Metastatic Choriocarcinoma of the Small Intestine Presenting as Refractory Anemia and Melena

A 57-year-old man presented with fatigue and 2-week history of melena. Medical history included acromegaly and a desmoid tumor invading the superior mesenteric artery, causing a cardiac arrest 11 years earlier. Exam revealed no abdominal tenderness, melena in the rectum, and a hemoglobin of 4.8 gm/dL. An esophagogastroduodenoscopy and colonoscopy revealed no source of bleeding. Capsule endoscopy showed a mass in the small bowel (Figure 1). An anterograde double balloon enteroscopy demonstrated a 4–5-cm mass 300 cm past the pylorus (Figure 2). Biopsies were consistent with a fibrinopurulent exudate. He underwent surgical resection of the mass, and histologic examination revealed a focal high-grade carcinoma with choriocarcinoma features, with clear margins without lymph node involvement (Figure 3). Serum s-hCG level was 9169 mIU/mL (normal <5 mIU/mL). An ultrasound of both testicles was normal. The patient died 7 weeks later due to multiple intracranial metastases.