Ahmed A. Elkafrawy, MD1, Laith Numan, MD1, Yousaf Zafar, MD2, Mohamed A. Elkhouly, MD, MSc3, Waled Bahaj, MD1, Cynthia Liu1, Fadi Hamid, MD4
1University of Missouri Kansas City School of Medicine, Kansas City, MO; 2University of Missouri, Kansas City, MO; 3Cook County Health and Hospital Systems, Chicago, IL; 4Saint Luke's Hospital, Kansas City, MO
Introduction: Merkel Cell Carcinoma (MCC) is a rare and aggressive skin cancer that was first described in 1972. Lymph node metastases are common in MCC and distant metastases occur in 8.4% of cases. We present a case of MCC complicated by melena and obstructive jaundice from GI metastases. To the best of our knowledge, less than 20 cases were reported with a similar presentation.
Case Description/Methods: The patient is a 67-year-old male with a history of CAD, COPD and metastatic MCC who was admitted with melena and severe blood loss anemia. He was diagnosed with MCC of the right eyebrow 2 years ago and had a recurrence in the parotid gland that was treated with resection, radiotherapy (RT) and chemotherapy. PET CT scan 3 months prior to admission showed no evidence of distant metastases. After resuscitation and initiation of appropriate medical therapy, the patient underwent an EGD that showed multiple (1 cm) lesions scattered in the stomach and a large (4 cm) ulcerated mass in the lesser curvature with stigmata of recent hemorrhage. Hemospray was applied successfully for hemostasis. Biopsies of the gastric lesions confirmed metastatic MCC. The patient was discharged home and was started on palliative immunotherapy (Atezolizumab) and RT. Repeated PET CT scan showed the progression of the disease with widespread lymphatic, pancreatic, right perinephric, diffuse gastric and bony metastases. Four weeks later he was admitted with jaundice. Bilirubin was 2.5 gm/dl, ALP 458, ALT 457 and AST 441. Abdominal ultrasound showed dilated intra and extrahepatic ducts. An ERCP was performed and it showed a distal CBD stricture. An uncovered metal stent was successfully placed. The patient continued to have recurrent melena and a repeated EGD showed a new friable 4 cm ulcerated periampullary duodenal mass that was not amenable to endoscopic intervention. Mesenteric arteriogram was performed and active bleeding from the duodenal mass with tumor blush in the third part of duodenum was seen. Coil embolization of the GDA and PDA was successfully performed with the cessation of the bleeding. The patient was discharged home to resume palliative RT and immunotherapy.
Discussion: Merkel cell carcinoma is rare and aggressive skin cancer. GI metastases are very uncommon. Close surveillance with PET CT scan is important and high suspicion of GI metastases should be exercised when clinically appropriate.
Citation: Ahmed A. Elkafrawy, MD; Laith Numan, MD; Yousaf Zafar, MD; Mohamed A. Elkhouly, MD, MSc; Waled Bahaj, MD; Cynthia Liu; Fadi Hamid, MD. P2246 - METASTATIC MERKEL CELL CARCINOMA PRESENTING WITH UPPER GI BLEEDING AND OBSTRUCTIVE JAUNDICE. Program No. P2246. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.