S6255 A Bleeding Stomach Reveals the Lung’s Hidden Agenda

Introduction: Gastrointestinal (GI) metastasis from non-GI cancers is uncommon, with spread from primary lung tumors being rare. The small bowel, stomach, and colon are the most frequently affected sites. Gastric metastasis typically occurs within 5 months of lung cancer diagnosis, often in older patients with a smoking history. Symptoms range from asymptomatic to melena, abdominal pain, obstruction, or perforation. We present a case of gastric metastasis from squamous cell lung carcinoma presenting with melena and symptomatic anemia. Notably, positron emission tomography (PET) imaging 1 month prior showed no metastases, and the patient had recently undergone lobectomy with mediastinal lymphadenectomy, which was negative for malignancy. Case Description/Methods: A 75-year-old man with hypertension, coronary artery disease, and a >50 pack-years smoking history underwent lung cancer screening, revealing a 12 mm spiculated nodule in the left upper lobe. PET showed low uptake and no distant disease. Upon follow-up, the lesion had grown to 3.0 × 2.3 cm, and lobectomy confirmed it to be moderately differentiated squamous cell carcinoma. Two weeks later, he presented to the hospital with fatigue, dyspnea, and melena. Hemoglobin was 5.1 g/dL (baseline ∼13). Esophagogastroduodenoscopy showed multiple small, raised, vascular-appearing lesions in the stomach and proximal duodenum. Biopsies revealed malignant cells morphologically and immunohistochemically consistent with pulmonary squamous cell carcinoma. Imaging revealed new liver lesions and suspected metastases to the mesentery, bone, and skull. His condition declined rapidly, and he passed away due to complications from metastatic and hospital-acquired conditions. Discussion: GI metastasis from lung cancer is a footprint for poor prognosis, with survival often measured in weeks. Upper GI involvement is uncommon, with an incidence ranging from 0.2% to 1.7%. Spread may occur via hematogenous dissemination, direct extension, or swallowing of malignant sputum. Diagnosis is typically made by endoscopy with biopsy and histologic confirmation. Endoscopic findings may include diffuse mucosal involvement, nodular lesions with or without ulceration, volcano-like masses, or, as in this case, vascular-appearing lesions. In select patients, palliative resection and systemic therapy may help, but treatment was deferred in this case due to rapid decline. This case highlights the importance of maintaining high suspicion when evaluating new GI symptoms in patients with lung cancer, even shortly after curative-intent treatment.