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CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 5  |  Page : 134-137

Undiagnosed primary lung carcinoma with initial manifestation of intestinal obstruction: A case report and literature review


Department of Radiation Oncology, Zhejiang Provincal Cancer Hospital, Hangzhou 310022, China

Date of Web Publication31-Aug-2015

Correspondence Address:
Dr. Jing Chen
Department of Radiation Oncology, Zhejiang Provincal Cancer Hospital, 38 Guangji Road, Hangzhou 310022
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.163873

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 > Abstract 

Small intestinal metastasis from primary lung carcinoma is infrequent and seen at the terminal stage of the disease as the first sign. These patients are often present as perforation and peritonitis but rarely with small bowel obstruction. We reported a case of a 61-year-old man who was admitted to our hospital with acute abdominal pain. Abdominal X-ray manifested an acute ileus. Ileoileal resection-anastomosis was performed after removal of two separate tumors in the small intestine. Histopathological result indicated metastatic adenocarcinoma. The patient had not been diagnosed as any carcinoma or lung disease previously. The postoperative thorax computed tomography scan showed a lesion at the right lung, which was pathologically defined as adenocarcinoma of the lung by bronchial brushing. This case is reported to arouse a clinical suspicion of intestinal metastasis in undiagnosed primary lung cancer presenting with acute abdominal pain. Early diagnosis and treatments are vital for improving survival of the patients.

Keywords: Abdominal pain, intestinal obstruction, metastatic adenocarcinoma, primary lung cancer


How to cite this article:
Chen J. Undiagnosed primary lung carcinoma with initial manifestation of intestinal obstruction: A case report and literature review. J Can Res Ther 2015;11, Suppl S1:134-7

How to cite this URL:
Chen J. Undiagnosed primary lung carcinoma with initial manifestation of intestinal obstruction: A case report and literature review. J Can Res Ther [serial online] 2015 [cited 2019 Sep 17];11:134-7. Available from: http://www.cancerjournal.net/text.asp?2015/11/5/134/163873


 > Introduction Top


Metastasis of small intestine is uncommon and usually affected by malignant melanoma, carcinoma of breast, colon, lung, and kidney. [1] Small intestine metastasis from primary lung cancer is infrequent, while secondary intestinal obstruction from metastatic lung cancer is extremely rare. This nonspecific onset and the difficult physical-instrumental approach to small bowel, led often to diagnosis at autopsy. [2] Berger et al. [3] reported that only 6 of 1399 (0.5%) patients with primary lung cancer progressed clinically apparent small intestinal metastasis. Based on literature review from 2000 to 2015 in China, nine cases have been reported the small intestine metastasis of nonsmall cell lung cancer, and this is first reported as an undiagnosed primary carcinoma of the lung manifested with initial symptom of intestinal obstruction. It indicates terminal stage of the disease with poor prognosis.


 > Case Report Top


Here, we present a case of metastatic intestinal adenocarcinoma from lung cancer with abdomen and intussusceptions as the first sign. A 61-year-old man was, a heavy smoker (a packet/day/40 years), admitted to our hospital with acute abdominal pain. He had the paroxysmal pain in right lower quadrant without any inducement for 40 days, and the colic pain could be released after defecation. The abdomen computed tomography (CT) showed a mass in root of mesentery about 5 cm in local hospital. He was admitted to our hospital because of the aggravated pain. Examination of the abdomen demonstrated a tender abdomen with rebound and guarding. Inside or outside intestine mass was impalpable in the rectal examination. Abdominal X-ray manifested intestine obstruction and intestinal pneumatosis [Figure 1]a. An emergent surgery was done because of the adbominal mass and acute pain. The ileoileal intussusception caused by two masses are located in the small intestine and adjacent mesentery was found at laparotomy, ileoileal resection-anastomosis was performed after the removal of two separate tumors in the small intestine. Subsequent histological examination of the resected tissue indicated metastatic adenocarcinoma [Figure 2], immunohistochemistry further showed thyroid transcription factor-1+ (TTF-1+), CK20−, caudal-related homeobo × 2− (CDX-2−), cytokeratins 7+++ (CK7+++) [Figure 3]a-d, NSE−, CD56−, Syn−, AFP−, Vim−. Chief complaint showed that he didn't have any respiratory symptoms such as cough, sputum, hemoptysis, and dyspnea before operation. Because the preoperative chest X-ray showed a mass in the right lung [Figure 1]. We thought that the two parts of masses must be associated and further examinations should be done. Postoperative thorax CT revealed a tumor at the carina level in the right pulmonary hilar area with lymph node invasion [Figure 4]. Then the bronchoscopy indicated a endobronchial lesion, which partially obstructed the right upper segment. Pathological result of the bronchial brushing demonstrated adenocarcinoma of the lung [Figure 5]. The histomorphology of small intestinal and lung tumor is similar with the features of adenocarcinoma, tumor cell arranged irregularly. The cells were round to oval with high nuclear: Cytoplasmic ratio, pleomorphic nuclei with rich chromatin, abnormal brisk mitosis, and eosinophilic cytoplasm. Immunohistochemistry of lung tumor showed TTF-1+, CK20−, CDX-2−, CK7+ [Figure 3]a-d. Brain magnetic resonance imaging scan and bone emission CT are normal. A diagnosis of small intestine metastatic adenocarcinoma of primary lung cancer was concluded. The patient had an uneventful postoperative course and has taken Iressa after discharged home. The patient is doing well after 3 months till date.
Figure 1: Abdominal X-ray: Free intraperitoneal air and a enlarged jejunum at the initial presentation (the arrow marks the enlarged jejunum)

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Figure 2: Small bowel metastasis; stain: H and E, ×100 and ×400 (histological sections with H and E stain indicate adenocarcinoma)

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Figure 3: Immunohistochemistry of small intestine metastasis and primary lung tumor: Original ×400, (small intestine metastasis: [a] TTF-1[+], [b] CK20[−], [c] CDX-2[−], [d] CK7[+]; primary lung tumor: [a] TTF-1[+], [B] CK20[−], [C] CDX-2[−], [d] CK7[+])

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Figure 4: Thorax computed tomography: (The arrow points the tumor at the carina level in the right lung)

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Figure 5: Lung cancer; stain: H and E, ×100 and ×400 (the bronchial brushing with H and E stain demonstrated adenocarcinoma)

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 > Discussion Top


Lung cancer commonly metastasizes to adrenals, brain, bone and liver, clinically significant metastases in the small bowel are rare and typically occurs only in the advanced stage of the diseases. [4] In most cases, clinical findings of small bowel metastasis consist of acute symptomatology such as perforation, peritonitis, small bowel obstruction or hemorrhage. Moreover, the patient can also present other generic and nonspecific symptoms, such as asthenia, anemia following occult intestinal chronic bleeding, abdominal pain, weight loss, nausea, and vomiting. [5],[6] Andreas Hillenbrand et al. [7] reported, in their review of 58 cases, that the most clinical symptom of small intestine metastatic cancer is perforation (34/58; 59%), obstruction (17/58; 29%), and haemorrhage (10%). Intestinal primary tumor can also exhibit these symptoms, so it is important to identify that the tumors are primary or metastatic. Campoli et al. [8] reviewed that the histologic samples of primary lung cancer with intestinal tract metastasis by immunohistochemistry. All cases were immunostained with CDX2, TTF-1, and CK7 and CK20, CK7 and TTF-1 were immunostained whereas CDX2 and CK20 were completely negative. [1] But primary carcinoma of the intestinal tract generally manifests CK20(+) and CK7(−). As a special marker of lung tumor, TTF-1 is negative in primary intestinal cancer. Therefore, by using immunohistochemical staining we could differentiate the tumor of the intestine as metastasis from lung cancer. Immunohistochemistry of the cases presented by us was consistent with the above results. Due to lack of definite diagnostic features on endoscopy or radiology to predict such metastasis, [9] the intestine metastasis of primary lung caner is often misdiagnosised in acute abdomen. The positive signs of small intestine are usually difficult to be fond in clinical examination. Therefore, the intestine metastasis should be taken into account when lung cancer patients with the following symptoms, such as abdominal distension, abdominal pain, diarrhea, asthenia, and anemia following occult intestinal chronic bleeding. The positron emission tomography/CT or abdominal CT should be done in the patients who arises metastasis of liver, bone or adrenal.

In rare cases, we reported, which displayed acute abdomen and intussusceptions as the first sign. Abdominal symptoms should be firstly relieved and then do further chemotherapy after the primary tumor is clearly found. Pathology and immunohistochemistry plays an important role in the diagnostic process. Therefore, in future clinical diagnosis, the patient arised intestinal obstruction with chest X-ray suggesting the existence of mass. We should consider whether there is a possibility of lung cancer with intestinal metastasis. Thorax CT and bronchoscopy are recommended for the further clear diagnosis. If the abdominal symptoms in patients who suffer from primary lung cancer are not obvious, conservative therapy and systemic chemotherapy should be considered. In this case, the significant pulmonary symptoms did not appear because the rapid development of the disease, the bronchial wall might not been markedly destroyed by primary cancer and the lumen was still unobstructed. Lymph node metastasis of lung cancer is earlier and the diffusion speed is fast. Lung cancer often spreads first to lymph nodes near the tumor, known as pulmonary hilar lymph nodes, and then to mediastinum lymph nodes. So, as the gastrointestinal metastases of the lung cancer, esophagus, and stomach are the common sites. Although the distance between lung and intestinal are far, there is abundant lymph nodes in intestine, the suitability of tumor growth affects the metastatic sites. When lung cancer cells travel through the intestinal lymph nodes they are carried to where they can lodge and grow. The metastatic sites depends on both of the organization type and the host factors. Nevertheless, the prognosis is considered to be very poor, and there are few guidelines to treat these cases. Optimal management of treatment remains controversial, with no operative policy or aggressive surgery. Aggressive abdominal surgery, despite its poor prognosis, provides good palliation and reasonable survival in a group of patients whose primary cancer be controlled well. [10]


 > Conclusion Top


In undiagnosed primary lung cancer presenting with acute abdominal pain, the intestine metastasis should be taken into account. Abdominal symptoms should be first relieved and then do further chemotherapy after the primary tumor is clearly found. Pathology, immunohistochemistry, thorax CT and bronchoscopy can assist the clinician with the diagnosis of metastasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Kini S, Kapadia RM, Amarapurkar A. Intussusception due to intestinal metastasis from lung cancer. Indian J Pathol Microbiol 2010;53:141-3.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Bonsignore A, Licursi M, Fiumara F, Leuzzi S, Cavallaro G, Angiò LG, et al. Acute abdomen due to jejunal perforation secondary to metastatic lung carcinoma. G Chir 2009;30:349-54.  Back to cited text no. 2
    
3.
Berger A, Cellier C, Daniel C, Kron C, Riquet M, Barbier JP, et al. Small bowel metastases from primary carcinoma of the lung: Clinical findings and outcome. Am J Gastroenterol 1999;94:1884-7.  Back to cited text no. 3
    
4.
Sakorafas GH, Pavlakis G, Grigoriadis KD. Small bowel perforation secondary to metastatic lung cancer: A case report and review of the literature. Mt Sinai J Med 2003;70:130-2.  Back to cited text no. 4
    
5.
Gitt SM, Flint P, Fredell CH, Schmitz GL. Bowel perforation due to metastatic lung cancer. J Surg Oncol 1992;51:287-91.  Back to cited text no. 5
    
6.
Antler AS, Ough Y, Pitchumoni CS, Davidian M, Thelmo W. Gastrointestinal metastases from malignant tumors of the lung. Cancer 1982;49:170-2.  Back to cited text no. 6
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7.
Hillenbrand A, Sträter J, Henne-Bruns D. Frequency, symptoms and outcome of intestinal metastases of bronchopulmonary cancer. Case report and review of the literature. Int Semin Surg Oncol 2005;2:13.  Back to cited text no. 7
    
8.
Campoli PM, Ejima FH, Cardoso DM, Silva OQ, Santana Filho JB, Queiroz Barreto PA, et al. Metastatic cancer to the stomach. Gastric Cancer 2006;9:19-25.  Back to cited text no. 8
    
9.
Rossi G, Marchioni A, Romagnani E, Bertolini F, Longo L, Cavazza A, et al. Primary lung cancer presenting with gastrointestinal tract involvement: Clinicopathologic and immunohistochemical features in a series of 18 consecutive cases. J Thorac Oncol 2007;2:115-20.  Back to cited text no. 9
    
10.
Nagashima Y, Okamoto H, Narita Y, Hida N, Naoki K, Kunikane H, et al. Perforation of the small intestine caused by metastasis from primary lung cancer: Report of two cases and the discussion of 48 cases published in the Japanese literature. Nihon Kokyuki Gakkai Zasshi 2007;45:430-5.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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