What happened, in summary

This 60-year-old woman had a history of superficially invasive urothelial carcinoma of the bladder before she was treated for a right upper-lobe lung cancer in January 2004. CT and FDG-PET at the time showed no lymph node involvement or distant metastases. She underwent lung bilobectomy. Pathology showed an undifferentiated large cell carcinoma measuring 3.3 cm in the lung parenchyma, without pleural invasion or regional lymph node metastasis, staged T2N0M0. No adjuvant treatment was recommended. Eleven months later, she returned with abdominal pain, weight loss, fatigue, and a palpable left abdominal mass. CT and double-balloon enteroscopy showed a mass in the proximal jejunum. Biopsy showed large undifferentiated cells, and immunohistochemistry was positive for TTF-1, CK8/18, CK7, and vimentin, matching the previous lung tumor profile. Mutation testing found the same tumor-specific KRAS codon 61 mutation in the original lung tumor and the jejunal lesion; the prior bladder carcinoma did not have this mutation. The jejunal mass was therefore confirmed as a metastasis from the lung cancer. Two days after diagnosis, intestinal obstruction occurred. At laparotomy, the tumor could not be removed because of mesothelial invasion, so surgeons performed a side-to-side duodenojejunostomy. Postoperative gastrointestinal bleeding stopped after palliative radiotherapy, 15 Gy in 5 fractions. Two months later, CT showed no residual jejunal tumor. She then received 3 cycles of cisplatin and vinorelbine, stopped because of hearing loss. As of January 2010, she was doing well with no evidence of disease 4 years after the jejunal metastasis diagnosis, despite the earlier obstruction and bleeding.