initial diagnosis did not identify
any metastasis. Patient underwent a right hemicolectomy
with curative intent and also completed 12 cycles of adjuvant
chemotherapy with FOLinic acid-Fluororuracil-OXaliplatin
(FOLFOX) regimen in August 2010. Subsequently patient
had a normal surveillance workup which included carcinoembryonic antigen (CEA) level, colonoscopy and computerized tomographic (CT) scan in August of 2011 showing no
evidence of disease recurrence.
During the current presentation, CT scan of abdomen
and pelvis with intravenous (IV) contrast revealed marked
distention with irregular wall thickening of the duodenum
just proximal to the genu causing a partial gastric outlet ob-

Manuscript accepted for publication January 17, 2013

a

Department of Internal Medicine, East Tennessee State University,

Johnson City, TN 37614, USA
b
Division of Gastroenterology and Hepatology, East Tennessee State
University, Johnson City, TN 37614, USA
c
Corresponding author: Atif Saleem, Division of Gastroenterology and
Hepatology, East Tennessee State University, P O Box 70622, Johnson
City, TN 37614, USA. Email: aatifsaleem786@gmail.com
doi: http://dx.doi.org/10.4021/wjon624w

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
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Brahmbhatt et al

World J Oncol 2013;4(2):102-106

Figure 1. CT scan of abdomen and pelvis with IV contrast (A) axial view and (B) coronal view showing
marked distention with irregular wall thickening of the duodenum just proximal to the genu causing a
partial gastric outlet obstruction.

struction (Fig. 1). It also showed enlarged lymph nodes within the small bowel mesentery as well as the retroperitoneum,
concerning for recurrent malignant disease.
Patient was hospitalized and an esophagogastroduodenoscopy (EGD) was performed which showed exophytic
mass covering 3 quarters of the circumference of the duodenal wall at the second portion of the duodenum with luminal
narrowing but no obstruction (Fig. 2). Biopsy specimen of
the mass was identified as a moderately differentiated adenocarcinoma and an immunohistochemical staining profile
showed CK-7 negative and CK-20 and CD-X2 strongly positive, supporting diagnosis of colon as the primary neoplasm
(Fig. 3).
A Positron Emission Tomography (PET) scan revealed
development of bilateral metastatic lung disease, metastatic
bone disease in the cervical and thoracic spine, adenopathy
in the mediastinum, right retrocrural and left iliac regions.
A Magnetic Resonance Imaging (MRI) of the brain also

showed three 7 mm enhancing nodules in the frontal and parietal lobes. Patient subsequently underwent a palliative gastrojejunostomy to bypass the obstruction caused by the duodenal mass and received palliative brain radiation therapy,
but chemotherapy was not started due to poor functional and
nutritional status. Patient was then placed on hospice care.

Discussion
While primary duodenal adenocarcinoma is a rare malignancy, metastasis from a primary colon adenocarcinoma is even
less common. About 45% of the all duodenal neoplasia are
located in the third and fourth portion of the duodenum, 40%
in the second part and only about 15% are located in the first
part of the duodenum [1]. Recurrence of colorectal cancer
is documented in about 30 to 40% of patients after primary
curative surgical resection and majority of these recurrences

Figure 2. Esophagogastroduodenoscopy (EGD) showing exophytic mass covering 3 quarters of the

circumference of the duodenal wall at the second portion of the duodenum.

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World J Oncol 2013;4(2):102-106

Figure 3. An immunohistochemical staining profile of duodenal biopsy showing CK-7 negative and CK-20 and
CD-X2 strongly positive, supporting diagnosis of metastatic colon as the primary neoplasm. A). Cytokeratins 7
(CK-7) negative; B). Cytokeratins 20 (CK-20) positive; C). CD X2 positive.

are seen in first 2 years after surgery [7]. The most common
sites of metastasis from colon cancer are the regional lymph
nodes, the liver, the lung, and the peritoneum. Occasional
cases of metastasis to bone, brain, thyroid and adrenals have
been reported in literatures [7, 8].
There is also an association between colorectal cancer
and cancer of the small bowel, and presence of one cancer
increases the risk of another cancer [9]. According to the report published by the Surveillance, Epidemiology and End
Results (SEER) Program, the patients with 5 or more years
of survival after the diagnosis of small intestine cancer found
to have 2 fold increase in risk of colon cancer. Similarly patients with colon cancer also found to have increased risk
of small intestine cancer and these risks were amplified in
patient whom primary cancer was diagnosed before 60 years
of age [10]. Although there is an association between cancer
of small and large bowel, surveillance EGD is not recommended at this time because of very low incidence.
According to Veen et al, it is extremely rare to have right
sided colonic tumors causing delayed metastatic involvement of the duodenum after resection of the primary tumor
[11]. Although very rare, cases of colon cancer with duodenal metastasis have been described in the literature along
with the pathogenesis of metastasis to the duodenum [12].
Lymphatics from the right colon drain to the periduodenal
104

lymph nodes leading to lymphatic spread from the colon to

the duodenum. Also, the mesentery of the hepatic flexure of
the colon lies in direct contact with the second portion of
the duodenum, forming a pathway for metastatic spread by
way of lymphatics [11-13]. Direct extension from the colon
to the duodenum is also possible, but its less likely. Various
primary neoplasms have their own distinct way of metastasis to duodenum, such as metastasis from lung, breast and
melanoma spreads via blood and lymphatics while metastasis from colon, ovary and stomach spreads via peritoneal
involvement [13].
Patients who underwent curative resection of colon
should be followed up closely according to surveillance
guidelines developed by various organizations. The National
Comprehensive Cancer Network (NCCN) has developed
guidelines for surveillance in patient with colorectal cancer
which includes history and physical examination along with
CEA measurement every 3 - 6 months for first 2 years and
then every 6 months for total 5 years for stage II and III disease. The joint update of guidelines by the American Cancer
Society and the US Multi-Society Task Force on Colorectal
Cancer along with NCCN also recommends colonoscopy in
1 year after the curative resection of primary neoplasm for
stages I through III disease [14, 15].
Because of vague presentation of duodenal carcinoma,

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Brahmbhatt et al

World J Oncol 2013;4(2):102-106

there is delay of around 6 - 8 months between the first symptom occurrence and diagnosis [13]. Often the first presenting
symptom is vague epigastric pain which starts or gets worse
with eating. Other symptoms include weakness, fatigue, and
weight loss. Once tumor gets enlarged, patient develops clinical manifestation of partial or complete obstruction such as
nausea and vomiting. Occult gastrointestinal bleeding is also
reported as presenting feature in the literature [1, 16, 17].
EGD and contrast studies are the first line for diagnosis
of duodenal carcinoma in suspected cases as it allows determination of location, severity and length of involvement.
EGD also allows taking biopsy of the lesion [16, 18]. As
with any other cancer, histologic confirmation is required
and patient also needs staging work up before starting treatment. Because of rarity of disease and very low incidence,
there are no major studies comparing different treatments. If
the patient is a candidate for surgery, aggressive surgery is
the only curative option. Generally Adenocarcinoma involving first and second portion is treated with pancreatoduodenectomy while cancer involving third and fourth portion of
duodenum requires duodenalsegmentectomy. Adjuvant radiotherapy and chemotherapy has also been used in selected
cases [1, 13, 16]. Often patients with extensive metastatic
disease receives only palliative and hospice care. The median age of survival for duodenal adenocarcinoma has been
reported as 18 months with 5-year survival rate of 23% [13].
Conclusion
Although rare, duodenal metastasis from colorectal cancer
has been described in the literature. Recurrence of colon
cancer is common, but metastasis to duodenum is very rare.
Various primary neoplasms have their own distinct way of
metastasis to duodenum. Lung cancer is the most common
primary neoplasm for duodenal metastasis. Vague epigastric discomfort and pain is often first presentation. There
is no specific presentation leading to diagnostic delay from
the first symptom. Although association between cancer of
small and large intestine has been documented, surveillance
EGD is not recommended at this time in patient with colon
cancer. Aggressive surgery is the only curative option.

Acknowledgement
The authors are grateful to Cynthia Forker and Brian Klazynski of Pathology department for providing images of an
immunohistochemical staining.

Authors Contributions
All authors participated fully in the conception, development, and creation of this manuscript. All authors read and

approved the final version of the manuscript.

Grant Support
None.

Conflict of Interest
None.

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