case_images: PMC10932551_01
case_images: CT. a Image showing a 34-mm spiculated lesion in the S6 lower lobe of the right lung with pleural depression. b Image showing right pulmonary artery involvement and multiple pulmonary artery thrombi (arrow) due to right hilar lymph node metastasis.
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case_images: PMC10932551_01_crg-2024-0018-0001-537778_F01.jpg
case_images: F1
case_images: Additional CT findings included right pulmonary artery involvement due to right hilar lymph node metastasis and multiple peripheral pulmonary artery thrombi showing poor contrast (shown in Fig. 1a, b).
case_images: CT, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). a CT showing an enlarged duodenal papilla (arrow) and gallbladder and a dilated common bile duct. b Esophagogastroduodenoscopy showing an ulcerated lesion on the main duodenal papilla with exudative bleeding from the cranial side of the ulcer base. c Endoscopic hemostasis is performed with clipping and PuraStat  application. d, e In ERCP, precut fistulotomy is performed on an oral ridge that appeared to be a dilated bile duct, and bile outflow is confirmed. Images of successful endoscopic biliary drainage with fully covered self-expandable metallic stent. f Dye endoscopy with indigo carmine, 9 days after EGFR TKI initiation, clearly showing an ulcerated tumor in the main duodenal papilla without bleeding.
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case_images: PMC10932551_01_crg-2024-0018-0001-537778_F02.jpg
case_images: F2
case_images: Duodenal papillary swelling, a dilated common bile duct, and an enlarged gallbladder were also observed (shown in Fig. 2a). Systems, Tokyo, Japan) performed to investigate anemia and melena revealed a mass lesion with fresh blood in the duodenal papilla. Side-viewing duodenoscopy (TJF-Q290V; Olympus Medical Systems, Tokyo, Japan) showed exudative bleeding on the cranial side of the ulceration (shown in Fig. 2b), which was endoscopically treated using clipping (SureClip; MC Medical, Tokyo, Japan) and application of PuraStat  (3D Matrix, Tokyo, Japan) (shown in Fig. 2c). Thereafter, bile duct cannulation was achieved by precut fistulotomy performed using a needle knife, and a fully covered biliary stent (10 mm diameter, 6 cm long, BONASTENT; Medico's Hirata, Osaka, Japan) was successfully placed for bile drainage (shown in Fig. 2d, e), thus improving obstructive jaundice and acute cholangitis. TKI initiation, a biopsy was performed on the duodenal papillary tumors (shown in Fig. 2f).
case_images: Hematoxylin and eosin staining of biopsy of mediastinal lymph nodes showing adenocarcinoma (a: x200). Immunohistochemistry showing tumor cells positive for TTF-1 (b: x200) and napsin A (c: x200). Hematoxylin and eosin staining of the duodenal papillary tumor biopsy showing adenocarcinoma by histopathological analysis (d: x200). Immunohistochemistry showing tumor cells positive for TTF-1 (e: x200) and AE1/AE3 (f: x200).
case_images: crg-2024-0018-0001-537778_F03.jpg
case_images: PMC10932551_01_crg-2024-0018-0001-537778_F03.jpg
case_images: F3
case_images: TKI, endoscopic ultrasonography-guided transbronchial needle aspiration (BF-UC290F; Olympus, Tokyo, Japan) was performed on the mediastinal lymph nodes. The analysis revealed adenocarcinoma by hematoxylin and eosin staining, thyroid transcription factor-1 (TTF-1), and napsin A positivity by immunohistochemistry (shown in Fig. 3a-c); this confirmed the diagnosis of primary lung adenocarcinoma. The biopsy results showed adenocarcinoma by hematoxylin and eosin staining and TTF-1 and AE1/AE3 positivity by immunohistochemistry (shown in Fig. 3d-f). The final diagnosis was duodenal papillary metastasis from primary lung adenocarcinoma.