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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 1  |  Page : 141-143
Intussusception due to intestinal metastasis from lung cancer


Department of Pathology, BYL Nair Hospital & TN Medical College, Mumbai- 400 008, India

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Date of Web Publication19-Jan-2010
 

   Abstract 

Intestinal metastasis from lung primary is very uncommon and seen at the terminal stage of the disease. Clinically, patients present as perforation or bleeding and rarely as intussusception. We report the case of a 78-year-old man who came with sudden onset of abdominal complaints of four to five days duration. A computerized tomography (CT) - scan abdomen showed mural thickening of short loop of jejunum with ileoileal intussusception. Resection-anastomosis revealed two separate nodules in the small intestine. The patient, a diagnosed case of primary carcinoma of lung seven months ago, had been treated with one cycle of chemotherapy. Histopathology of the small intestinal nodules showed features of adenocarcinoma consistent with the known primary lung cancer. We present this case to arouse a clinical suspicion of intestinal metastasis in known cases of primary lung cancer presenting with the sudden onset of abdominal complaints. Early diagnosis and management improves the survival of these patients.

Keywords: Intussusception, lung primary, small intestine metastasis

How to cite this article:
Kini S, Kapadia RM, Amarapurkar A. Intussusception due to intestinal metastasis from lung cancer. Indian J Pathol Microbiol 2010;53:141-3

How to cite this URL:
Kini S, Kapadia RM, Amarapurkar A. Intussusception due to intestinal metastasis from lung cancer. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Oct 15];53:141-3. Available from: http://www.ijpmonline.org/text.asp?2010/53/1/141/59208



   Introduction Top


Metastasis to small intestine is usually seen in malignant melanomas; carcinomas of breast, colon, lung and kidney. The occurrence of such metastasis, although reported in the literature, continues to be rare. Gastrointestinal (GI) metastasis in known primary carcinoma of lung is most unusual. It indicates terminal stage of the disease and heralds a dismal prognosis. Clinically, the complaints vary from more common presentation such as perforation and hemorrhage to rarer presentation as intussusception.

We report this unusual case to clinically suspect for GI metastasis in patients of known bronchogenic carcinoma presenting with acute abdomen and intussusception.


   Case Report Top


A 78 year-old man presented with pain and distension of abdomen of four to five days duration. The patient did not have any other GI complaints. On examination, the abdomen was distended and tender. CT of abdomen showed a circumferential mural thickening of short jejunal loop with ileoileal intussusception. CT-scan thorax showed multiple paratracheal and paracaval lymph nodes, all measuring less than one cm. A bone scan showed normal results. A resection-anastomosis of the involved small intestinal segments was performed.

Resected specimens of two segments of small intestine, nine cm and six cm in length, were received. The larger segment showed presence of a single transmural ulceronodular lesion of 4.5 cm x 3.8 cm x 1.8 cm with prominent serosal nodule [Figure 1] and the smaller segment showed a stricturous mural thickening measuring 2.8 cm x 1.8 cm x 0.4 cm with overlying ulcerated mucosa [Figure 2].

The patient was a diagnosed case of primary adenocarcinoma of lung on transbronchial biopsy seven months ago elsewhere. CT-scan thorax done earlier had revealed a solitary, well circumscribed nodular mass with necrotic areas in the right lung. Subsequently, the patient received one cycle of chemotherapy with cisplatinum - gemcitabine, the last session being two months prior to the presentation of GI symptoms.

The histomorphology of small intestinal lesions revealed features of moderately differentiated adenocarcinoma; tumor arranged in solid, glandular, and papillary pattern. Individual cells were round to oval with high nuclear: cytoplasmic ratio, nuclear pleomorphism, vesicular nuclei with prominent nucleoli, moderate eosinophilic cytoplasm and brisk abnormal mitosis. Tumor was seen infiltrating all the layers of the intestine with no transformation zone noted [Figure 3] and [Figure 4]. Review of previous lung biopsy slides showed similar tumor morphology.

A diagnosis of metastatic adenocarcinoma of small intestine of lung primary origin over primary small intestinal origin was concluded.

Postoperative follow-up of the patient has been uneventful and patient is doing well after five months till date.


   Discussion Top


Lung carcinoma commonly metastasizes to adrenals, brain, bone and liver. Metastasis to GI from lung cancer is not as uncommon as previously thought and incidence in the literature varies widely from 10-14% [1],[2] and 0.5-2%. [3]

GI metastasis from lung cancer occurs following hematogenous spread and indicates terminal stage of the disease. Clinically, GI metastasis may be asymptomatic or symptomatic. The most common clinical presentation is perforation. Andreas Hillenbrand et al. reviewed 58 cases of small intestinal metastasis of primary lung cancer over 42 years and found common GI presentation as perforation (59%), obstruction (29%) and hemorrhage (10%) with one patient (2%) diagnosed in a staging CT scan. [2] Intussusception continues to be an unusual presentation of GI metastasis as observed in the present case. [4]

Among the various common histological subtypes of primary lung cancer metastasizing to GI, squamous cell carcinoma of the lung was thought to be the most common type. [5],[3] However, in recent literature, poorly differentiated adenocarcinoma and large cell undifferentiated carcinoma are described as more common subtypes. [6],[7] The histological subtypes presenting with intussusception are large cell and non-small cell carcinoma, [3],[4] as observed in the present case with features of adenocarcinoma.

The multifocal involvement of small intestine on gross and absence of transformation zone on histology was sufficient to conclude as small intestinal metastasis of lung primary in the present case. Histologically, the tumor was similar to the primary lung biopsy on review. These findings obviated the necessity to perform a panel of IHC markers such as TTF-1, CK 7 and CK 20. [7]

Due to lack of definite diagnostic features on radiology or endoscopy to predict such metastasis, [8] a strong clinical suspicion of GI metastasis is highly suggested in sudden onset of abdominal complaints in known cases of primary lung carcinoma; it requires confirmation on histology. Early diagnosis with palliative surgery and chemotherapy has shown to increase the rate of survival and improve quality of life of these patients.

 
   References Top

1.Mcneill PM, Wagman LD, Neidfeld JP. Small bowel metastasis from primary carcinoma of the lung. Cancer 1987:59:1486-9.  Back to cited text no. 1      
2.Hillenbrand A, Strater J, Henne-Bruns D. Frequency, symptoms and outcome of intestinal metastases of bronchopulmonary cancer Case report and review of literature. Int Semin Surg Oncol 2005;2:1-5.  Back to cited text no. 2      
3.Berger A, Cellier C, Daniel C, Kron C, Riquet M, Barbier JP, et al. Small bowel metastasis from primary carcinoma of the lung: clinical findings and outcome. Am J Gastroenterol 1999;4:1884-7.  Back to cited text no. 3      
4.Issa K, Mullen KD. Large- cell carcinoma of the lung with major bleeding and intussusception. J Clin Gastroenterol 1992;15:142-5.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Antler AS, Ough Y, Pitchumoni CS, Davidian M, Thelmo W. Gastrointestinal metastases from malignant tumours of the lung. Cancer 1982;49:170-2.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Tomas D, Ledinsky M, Belicza M, Kruslin B. Multiple metastases to the small bowel from large cell bronchial carcinomas. World J Gastroenterol 2005;11:1399-402.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.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. 7  [PUBMED]  [FULLTEXT]  
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  [PUBMED]  [FULLTEXT]  

Top
Correspondence Address:
Sangeeta Kini
Flat No. 5, Sat-sang CHS, Sector 9A, Plot 32, Vashi, Navimumbai-400 703
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.59208

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    Figures

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

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