Journal of Clinical Oncology, Vol 18, Issue 1
(January), 2000: 227
© 2000 American Society for Clinical Oncology
Case 1: Small Bowel Obstruction Due to Metastatic Lung Cancer
EDITOR’S NOTE: A review of small bowel metastases by Lars E. Stenbygaard and Jens B. Sorensen, entitled "Small Bowel Metastases in Non-Small Cell Lung Cancer," was published recently (Lung Cancer 26:95-101, 1999).
Arthur Skarin, MD, Consultant Editor
Matthew Galsky,
Marla Darling,
Jonathan Hecht,
Ravi Salgia
Beth-Israel Deaconess Medical Center, Dana-Farber Cancer Institute, Brigham & Women’s Hospital, and, Harvard Medical School, Boston, MA
A 58-year-old woman presented to her primary care physician with complaints of recurrent bilateral lower abdominal pain and nausea and vomiting. She was found to be anemic with gauaic-positive stool on rectal examination. After an unrevealing colonoscopy, an abdominal computed tomography (CT) scan revealed a 4 x 5-cm complex lesion in the midlower abdomen (Fig 1; note the dilated small bowel loop with exophytic mass at the level of the obstruction). The patient then underwent an exploratory laparotomy and resection of a jejunal mass which was identified as undifferentiated carcinoma (Fig 2A: low-power scan shows infiltration of tumor cells between nonneoplastic glands; Fig 2B: high-power scan shows pleomorphic malignant cells with frequent mitoses invading normal mucosal glands). Immunohistologic staining of the specimen was positive for cytokeratin 7 (Fig 2C) and negative for cytokeratin 20. A metastatic workup included a chest CT scan, which revealed a 2.5-cm left upper lobe mass and a 1-cm right upper lobe mass (Fig 3: bilateral spiculated lung masses with emphysematous changes). Based upon these pathologic and radiologic findings, the most likely diagnosis was metastatic lung cancer. While contemplating chemotherapy, the patient developed clinically apparent metastases to her adrenal glands (Fig 4, arrows) and brain, for which she received radiation therapy. Her course was further complicated by persistent vomiting that required hospitalization, during which extensive spread of her small bowel metastases was discovered on an abdominal CT scan. She was eventually discharged; home and comfort care measures were initiated.
Approximately one half of patients with lung cancer have metastatic disease at the time of initial diagnosis. The bone, liver, adrenal glands, and lymph nodes are the organs most commonly involved, whereas metastases to the small bowel are much less common.1,2 McNeill et al3 reviewed 6,006 hospital admissions for lung cancer over an 11-year period. Of the 431 patients who underwent autopsy, small bowel metastases were present in 46. Only six patients in this series had clinically apparent small bowel metastases. The presentation of lung cancer with a metastatic lesion to the small bowel is uncommon. Histologically, metastatic bowel cancer may be difficult to distinguish from lung cancer, but positive cytokeratin 7 with negative cytokeratin 20 favors lung cancer, whereas the reverse pattern is more consistent with colon cancer.4 Mosier et al5 reported 37 cases of isolated small bowel metastasis from primary lung cancer. Nine of the 37 patients presented with small bowel symptoms in the absence of a diagnosed primary lung tumor. Common symptoms of these metastases included abdominal pain, weight loss, vomiting, and melena. Small bowel perforation was the initial finding in the majority of patients with an unknown primary lung cancer.6 In both studies, metastases to the small bowel were associated with a poor prognosis. However, aggressive surgical intervention has been associated with successful palliation and improved short-term survival.5
Copyright 2000 American Society of Clinical Oncology
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Mosier D, Bloch R, Cunningham P, et al: Small bowel metastases from primary lung carcinoma: A rarity waiting to be found? Am Surg58:677-682, , 1992[Medline]
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