Scientific letter
Rare cause of acute abdomen: Small bowel metastasis from lung cancer
Causa rara de abdomen agudo: metátasis intestinales de cáncer de pulmón
Maria Dolores Picardo Gomendioa,
, Alba Manuel Vázqueza, Cristina Garcia Amadora, Yuri Rodrigues Figueirab, Antonio Candiab, Roberto de la Plaza Llamasa, José Manuel Ramia Ángelc
Corresponding author
a Servicio de Cirugía y del Aparato Digestivo, Hospital General Universitario de Guadalajara, Guadalajara, Spain
b Servicio de Anatomía Patológica, Hospital General Universitario de Guadalajara, Guadalajara, Spain
c Hospital General Universitario de Alicante; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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Infiltración desde capa peritoneal hacia mucosa, en la que se observan pequeños nidos tumorales, ulceración y necrosis de la superficie. <span class="elsevierStyleBold">C</span>) Inmunohistoquímica del caso 1. Positividad para citoqueratina 7 en la membrana y citoplasma en la tumoración. <span class="elsevierStyleBold">D</span>) Inmunohistoquímica del caso 1. TTF-1 positivo en la tumoración infiltrante. <span class="elsevierStyleBold">E-G)</span> TC abdominal del caso 2: invaginación de intestino delgado (flecha). <span class="elsevierStyleBold">H)</span> Histología del caso 2: visión panorámica de la pared intestinal ulcerada e infiltrada por adenocarcinoma en todo su espesor. <span class="elsevierStyleBold">I</span>) Histología del caso 2: crecimiento en sábana de la neoplasia formando nidos sólidos, células con presencia de vacuolas intracitoplasmáticas y luces celulares.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María Dolores Picardo Gomendio, Alba Manuel Vázquez, Cristina García Amador, Yuri Rodrigues Figueira, Antonio Candia, Roberto de la Plaza Llamas, José Manuel Ramia Ángel" "autores" => array:7 [ 0 => array:2 [ "nombre" => "María Dolores" "apellidos" => "Picardo Gomendio" ] 1 => array:2 [ "nombre" => "Alba" "apellidos" => "Manuel Vázquez" ] 2 => array:2 [ "nombre" => "Cristina" "apellidos" => "García Amador" ] 3 => array:2 [ "nombre" => "Yuri" "apellidos" => "Rodrigues Figueira" ] 4 => array:2 [ "nombre" => "Antonio" "apellidos" => "Candia" ] 5 => array:2 [ "nombre" => "Roberto" "apellidos" => "de la Plaza Llamas" ] 6 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Ramia Ángel" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382421001796" "doi" => "10.1016/j.gastre.2021.09.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382421001796?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570520303745?idApp=UINPBA00004N" "url" => "/02105705/0000004400000009/v1_202110240545/S0210570520303745/v1_202110240545/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2444382421001772" "issn" => "24443824" "doi" => "10.1016/j.gastre.2020.07.025" "estado" => "S300" "fechaPublicacion" => "2021-11-01" "aid" => "1651" "copyright" => "Elsevier España, S.L.U." 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Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Causa rara de abdomen agudo: metátasis intestinales de cáncer de pulmón" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1172 "Ancho" => 1750 "Tamanyo" => 347655 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A</span>) Case 1 abdominal CT axial slice: pneumoperitoneum (arrow). <span class="elsevierStyleBold">B</span>) Case 1 histology: wall of the small intestine infiltrated by the tumour. Infiltration from the peritoneal layer towards the mucosa, in which small tumour nests, ulceration and surface necrosis are observed. <span class="elsevierStyleBold">C</span>) Case 1 immunohistochemistry. Positivity for cytokeratin 7 in the membrane and cytoplasm in the tumour. <span class="elsevierStyleBold">D</span>) Case 1 immunohistochemistry. Positive TTF-1 in the infiltrating tumour. <span class="elsevierStyleBold">E–G)</span> Case 2 abdominal CT: small intestine invagination (arrow). <span class="elsevierStyleBold">H)</span> Case 2 histology: panoramic view of the ulcerated intestinal wall infiltrated by adenocarcinoma throughout its thickness. <span class="elsevierStyleBold">I</span>) Case 2 histology: sheet-like growth of the neoplasm, forming solid nests, cells with the presence of intracytoplasmic vacuoles and cell lumina.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lung cancer small bowel metastases are rare.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Their diagnosis is difficult, as most of them are asymptomatic, although they can sometimes cause symptoms related to complications. In the presence of abdominal symptoms in patients with lung cancer, we should suspect a lung cancer small bowel metastasis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe 2 cases of patients with acute abdomen secondary to lung cancer small bowel metastasis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">58-year-old male, smoker, who presented in the Emergency Room for a seizure. Bilateral supratentorial masses consistent with brain metastases were observed on the brain computed tomography (CT). The chest-abdomen-pelvis CT revealed a pulmonary nodule in the left upper lobe infiltrating the pleura, with mediastinal and intra-abdominal lymphadenopathy. On° day 7, a CT scan was performed for abdominal pain, which revealed pneumoperitoneum, distension of the small bowel loops and free fluid (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Urgent surgery was performed, in which a perforated jejunal tumour and generalised peritonitis were observed. Segmental resection and anastomosis were performed. Subsequently, CT-guided chest puncture histology revealed a lung adenocarcinoma. The patient was discharged 8 days later without complications (Clavien 0, CCI: 0). The histological study of the small intestine showed a poorly differentiated adenocarcinoma consistent with pulmonary origin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and C). The patient died 2 months after surgery due to tumour progression (Clavien V, CCI: 100).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 46-year-old woman, on immunotherapy with nivolumab for undifferentiated stage IV carcinoma of unknown origin, stable for one year. She was hospitalised for general malaise and vomiting. Intestinal obstruction secondary to jejunal invagination was observed on the abdominal CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E–G). The surgery confirmed invagination, with a palpable and indurated lesion inside, with no further findings; segmental resection and anastomosis were performed. The histological result was infiltration due to lung adenocarcinoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>H and I). The patient presented with deep vein thrombosis and acute respiratory failure secondary to pleural effusion (Clavien IIIb, CCI: 33.5). She was readmitted one month later for pleural effusion. She received palliative treatment and subsequently died (Clavien V, CCI: 100).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Approximately 50% of lung cancer patients have metastases at diagnosis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the incidence of locoregional or distant recurrence after treatment is 50% at 2 years.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Lung cancer can spread lymphatically or haematogenously; the liver, brain, adrenal gland and bone are the most common locations,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> although dissemination patterns vary according to histological type.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Metastatic involvement in other locations is rare (less than 5%), is more frequent in men and usually presents with multiple lesions.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> It usually appears in terminal patients with disseminated disease in several locations.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Of these lesions, gastrointestinal lesions have an incidence of 0.3%–1.7%<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>, and are located, in order of frequency, in the oesophagus, small intestine, stomach and colon.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> In the small intestine, they predominantly affect the jejunum-ileum, as in our patients, and to a lesser extent the duodenum.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical manifestations of lung cancer small bowel metastases are usually rare or confused with the gastrointestinal effects of chemotherapy. In fact, in <span class="elsevierStyleItalic">post mortem</span> studies, their incidence increases to 4.6%–14%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In rare cases, the first clinical manifestation of lung cancer is due to gastrointestinal metastatic involvement.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Symptomatic intestinal metastases due to complications such as upper gastrointestinal bleeding, perforation or obstruction have been described.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Therefore, in patients with acute abdomen and lung cancer, they should be considered in the differential diagnoses.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The most appropriate treatment for intestinal metastases is under debate and is influenced by the clinical picture. In the case of complications, as in our patients, the recommended treatment is surgery, with segmental intestinal resection and anastomosis. In the case of invagination, previous disinvagination should be avoided due to the risk of neoplastic spread, perforation and complications in the anastomosis caused by manipulation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Gastrointestinal metastases in lung cancer worsen the prognosis and reduce survival.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The presence of intestinal perforation, other extraintestinal metachronous metastases and age are factors that tend to indicate a poorer prognosis. In these cases, survival is usually a question of weeks or months.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Lung cancer small bowel metastases are rare and mostly asymptomatic. Therefore, a high degree of suspicion is required to make the right diagnosis. Their appearance is associated with a worse prognosis and lower survival.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Picardo Gomendio MD, Manuel Vázquez A, Garcia Amador C, Rodrigues Figueira Y, Candia A, de la Plaza Llamas R, et al. Causa rara de abdomen agudo: metátasis intestinales de cáncer de pulmón. Gastroenterol Hepatol. 2021;44:656–658.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1172 "Ancho" => 1750 "Tamanyo" => 347655 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A</span>) Case 1 abdominal CT axial slice: pneumoperitoneum (arrow). <span class="elsevierStyleBold">B</span>) Case 1 histology: wall of the small intestine infiltrated by the tumour. Infiltration from the peritoneal layer towards the mucosa, in which small tumour nests, ulceration and surface necrosis are observed. <span class="elsevierStyleBold">C</span>) Case 1 immunohistochemistry. Positivity for cytokeratin 7 in the membrane and cytoplasm in the tumour. <span class="elsevierStyleBold">D</span>) Case 1 immunohistochemistry. Positive TTF-1 in the infiltrating tumour. <span class="elsevierStyleBold">E–G)</span> Case 2 abdominal CT: small intestine invagination (arrow). <span class="elsevierStyleBold">H)</span> Case 2 histology: panoramic view of the ulcerated intestinal wall infiltrated by adenocarcinoma throughout its thickness. <span class="elsevierStyleBold">I</span>) Case 2 histology: sheet-like growth of the neoplasm, forming solid nests, cells with the presence of intracytoplasmic vacuoles and cell lumina.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metástasis gastrointestinales de carcinoma pulmonar primario. Serie de casos y revisión sistemática de la literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Balla" 1 => "J.D. Subiela" 2 => "J. Bollo" 3 => "C. Martínez" 4 => "C. Rodriguez Luppi" 5 => "P. Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ciresp.2017.12.011" "Revista" => array:6 [ "tituloSerie" => "Cir Esp" "fecha" => "2018" "volumen" => "96" "paginaInicial" => "184" "paginaFinal" => "197" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29567360" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribution and prognosis of uncommon metastases from non-small cell lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.Y. Niu" 1 => "Q. Zhou" 2 => "J.J. Yang" 3 => "W.Z. Zhong" 4 => "Z.H. 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Singh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bcr-2016-217539" "Revista" => array:4 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2016" "volumen" => "2016" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26783007" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ileal intussusception due to metastasis from squamous cell carcinoma of the lung resected 12 years previously" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Nakamura" 1 => "O. Chino" 2 => "T. Tajima" 3 => "Y. Tanaka" 4 => "D. Yokoyama" 5 => "T. Hanashi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Tokai J Exp Clin Med" "fecha" => "2015" "volumen" => "40" "paginaInicial" => "137" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26662663" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribution patterns of the metastases of the lung carcinoma in relation to histological type of the primary tumor: an autopsy study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I.S. Milovanovic" 1 => "M. Stjepanovic" 2 => "D. Mitrovic" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/atm.ATM_276_16" "Revista" => array:5 [ "tituloSerie" => "Ann Thorac Med" "fecha" => "2017" "volumen" => "12" "paginaInicial" => "191" "paginaFinal" => "198" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000004400000009/v1_202111050718/S2444382421001796/v1_202111050718/en/main.assets" "Apartado" => array:4 [ "identificador" => "71324" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientifics letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004400000009/v1_202111050718/S2444382421001796/v1_202111050718/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382421001796?idApp=UINPBA00004N" ]
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