IMAGE CHALLENGE

A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration. The pain was continuous, worsened with eating, was associated with nausea, and radiated to her back. She reported no vomiting, fever, diarrhea, or weight loss, and her vital signs were normal.

Her abdomen was distended, diffusely tender on palpation, and tympanic on percussion on the upper half and dull on the lower half. Bowel sounds were missing on the left side, and a large mass was palpated in that area. Laboratory evaluation was unremarkable. Computed tomography (CT) showed massive dilatation of the stomach, and gas was seen distally on a CT scan.

More than 4 liters of fluid was drained from the patient's stomach during the first 24 hours. Upper gastrointestinal endoscopy showed no evidence of peptic ulcer disease or cancer but did show hypertrophic pyloric stenosis. She underwent endoscopic balloon dilation of the pyloric sphincter, with immediate symptomatic relief and resolution of gastric dilatation. Within a few days, the patient returned to a normal diet, and 20 months later, she continued to do well.

A 78-year-old woman presented with dyspnea, cough, and a pleural effusion on the left side. She had fractured a hip 3 years earlier, and a chronic decubitus ulcer developed while she was bedridden during an extended recovery period. The ulcer had been treated by local débridement.

A year earlier, a squamous-cell carcinoma had been diagnosed adjacent to the ulcer and had been completely resected. A malignant pleural effusion was also identified at that time, but the patient declined any further therapy. Computed tomography of the chest performed after the administration of contrast material revealed multiple pericardial masses with central necrosis compatible with metastatic disease.

The patient did not want to undergo a biopsy but agreed to radiotherapy as a treatment for her metastatic squamous-cell cancer. She died at home 4 months after receiving the diagnosis, and her family did not give permission for an autopsy.

Squamous-cell carcinoma is the second most common skin cancer and is associated with a risk of metastasis. It may develop in injured and chronically diseased skin areas, such as a long-standing ulcer or fistulous tract. Cancer arising from such areas may not be noticed for years, thus increasing the risk of metastasis, and the prognosis with distant metastases is poor.

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