disease with meningeal carcinomatosis. The necropsy con- firmed the diagnosis of a poorly differentiated adenocarcinoma of the lung over a previous scar on ...
1130-0108/2008/100/3/179-187 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2008 ARÁN EDICIONES, S. L.
REV ESP ENFERM DIG (Madrid) Vol. 100, N.° 3, pp. 179-187, 2008
Letters to the Editor
Intestinal obstruction as early clinic manifestation of lung adenocarcinoma Palabras clave: Adenocarcinoma de pulmón. Obstrucción intestinal. Metástasis.
Key words: Lung adenocarcinoma. Intestinal obstruction. Metastases. Dear Editor,
Gastrointestinal tract metastases of lung cancer are not uncommon, but their clinical manifestations are rare. These may be perforation, obstruction and haemorrhage which typically occur in the advanced stage of the disease, and they usually accompany typical symptoms of the thoracic disease. Case report
We report a 71-years-old smoker man with a personal history of a fibrotic pulmonary pseudonodule in the right upper lobe under surveillance with repeated citologies showing no-malignancy. He required admission because of a colic abdominal pain associated to obstructive constipation. The fisical examination showed a tympanic abdomen with increased peristalsis. A small bowel dilatation was evidenced by X-ray, and several days after a gastrointestinal barium study revealed a jejunal estenosis. The CT did not show any abdominal masses nor any changes in the lung pseudonodule. An abdominal laparotomy was performed and surgeons found a three centimeters obstructive tumour at the jejunum which was completly resected. The histologic diagnosis confirmed the small bowel with a metastatic poorly differentiated carcinoma infiltrating the wall of the organ (Fig. 1). The immunohistologic staining
was positive for cytokeratin 7, TTF-1, AE-1/AE-3 and negative for cytokeratin-20. The PET showed a pathologic hypercaptation at the right upper lobe and mediastinic nodes. The patient refused to carry out a lung biopsy, a mediastinoscopy or receive any additional treatment at that moment. Three months later he was admitted again due to progressive dysphagia associated to cephalea. The endoscopic study revealed an upper esophageal estenosis with appearance of extraluminal compression, that didn’t alow the progression of the scope, so a surgical gastrostomy was perfomed. The thoracic CT demonstrated the growth of the lung nodule and the mediastinic lymph nodes with esophagic involvement. The cranial CT evidenced multiple brain metastases. At this moment, the patient was proposed again the possibility of treatment, and he eventually accepted. At the Oncology division, holocraneal irradiation (30 Gy) and 6 courses of chemotherapy (carboplatin + paclitaxel) were administrated achieving an stable disease, according to RECIST (1) criteria (malignancy size growth less than 20%).
Fig. 1. Small bowel with a metastatic poorly differentiated carcinoma infiltrating the wall of the organ (hematoxylin-eosin, 200x).
2
LETTERS TO THE EDITOR
The patient finally died two months later due to progressive disease with meningeal carcinomatosis. The necropsy confirmed the diagnosis of a poorly differentiated adenocarcinoma of the lung over a previous scar on the right upper lobe (scar cancer) showing the same immunohistologic staining than the intestinal tumour, and with metastases to the esophagus, trachea, thyroid gland, mediastinic lymph nodes, large bowel, brain, cerebellum and meninges.
Discussion
The secondary involvement of the small intestine is more frequent than primary neoplasia. Primary tumours of the colon, ovary, uterus and stomach usually involve the small bowel, either by direct invasion or by intraperitoneal spread, whereas primaries from breast, lung and melanoma, which are the most common, metastasize to the small bowel hematogeneously (2). Melanoma, hypernephroma and Kaposi’s sarcoma are more often the cause of isolated or solitary metastases (3). Gastrointestinal tract metastases of lung cancer aren’t uncommon, but their clinical manifestations are rare (4,5). Their frequency in autopsy series is around 11-14%, whereas the involvement of the small bowel is 4.6% (6). The most common histologic types of lung cancer causing small bowel metastasis are squamous cell and large cell carcinomas, mainly poorly differentiated ones, being more infrequent this type of involvement in adenocarcinomas. Patients with small bowell metastases usually have at least one other site of metastatic disease with an average of 4.8 sites (6-8). The clinical manifestations may be perforation (59%), obstruction (29%) and haemorrhage (10%). Typically, they occur in the advanced stage of the disease, but they have also been described before any pulmonary disease has been considered. In
REV ESP ENFERM DIG (Madrid)
these cases perforation is the most frequent clinical presentation, being obstruction an extremely rare initial complication (5,8). In conclusion, we report an uncommon case of a lung adenocarcinoma presented with gastrointestinal symptoms consisted in a small bowel obstruction before the diagnosis of malignancy. I. Álvarez-Busto, J. Alcedo1, J. Vera2, L. Borderias3, L. Ligorred4, D. Quiles, R. Lastra and L. Martínez Moya
Oncology, 1Gastroenterology and Hepatology, 2Pathology, Neumology, and 4Surgery Departments. San Jorge Hospital. Huesca, Spain
3
References 1.
2.
3.
4.
5. 6.
7. 8.
Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer treatment. Cancer 1981; 47: 207-14. Gill SS, Heumann DM, Mihas AA. Small intestinal neoplasms. J Clin Gastroenterol 2001: 33 (4): 267-82. Ashley SW, Wells SA Jr. Tumors of the small intestine. Semin Oncol 1988: 15 (2): 116-28. Kabwa L, Mattei JP, Noel JP. Intestinal metastases of bronchopulmonary cancer. A propos of a case. J Chir (Paris) 1996; 133: 290-3. Hillenbrand A, Straeter J, Henne-Bruns D. Frecuency, symptoms and outcome of intestinal metastases of bronchopulmonary cancer. Case report and review of the literature. Int Semin Surg Oncol 2005; 2: 13. Stenbygaard LE, Sorensen JB. Small bowel metastases in non-small cell lung cancer. Lung Cancer 1999; 26: 95-101. Berger A, Cellier C, Daniel C, et al. Small bowel metastases from primary carcinoma of the lung: Clinical findings and outcome. Am J Gastroenterol 1999; 94: 1884-7. Sakaforas GH, Pavlakis G, Grigoriadis KD. Small bowel perforation secondary to metastatic lung cancer: A case report and review of the literature. Mt Siani J Med 2003; 70: 130-2.
REV ESP ENFERM DIG 2008; 100 (3): 179-187
