Upper Gastrointestinal Bleeding Secondary To Gastric Metastasis Of Pleomorphic Dermal Sarcoma

INTRODUCTION: Pleomorphic dermal sarcoma (PDS) is a rare cutaneous malignancy, seen primarily in sun exposed areas of elderly individuals. Along with atypical fibroxanthoma (AFX), it is believed to belong to a spectrum of malignant disorders arising from a similar fibrohistiocytic mesenchymal origin. Compared to AFX, PDS represents a more aggressive phenotype of disease with higher rates of recurrence and metastasis. CASE DESCRIPTION/METHODS: An 87-year-old male with a history PDS of the scalp with metastasis to the right humerus presented to the hospital with one week of melena. Pertinent past medical history included non-small cell lung cancer, chronic lymphocytic leukemia, melanoma, squamous and basal cell carcinoma of the skin. On presentation he was noted to be anemic with a hemoglobin of 6.8 g/dL and hematocrit of 22%. He was started on intravenous (IV) proton pump inhibitor (PPI) and underwent an esophagogastroduodenoscopy (EGD). Upon visualization of the stomach, four masses were identified along the greater curvature ranging between 1cm and 2.5cm in size, three of which were actively bleeding. Biopsies of these masses were obtained with cold biopsy forceps. No alternative source of bleeding was identified on exam. Following EGD, supportive measures were continued with IV PPI and packed RBC transfusions. Tissue histology of the gastric masses were consistent with a malignant spindle cell neoplasm, identical to that of the patient's known PDS. Additional imaging revealed new soft tissue lesions in the left hepatic lobe, right kidney, bladder and peritoneum. Given his diffusely metastatic disease, co-morbidities and frailty, therapeutic options were limited. He was deemed not an appropriate chemotherapy candidate and ultimately pursued hospice care. DISCUSSION: We present a case of upper gastrointestinal bleeding secondary to gastric metastasis of PDS. Metastasis occurs in approximately 10-20% of patients with PDS, most commonly involving the lungs and skin1. PDS had previously been classified as undifferentiated pleomorphic sarcoma or malignant fibrous histiocytoma. Under this nomenclature it has rarely been described to metastasize to the stomach and few cases have presented with gastrointestinal bleeding. This case contributes to the general understanding that the stomach can be a metastatic site for a wide variety of non-gastrointestinal cancers.Figure 1.: Proximal gastric body mass along the greater curvature.Figure 2.: Distal gastric body mass along the greater curvature.