A 46 year old man with carcinoma of unknown primary site

A 46 year old white man presented via the general medical on-call team with hypotensive collapse and melaena. Emergency oesophagogastroduodenoscopy after initial resuscitation showed bleeding duodenal ulcers that were amenable to endoscopic injection. On subsequent questioning by the admitting doctor, he reported gradually increasing abdominal girth, weight loss, and intermittent abdominal pain over the past two years. Systematic review yielded no further symptoms. His medical history was unremarkable and the only drug that he currently took was paracetamol. He smoked 15 cigarettes a day (20 pack years) and had no history of excess alcohol use.

Positive findings on examination were nodular hepatomegaly (2 cm below the costal margin) and a firm fixed 2 cm nodule at the umbilicus. He had no signs of chronic liver disease, and external genitalia and digital rectal examination were normal. There was no palpable lymphadenopathy and the remainder of the physical examination (including comprehensive skin examination for melanoma) was normal.

Computed tomography showed widespread liver omental and splenic deposits, consistent with metastases, and a 2 cm umbilical nodule. The primary source of the metastatic disease was not apparent.

Percutaneous biopsy of the umbilical nodule was performed. The provisional histology report confirmed that it was malignant and the patient was referred for an oncology opinion.