DIGES TIVE DISEASES Metastatic Disease Involving the Stomach Leslie S. Menuck, MD, and John R. Amberg, MD
Metastatic disease involving the stomach is an unusual and difficult clinical problem. A review of 1010 autopsies of patients with cancer disclosed 17 cases of gastric metastases (an incidence of 1.7%), with breast cancer, lung cancer, and melanoma being the most frequent primaries. The clinical manifestations of epigastric pain, melena, and anemia are nonspecific, necessitating radiographic examination of the gastrointestinal tract. The radiographic findings are usually sufficient to suggest the diagnosis.
Metastatic disease involving the stomach is an unusual and difficult clinical problem. M o dalities which may palliate metastatic disease are available so an early and accurate diagnosis should be made whenever possible. W i t h a correct diagnosis and p r o p e r treatment, relief of symptoms and prolongation of life can sometimes be achieved. "]['he present study was undertaken to clarify the incidence, p r i m a r y sites, symptoms, and effects of palliation in metastatic disease of the stomach.
MATERIALS AND METHODS Two groups of cancer patients fl'omthe Veterans Administration Hospital and the University of California Medical Center in San Diego from 1970 to 1974 were studied. One group consisted of 17 patients in whmn metastatic disease invo]ving the stomach was fotmd at autopsy. The other group was composed of 5 patients in whom a clinical diagnosis of metastatic disease of the stmnach was made. (2 are still alive; 3 were lost to follow-up.) From the Departmeints of Radiology, University Hospital, and Veterans Administration Hospital, University of Califorrfia at San Diego, School of Medicine, La Jolla, California. Address for reprint requests: Dr. Leslie S. Menuck, Department of Radiology, Veterans Administration Hospital, 3350 La Jolla Village Drive, San Diego, California 92161.
Digestive Diseases, Vol. 20, No. 10 (October 1975)
RESULTS in a review of 1010 autopsies on patients with malignancy at the Veterans Administration Hospital and the University of California Medical Center, San Diego, 17 patients with metastases to the stomach were found. While the preponderance of males at the Veterans Administration Hospital makes applicability of the statistics to the general population impossible, it does indicate that gastric involvement is not rare. T h e p r i m a r y malignancies seen in this series were melanoma and cancers of the lung, breast, pancreas, testis, and ovary. L y m p h o m a s were excluded. Except for melanoma, these malignancies are also most prevalent in the general population. In the 17 cases With metastatic involvement of the stomach, 10 patients did not seem to have clinically significant metastatic disease. Of the other 7 patients, epigastric pain, melena, and anemia were the most common clinical manifestations. T h e pt'esence of anemia was felt to be related to bleeding gastric metastasis because these patients had either gross hemorrhage or occult blood in the stool.
903
MENUCK & AMBERG
Fig 1. Metastatic carcinoma of breast. A 68-year-old female, 6 years post radical mastectomy with stable metastatic bone lesions, presented with a 4-month history of epigastric pain, melena, and anemia. Barium study of the stomach demonstrated an infiltrating constricting antral lesion identical to "linitis plastic&" Gastric resection was performed for chronic hemorrhage and disclosed metastatic carcinoma of the breast. The patient is alive I year later.
It is only possible to present anecdotal results of palliative therapy in this small group of patients. It is of interest that 1 patient with breast cancer and 1 with melanoma are still alive and relatively well 1 year after discovery of the gastric lesions. The gastric metastasis from carcinoma of the breast was surgically removed because of repeated gastrointestinal hemorrhage. The patient with metastatic melanoma and gastric involvement was treated with chemotherapy and the lesions regressed in size and number on follow-up radiographic examinations. 904
Radiological F i n d i n g s
Of the 17 patients with metastatic involvement of the stomach, 13 had radiographic studies of the upper-gastrointestinal tract. Of these 13, 3 had normal radiographic findings and at autopsy were found to have small submucosal involvement. Of the 10 patients with identifiable abnormalities, 5 had solitary polypoid lesions, 3 with ulceration and 2 without. 3 of the patients had multiple separate sites of involvement within the stomach. 2 patients had lesions of an infiltrative type similar to a "linitis Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
plastica." The variation of radiographic appearances are shown in Figures 1-6. Hematogenous metastases usually implant in the submucosa of the stomach. As they enlarge, they form polypoid submucosal masses or, less commonly, extend as circumscribed plaques within the submucosa. These lesions will often extend into the mucosa and subsequently ulcerate(l). As the radiographic findings reflect these morphological changes, several patterns are seen: (1) solitary polypoid submucosal mass, which may ulcerate; (2) multiple polypoid submucosal masses, which may ulcerate; (3) infiltrating constricting pattern similar to a "linitis plastica." While most gastric metastases are indistinguishable from one another, carcinoma of the breast and melanoma do have radiographic patterns which are somewhat distinctive. An infiltrating "linitis plastica" pattern is seen in about 50% of gastric metastases from carcinoma of the breast (2, 3). This finding is distinctly uncommon in other malignancies, although it was observed in one of our patients with carcinoma of the lung. Melanoma metastatic to the stomach often develops muhiple small ulcerating masses. These sharply delineated submucosal lesions have been described as having a "bull's-eye" or "target" configuration. While these can be seen in other metastatic lesions, they are certainly more common in melanoma (4). DISCUSSION
T h e incidence of metastatic disease of the stomach in our autopsy series of cancer patients was 1.7%. McNeer and Pack, in 1180 autopsies on patients with carcinoma, found 0.7~ developed gastric metastases (5). Table 1 shows the primary sites of gastric metastases reported in three series (1, 6, 7). The most common neoplasms metastasizing to the stomach are breast cancer, melanoma, and lung cancer. Aside from melanoma, which has an unusual predilection for metastasis to the gastrointestinal tract, the primary sites generally mirror the incidence of malignancy in the general population. There Digestive Diseases, Vol. 20, No. 10 (October 1975)
Table 1. Secondary Gastric Lesions* N u m b e r of gastric metastases r e p o r t e d by:
P r i m a r y site
Higgins
Davis & Zollinger
Willis-i-
Bronchus Breast Melanoma Testes Thyroid Cervix/uterus Ovary Pancreas Kidney Liver/biliary Bladder Colon Miscellaneous
21 21 4 3 2 4 5 2 -2 --10
10 3 4 1 1 5 3 7 -2 1 1 13
8 45 51 5 5 5 --6 ---8
64
53
133
Totals
* D i r e c t e x t e n s i o n was e x c l u d e d ; l y m p h o m a s w e r e excluded. 1-Much of this d a t a was p r i o r to t h e m a r k e d l y inc r e a s e d i n c i d e n c e of b r o n c h o g e n i c c a r c i n o m a .
are some exceptions, such as the infrequent oc.currence of gastric metastases from carcinoma of the colon, bladder, or kidney. In patients dying of breast carcinoma, gastric metastases were found in 6-18% of the patients at autopsy (3, 8, 9). This is felt to reflect both the diffuse nature of the disease and possibly some predilection for gastric involvement. T h e incidence of melanoma involving the stomach was 1026~ in most large series (4, 10, 11). Bronchogenie carcinoma involving the stomach shows a marked increase in incidence, varying from 4% in early series to 30% in recent ones (1, 5, 12, 13). In our series, and those previously reported, nonspecific epigastric pain and melena are the symptoms that most commonly lead to the proper diagnosis. Because the blood loss may be quite slow, symptoms produced by an iron-deficiency anemia may be the only manifestation of a gastric lesion. This emphasizes the importance of testing for occult blood in the stool and not just assuming that anemia is due to exten905
MENUCK & AMBERG
sive systemic neoplasm. Although gastric metastases are usually found in the terminal phases of the disease, they can occur early and at times may be the earliest manifestation of metastatic disease. Further, gastric metastases may culminate in a catastrophic event such as gastric outlet obstruction, massive gastric hemorrhage, or gastric perforation (7, 8, 13). In these cases, a surgical approach to palliation of the gastric lesions may be indicated. More commonly, the clinical symptoms are chronic, and palliation is 906
attempted with chemotherapy, hormonal manipulation, or radiotherapy. The presence of a gastric lesion is also very useful in measuring the effectiveness of the treatment, as it can be measured and observed sequentially. While endoscopy was used infrequently in our series of patients, it certainly seems indicated in this situation. The ability carefully to observe the entire gastric area and to obtain a histologic diagnosis can be very important in management of this difficult clinical problem. Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 2. (above and facing page) Metastatic melanoma. This 38year-old male had a melanoma removed from his back 2 years ago. He remained well until 3 weeks prior to his admission, when he noted dull upper-abdominal pain and melena. Radiographic examination of the stomach showed multiple small ("bull's-eye") and large ulcerating masses, which endoscopic biopsy confirmed as metastatic melanoma. The patient was placed on chemotherapy and is alive 1 year later.
Digestive Diseases, Vol. 20, No. 10 (October 1975)
907
MENUCK & AMBERG
Fig 3. Metastatic bronchogenic carcinoma. A 48-year-old male with a 1 -year history of epidermoid carcinoma of the lung presented with a 3-week history of nausea, epigastric pain, and melena. Barium study of the stomach showed a circumferential, rigid, irregular, and slightly narrowed area of the proximal body of the stomach. 3 months later the patient died and autopsy confirmed the infiltrating metastatic bronchogenic carcinoma.
908
Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 4, Metastatic ovarian carcinoma. This 53-year-old female with disseminated ovarian carcinoma presented with asymptomatic melena and anemia. Radiographic examination of the stomach showed a solitary gastric mass. Several months later she died and at necropsy a large solitary gastric metastasis was found.
Diigestive Diseases, Voh 20, No. 10 (October 1975)
909
MENUCK & AMBERG
910
Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
o~O~
"O
L~
._
r~_ ~
.IZ
~
e'-
E ~
-
E.E o~~g
.~o~
~s e ~ -
9
~'
0
:'6
--
,,', ~, E ~ ~ ~E'5~
Digestive Diseases, Voh 20, No. 10 ( O c t o b e r 1975)
e
911
MENUCK & AMBERG
REFERENCES
1. Willis RA: Spread of Tumours in the Body. London, Butterworths, 1967 2. Bloch C, Peck HM: Metastatic involvement of the stomach from primary carcinoma of the breast. J Mt Sinai Hosp, NY 29:446, 1962 3. Choi SH, Sheehan FR, Pickren J W : Metastatic involvement of the stomach by breast cancer. Cancer 17:791-797, 1964 4. Potchen E J, Khung CL, Yatsukaski M: X-ray 912
diagnosis of gastric melanoma. N Engl J Med 271:133-136, t964 5. McNeer G, Pack GT: Neoplasms of Stomach. Philadelphia, J.B. Lippineott, 1967 6. Davis GH, Zollinger RW: Metastatic melanoma of the stomach. Am J Surg 99:94-96, 1960 7. Higgins PM: Pyloric obstruction due to metastatic deposits from carcinoma of the bronchus. Can J Surg 5:438-441, 1962 Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 6. (above and facing page) Metastatic carcinoma of the pancreas. This 62-year-old male presented with a 20-1b weight loss, malaise, and cervical adenopathy over a period of several months. Radiographic examination of the upper-gastrointestinal tract showed 2 ulcerating gastric masses. Biopsy of the neck mass disclosed metastatic adenocarcinoma of unknown origin. 2 months later the patient died, and an autopsy disclosed a large infiltrating carcinoma of the body and tail of the pancreas with the 2 metastatic ulcerating gastric lesions.
8. Asch M J, Widel P, Haluf D: GI metastases from carcinoma of the breast. Arch Surg 96:840-843, 1968 9. Hartmann WH, Sherlock P: Gastroduodenal metastases from carcinoma of the breast. An adrenal steroid-induced phenomenon. Cancer 14:426-430, 1961 10. Booth JB: Metastatic melanoma of the stomach. Br J Surg 52:262-270, 1965 Digestive Diseases, Vol. 20, No. 10 (October 1975)
11. Das Gupta TK, Brasfield R: Metastatic melanoma of the GI tract. Arch Surg 88:969-973, 1964 12. Dick R, Pattinson JW: Metastases to the stomach presenting as a single polyp. Br J Radiol 45:761-764, 1972 13. Morton WJ, Tedesco FJ: Metastatic bronchogenic carcinoma seen as a gastric ulcer. Am J Dig Dis 191:766, 1974 913
Metastatic disease involving the stomach is an unusual and difficult clinical problem. A review of 1010 autopsies of patients with cancer disclosed 17 cases of gastric metastases (an incidence of 1.7%), with breast cancer, lung cancer, and melanoma being the most frequent primaries. The clinical manifestations of epigastric pain, melena, and anemia are nonspecific, necessitating radiographic examination of the gastrointestinal tract. The radiographic findings are usually sufficient to suggest the diagnosis.
Metastatic disease involving the stomach is an unusual and difficult clinical problem. M o dalities which may palliate metastatic disease are available so an early and accurate diagnosis should be made whenever possible. W i t h a correct diagnosis and p r o p e r treatment, relief of symptoms and prolongation of life can sometimes be achieved. "]['he present study was undertaken to clarify the incidence, p r i m a r y sites, symptoms, and effects of palliation in metastatic disease of the stomach.
MATERIALS AND METHODS Two groups of cancer patients fl'omthe Veterans Administration Hospital and the University of California Medical Center in San Diego from 1970 to 1974 were studied. One group consisted of 17 patients in whmn metastatic disease invo]ving the stomach was fotmd at autopsy. The other group was composed of 5 patients in whom a clinical diagnosis of metastatic disease of the stmnach was made. (2 are still alive; 3 were lost to follow-up.) From the Departmeints of Radiology, University Hospital, and Veterans Administration Hospital, University of Califorrfia at San Diego, School of Medicine, La Jolla, California. Address for reprint requests: Dr. Leslie S. Menuck, Department of Radiology, Veterans Administration Hospital, 3350 La Jolla Village Drive, San Diego, California 92161.
Digestive Diseases, Vol. 20, No. 10 (October 1975)
RESULTS in a review of 1010 autopsies on patients with malignancy at the Veterans Administration Hospital and the University of California Medical Center, San Diego, 17 patients with metastases to the stomach were found. While the preponderance of males at the Veterans Administration Hospital makes applicability of the statistics to the general population impossible, it does indicate that gastric involvement is not rare. T h e p r i m a r y malignancies seen in this series were melanoma and cancers of the lung, breast, pancreas, testis, and ovary. L y m p h o m a s were excluded. Except for melanoma, these malignancies are also most prevalent in the general population. In the 17 cases With metastatic involvement of the stomach, 10 patients did not seem to have clinically significant metastatic disease. Of the other 7 patients, epigastric pain, melena, and anemia were the most common clinical manifestations. T h e pt'esence of anemia was felt to be related to bleeding gastric metastasis because these patients had either gross hemorrhage or occult blood in the stool.
903
MENUCK & AMBERG
Fig 1. Metastatic carcinoma of breast. A 68-year-old female, 6 years post radical mastectomy with stable metastatic bone lesions, presented with a 4-month history of epigastric pain, melena, and anemia. Barium study of the stomach demonstrated an infiltrating constricting antral lesion identical to "linitis plastic&" Gastric resection was performed for chronic hemorrhage and disclosed metastatic carcinoma of the breast. The patient is alive I year later.
It is only possible to present anecdotal results of palliative therapy in this small group of patients. It is of interest that 1 patient with breast cancer and 1 with melanoma are still alive and relatively well 1 year after discovery of the gastric lesions. The gastric metastasis from carcinoma of the breast was surgically removed because of repeated gastrointestinal hemorrhage. The patient with metastatic melanoma and gastric involvement was treated with chemotherapy and the lesions regressed in size and number on follow-up radiographic examinations. 904
Radiological F i n d i n g s
Of the 17 patients with metastatic involvement of the stomach, 13 had radiographic studies of the upper-gastrointestinal tract. Of these 13, 3 had normal radiographic findings and at autopsy were found to have small submucosal involvement. Of the 10 patients with identifiable abnormalities, 5 had solitary polypoid lesions, 3 with ulceration and 2 without. 3 of the patients had multiple separate sites of involvement within the stomach. 2 patients had lesions of an infiltrative type similar to a "linitis Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
plastica." The variation of radiographic appearances are shown in Figures 1-6. Hematogenous metastases usually implant in the submucosa of the stomach. As they enlarge, they form polypoid submucosal masses or, less commonly, extend as circumscribed plaques within the submucosa. These lesions will often extend into the mucosa and subsequently ulcerate(l). As the radiographic findings reflect these morphological changes, several patterns are seen: (1) solitary polypoid submucosal mass, which may ulcerate; (2) multiple polypoid submucosal masses, which may ulcerate; (3) infiltrating constricting pattern similar to a "linitis plastica." While most gastric metastases are indistinguishable from one another, carcinoma of the breast and melanoma do have radiographic patterns which are somewhat distinctive. An infiltrating "linitis plastica" pattern is seen in about 50% of gastric metastases from carcinoma of the breast (2, 3). This finding is distinctly uncommon in other malignancies, although it was observed in one of our patients with carcinoma of the lung. Melanoma metastatic to the stomach often develops muhiple small ulcerating masses. These sharply delineated submucosal lesions have been described as having a "bull's-eye" or "target" configuration. While these can be seen in other metastatic lesions, they are certainly more common in melanoma (4). DISCUSSION
T h e incidence of metastatic disease of the stomach in our autopsy series of cancer patients was 1.7%. McNeer and Pack, in 1180 autopsies on patients with carcinoma, found 0.7~ developed gastric metastases (5). Table 1 shows the primary sites of gastric metastases reported in three series (1, 6, 7). The most common neoplasms metastasizing to the stomach are breast cancer, melanoma, and lung cancer. Aside from melanoma, which has an unusual predilection for metastasis to the gastrointestinal tract, the primary sites generally mirror the incidence of malignancy in the general population. There Digestive Diseases, Vol. 20, No. 10 (October 1975)
Table 1. Secondary Gastric Lesions* N u m b e r of gastric metastases r e p o r t e d by:
P r i m a r y site
Higgins
Davis & Zollinger
Willis-i-
Bronchus Breast Melanoma Testes Thyroid Cervix/uterus Ovary Pancreas Kidney Liver/biliary Bladder Colon Miscellaneous
21 21 4 3 2 4 5 2 -2 --10
10 3 4 1 1 5 3 7 -2 1 1 13
8 45 51 5 5 5 --6 ---8
64
53
133
Totals
* D i r e c t e x t e n s i o n was e x c l u d e d ; l y m p h o m a s w e r e excluded. 1-Much of this d a t a was p r i o r to t h e m a r k e d l y inc r e a s e d i n c i d e n c e of b r o n c h o g e n i c c a r c i n o m a .
are some exceptions, such as the infrequent oc.currence of gastric metastases from carcinoma of the colon, bladder, or kidney. In patients dying of breast carcinoma, gastric metastases were found in 6-18% of the patients at autopsy (3, 8, 9). This is felt to reflect both the diffuse nature of the disease and possibly some predilection for gastric involvement. T h e incidence of melanoma involving the stomach was 1026~ in most large series (4, 10, 11). Bronchogenie carcinoma involving the stomach shows a marked increase in incidence, varying from 4% in early series to 30% in recent ones (1, 5, 12, 13). In our series, and those previously reported, nonspecific epigastric pain and melena are the symptoms that most commonly lead to the proper diagnosis. Because the blood loss may be quite slow, symptoms produced by an iron-deficiency anemia may be the only manifestation of a gastric lesion. This emphasizes the importance of testing for occult blood in the stool and not just assuming that anemia is due to exten905
MENUCK & AMBERG
sive systemic neoplasm. Although gastric metastases are usually found in the terminal phases of the disease, they can occur early and at times may be the earliest manifestation of metastatic disease. Further, gastric metastases may culminate in a catastrophic event such as gastric outlet obstruction, massive gastric hemorrhage, or gastric perforation (7, 8, 13). In these cases, a surgical approach to palliation of the gastric lesions may be indicated. More commonly, the clinical symptoms are chronic, and palliation is 906
attempted with chemotherapy, hormonal manipulation, or radiotherapy. The presence of a gastric lesion is also very useful in measuring the effectiveness of the treatment, as it can be measured and observed sequentially. While endoscopy was used infrequently in our series of patients, it certainly seems indicated in this situation. The ability carefully to observe the entire gastric area and to obtain a histologic diagnosis can be very important in management of this difficult clinical problem. Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 2. (above and facing page) Metastatic melanoma. This 38year-old male had a melanoma removed from his back 2 years ago. He remained well until 3 weeks prior to his admission, when he noted dull upper-abdominal pain and melena. Radiographic examination of the stomach showed multiple small ("bull's-eye") and large ulcerating masses, which endoscopic biopsy confirmed as metastatic melanoma. The patient was placed on chemotherapy and is alive 1 year later.
Digestive Diseases, Vol. 20, No. 10 (October 1975)
907
MENUCK & AMBERG
Fig 3. Metastatic bronchogenic carcinoma. A 48-year-old male with a 1 -year history of epidermoid carcinoma of the lung presented with a 3-week history of nausea, epigastric pain, and melena. Barium study of the stomach showed a circumferential, rigid, irregular, and slightly narrowed area of the proximal body of the stomach. 3 months later the patient died and autopsy confirmed the infiltrating metastatic bronchogenic carcinoma.
908
Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 4, Metastatic ovarian carcinoma. This 53-year-old female with disseminated ovarian carcinoma presented with asymptomatic melena and anemia. Radiographic examination of the stomach showed a solitary gastric mass. Several months later she died and at necropsy a large solitary gastric metastasis was found.
Diigestive Diseases, Voh 20, No. 10 (October 1975)
909
MENUCK & AMBERG
910
Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
o~O~
"O
L~
._
r~_ ~
.IZ
~
e'-
E ~
-
E.E o~~g
.~o~
~s e ~ -
9
~'
0
:'6
--
,,', ~, E ~ ~ ~E'5~
Digestive Diseases, Voh 20, No. 10 ( O c t o b e r 1975)
e
911
MENUCK & AMBERG
REFERENCES
1. Willis RA: Spread of Tumours in the Body. London, Butterworths, 1967 2. Bloch C, Peck HM: Metastatic involvement of the stomach from primary carcinoma of the breast. J Mt Sinai Hosp, NY 29:446, 1962 3. Choi SH, Sheehan FR, Pickren J W : Metastatic involvement of the stomach by breast cancer. Cancer 17:791-797, 1964 4. Potchen E J, Khung CL, Yatsukaski M: X-ray 912
diagnosis of gastric melanoma. N Engl J Med 271:133-136, t964 5. McNeer G, Pack GT: Neoplasms of Stomach. Philadelphia, J.B. Lippineott, 1967 6. Davis GH, Zollinger RW: Metastatic melanoma of the stomach. Am J Surg 99:94-96, 1960 7. Higgins PM: Pyloric obstruction due to metastatic deposits from carcinoma of the bronchus. Can J Surg 5:438-441, 1962 Digestive Diseases, Vol. 20, No. 10 (October 1975)
GASTRIC METASTASES
Fig 6. (above and facing page) Metastatic carcinoma of the pancreas. This 62-year-old male presented with a 20-1b weight loss, malaise, and cervical adenopathy over a period of several months. Radiographic examination of the upper-gastrointestinal tract showed 2 ulcerating gastric masses. Biopsy of the neck mass disclosed metastatic adenocarcinoma of unknown origin. 2 months later the patient died, and an autopsy disclosed a large infiltrating carcinoma of the body and tail of the pancreas with the 2 metastatic ulcerating gastric lesions.
8. Asch M J, Widel P, Haluf D: GI metastases from carcinoma of the breast. Arch Surg 96:840-843, 1968 9. Hartmann WH, Sherlock P: Gastroduodenal metastases from carcinoma of the breast. An adrenal steroid-induced phenomenon. Cancer 14:426-430, 1961 10. Booth JB: Metastatic melanoma of the stomach. Br J Surg 52:262-270, 1965 Digestive Diseases, Vol. 20, No. 10 (October 1975)
11. Das Gupta TK, Brasfield R: Metastatic melanoma of the GI tract. Arch Surg 88:969-973, 1964 12. Dick R, Pattinson JW: Metastases to the stomach presenting as a single polyp. Br J Radiol 45:761-764, 1972 13. Morton WJ, Tedesco FJ: Metastatic bronchogenic carcinoma seen as a gastric ulcer. Am J Dig Dis 191:766, 1974 913
