Journal of Surgical Oncology 51:287-291 (1992)
Bowel Perforation Due to Metastatic lung Cancer STEVEN M. GITT,
PATRICIA FLINT, MD, C. HERBERT FREDELL, MU, AND GERALD L. SCHMITZ, MD From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan (S.M.C.); Surgical Service Department, Carl T . Hayden Veterans Affairs Medical Center, and Phoenix Integrated Surgical Residency Program, Phoenix, Arizona (P.F., C.H.F., C.L.S.) MD,
Lung cancer infrequently metastasizes to the bowel. When this occurs, the symptoms may vary from mild to emergent in nature. Three patients are presented illustrating the life threatening complications that may occur due to bowel metastases of lung carcinoma. A review of the literature reveals that only four of 24 reported patients have survived bowel perforation due to metastatic lung carcinoma. One of the three patients presented herein survived to be discharged home. Patients with known lung carcinoma who develop abdominal complaints should be investigated aggressively to prevent life-threatening complications by early intervention. 0 1992 Wiley-Liss, Inc.
KEYWORDS: differential diagnosis, prognosis, lung cancer
evaluation of a left upper lobe lung lesion seen on chest INTRODUCTION More than 100,000 people die annually of lung cancer roentgenogram, which had enlarged over the previous 2 in the United States [l]. In approximately one-half of years. Bronchoscopic biopsy of this apical posterior segthese patients, metastases are present at the time of initial ment mass disclosed poorly differentiated squamous cell diagnosis. The unfavorable prognosis for these patients is carcinoma. Computerized tomography of the chest redue to the presence of extensive disease at initial presen- vealed marked mediastinal lymphadenopathy and deviatation. The degree of metastatic disease has correlated tion of the trachea to the right. The patient then received 3,250 cGy over six weeks. with cell type (most frequent in large and small cell, least He developed acute chest pain and shortness of breath in squamous cell). The commonest reported sites of disnine weeks later and was readmitted with benign pericartant metastases include bone, liver, and adrenal glands dial and pleural effusions. He also had multiple soft tissue [2], while the gastrointestinal tract is rarely noted. There metastases of the upper arm, chest wall, and mandible. have been only 24 cases of bowel perforation due to The patient developed abdominal pain with diffuse metastatic lung cancer reported to date [3-91. Such enguarding and rebound tenderness four weeks later. Abteric metastases are dire prognosticators, occurring typidominal radiographs showed free intraperitoneal air (Fig. cally in the end stages of widely spread disease [S] . Three 1). A solitary, circular, 1-cm well-circumscribed perfoadditional unusual cases of perforated viscus as a result of metastatic carcinoma of the lung are reported. One case rated cecal tumor with purulent peritonitis was found at demonstrated adenocarcinoma, and two were squamous laparotomy . Ileocecectomy with end ileostomy and colonic mucus fistula was done. The remainder of the abcell carcinoma (SCCA). dominal exploration was unremarkable. CASE REPORTS Case 1 A 7 1-year-old man presented with a five month history Accepted for publication May 18, 1992. reprint requests to Dr. Steven M. Gitt, Section of Plastic and of cough, night sweats, and fever. He also complained of Address Reconstructive Surgery, University of Michigan Medical Center, 2 130 hemoptysis, fatigue, hoarseness, and 12-pound weight Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI loss over the preceding 2 months. He was admitted for 48109-0340. 0 1992 Wiley-Liss, Inc.
288
Gitt et al.
Fig. I .
Case I . Free intraperitoneal air
Microscopic examination of the tumor confirmed a metastatic, poorly differentiated squamous cell carcinoma involving the cecum and terminal ileum with four lymph nodes containing metastatic disease (Fig. 2a,b). The lesion was histologically identical to the previously biopsied lung mass (Fig. 3). Postoperatively, his severe peritonitis with sepsis persisted and multiple organ failure developed. In spite of intensive combined therapy, he expired 21 days later.
Case 2 A 39-year-old man with known adenocarcinoma of the lung with brain metastases presented with abdominal pain, anorexia, obstipation, and distension of I -week duration. His medications included dexamethasone, furosemide, laxatives, and narcotic analgesics. Physical examination revealed a nontender, tympanitic markedly distended abdomen. His leukocyte count was 6,600, without leftward shift. Abdominal radiographs showed dilated loops of bowel with multiple air-fluid levels and a large amount of stool in the rectum.
Fig. 2. Squamous cell carcinoma in ileal wall. a: Low-power view. b: High-power view.
A functional bowel obstruction due to narcotic ileus was suspected. Fourteen days later, the patient developed worsening distension, but remained pain free. Abdominal radiographs disclosed free air under the diaphragm. At laparotomy , diffuse purulent peritonitis, a phlegmonous mass of small bowel with multiple interloop ab-
Bowel Perforation and Lung Carcinoma
289
Fig. 4. Metastatic adenocarcinoma in bowel mucosa.
Fig. 3 . Case 1. Primary squamous cell carcinoma of the lung.
scesses, and several focal small bowel perforations were found. Hepatic metastases were present. The involved segment of small bowel was resected with jejunoileostomy reconstruction. Microscopic examination revealed rnultifocal deposits of metastatic adenocarcinoma extensively involving all layers of the intestine, mesentery, and omentum (Fig. 4). There was a malignant enterocolic fistula. The metastatic lesion was histologically identical to the previously biopsied lung mass (Fig. 5). Postoperatively, he had continuing severe sepsis with organ failure for 10 days prior to his demise.
Case 3 A 57-year-old man with known adenocarcinoma of the lung with brain metastases presented complaining of increasing lethargy and decreased level of consciousness. He had previously undergone left lower lobectomy and radiation therapy to the brain. Medications included phenytoin, dexamethasone, atenalol , and codeine. Physical examination revealed mild abdominal distension as well as diffuse rebound and guarding. Abdominal radiographs
Fig. 5 .
Case 2. Primary lung adenocarcinoma.
were unremarkable. The diagnosis of acute appendicitis was made. At laparotomy, a phlegmonous mass of jejunum was found. Two distinct foci of metastatic tumor of the jeju-
290
Gitt et al.
Fig. 6. Case 3. Metastatic squamous cell carcinoma. a: In jejunal wall. b: In jejunal rnucosa.
num had perforated. Segmental jejunectomy with jejunojejunostomy was performed. Microscopic examination revealed metastatic, poorly differentiated squamous cell carcinoma consistent with the primary lung (Fig. 6a,b). Postoperatively, the patient remained afebrile and was tolerating a regular diet at the time of his discharge on postoperative day number 10.
DISCUSSION Lung cancer is the most frequent malignancy as well as the commonest cause of cancer related death [ 11. Approximately one-half of all patients with lung carcinoma have metastases when first seen. However, acutely perforated viscus due to metastatic lung carcinoma is extremely rare. There have been only 24 previous cases reported [3-91. Four of these patients achieved satisfactory surgical palliation. The remaining 20 patients expired postoperatively [6-91. Among the 24 reported cases of bowel perforation due to metastatic lung carcinoma, nine primary lung tumors were iarge cell, seven squamous cell, six adenocarcino-
mas, and two were SCCA. The commonest locations of these metastatic deposits have been small bowel (22 patients) and cecum (2 patients). Woods and Koretz [7] reported 13 patients with metastatic lung cancer who underwent exploratory laparotomy. Eleven presented with complaints of abdominal pain, nausea, and vomiting. Only three of these patients presented with perforation, while 12 had enteric metastases. McNeil et al. [8] found occult small bowel metastases in 46 of 431 patients ( 1 1%) with primary lung cancer who underwent autopsy during an 1 1 -year period. During this same period, five clinical cases of small bowel perforation and one of small bowel obstruction due to metastatic lung cancer were encountered at their institution. Five of these six patients expired within 1 week. Enteric metastases may present as hemorrhage, obstruction, malabsorption, or perforation. While perforated viscus in the lung cancer patient may occur due to metastatic disease, the differential diagnosis should also include diverticular perforation, perforated peptic ulcer, perforated appendix, and perforated colonic carcinoma.
Bowel Perforation and Lung Carcinoma
291
CONCLUSIONS
REFERENCES
Perforated viscus due to metastatic lung cancer is a highly fatal event occurring in the latter phases of the disease. Despite the poor prognosis, early and aggressive intervention has occasionally yielded successful surgical palliation. A high degree of clinical suspicion coupled with rapid diagnosis and prompt intervention are of critical importance. Our experience with three cases of bowel perforation due to metastatic lung cancer further demonstrates its poor prognosis. Yet, as we have seen, mortality is, indeed, not uniform. We concur with Woods and Koretz [ 131, who noted that early diagnosis and aggressive surgical intervention for abdominal complaints and findings is needed to palliate and to improve short term survival. Late intervention is associated with near uniform early fatality.
1 . Silverberg E, Lubera J: Cancer statistics. CA 39(1):3-22, 1989. 2. Sternberg A, Giler S , Segal 1, Shmuter Z , Kott I: Small bowel perforation as the presenting symptom of squamous cell carcinoma of the lung. Clin Oncol6:181-186, 1980. 3. Line D, Deeley T: The necropsy findings in carcinoma of the bronchus. Br J Dis Chest 65:238-242, 1971. 4. Galluzzi S, Payne P: Bronchial carcinoma: A statistical study of 741 necropsies with special reference to the distribution of blood borne metastases. Br J Cancer 9:s 1 1-527, 1955. 5 . Gabot R: Primary carcinoma of the left bronchus with metastases to the adrenals, jejunum, appendix and mesentery. N Engl J Med 2 12: 1224-1 226, 1935. 6. Pang J, King W: Bowel haemorrhage and perforation from metastatic lung cancer. Report of three cases and a review of the literature. Aust NZ J Surg 57379-783, 1987. 7. Woods J, Koretz M: Emergency abdominal surgery for complications of metastatic lung carcinoma. Arch Surg 125:583-585, 1990. 8. McNeil P, Wagman L, Neifeld JP: Small bowel metastases from primary carcinoma of the lung. CA 59: 1486-1489, 1987. 9. Shirani S, Brackett J: Lung cancer presenting as small bowel perforation. Conn Med 53:455-456, 1989.
Bowel Perforation Due to Metastatic lung Cancer STEVEN M. GITT,
PATRICIA FLINT, MD, C. HERBERT FREDELL, MU, AND GERALD L. SCHMITZ, MD From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan (S.M.C.); Surgical Service Department, Carl T . Hayden Veterans Affairs Medical Center, and Phoenix Integrated Surgical Residency Program, Phoenix, Arizona (P.F., C.H.F., C.L.S.) MD,
Lung cancer infrequently metastasizes to the bowel. When this occurs, the symptoms may vary from mild to emergent in nature. Three patients are presented illustrating the life threatening complications that may occur due to bowel metastases of lung carcinoma. A review of the literature reveals that only four of 24 reported patients have survived bowel perforation due to metastatic lung carcinoma. One of the three patients presented herein survived to be discharged home. Patients with known lung carcinoma who develop abdominal complaints should be investigated aggressively to prevent life-threatening complications by early intervention. 0 1992 Wiley-Liss, Inc.
KEYWORDS: differential diagnosis, prognosis, lung cancer
evaluation of a left upper lobe lung lesion seen on chest INTRODUCTION More than 100,000 people die annually of lung cancer roentgenogram, which had enlarged over the previous 2 in the United States [l]. In approximately one-half of years. Bronchoscopic biopsy of this apical posterior segthese patients, metastases are present at the time of initial ment mass disclosed poorly differentiated squamous cell diagnosis. The unfavorable prognosis for these patients is carcinoma. Computerized tomography of the chest redue to the presence of extensive disease at initial presen- vealed marked mediastinal lymphadenopathy and deviatation. The degree of metastatic disease has correlated tion of the trachea to the right. The patient then received 3,250 cGy over six weeks. with cell type (most frequent in large and small cell, least He developed acute chest pain and shortness of breath in squamous cell). The commonest reported sites of disnine weeks later and was readmitted with benign pericartant metastases include bone, liver, and adrenal glands dial and pleural effusions. He also had multiple soft tissue [2], while the gastrointestinal tract is rarely noted. There metastases of the upper arm, chest wall, and mandible. have been only 24 cases of bowel perforation due to The patient developed abdominal pain with diffuse metastatic lung cancer reported to date [3-91. Such enguarding and rebound tenderness four weeks later. Abteric metastases are dire prognosticators, occurring typidominal radiographs showed free intraperitoneal air (Fig. cally in the end stages of widely spread disease [S] . Three 1). A solitary, circular, 1-cm well-circumscribed perfoadditional unusual cases of perforated viscus as a result of metastatic carcinoma of the lung are reported. One case rated cecal tumor with purulent peritonitis was found at demonstrated adenocarcinoma, and two were squamous laparotomy . Ileocecectomy with end ileostomy and colonic mucus fistula was done. The remainder of the abcell carcinoma (SCCA). dominal exploration was unremarkable. CASE REPORTS Case 1 A 7 1-year-old man presented with a five month history Accepted for publication May 18, 1992. reprint requests to Dr. Steven M. Gitt, Section of Plastic and of cough, night sweats, and fever. He also complained of Address Reconstructive Surgery, University of Michigan Medical Center, 2 130 hemoptysis, fatigue, hoarseness, and 12-pound weight Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI loss over the preceding 2 months. He was admitted for 48109-0340. 0 1992 Wiley-Liss, Inc.
288
Gitt et al.
Fig. I .
Case I . Free intraperitoneal air
Microscopic examination of the tumor confirmed a metastatic, poorly differentiated squamous cell carcinoma involving the cecum and terminal ileum with four lymph nodes containing metastatic disease (Fig. 2a,b). The lesion was histologically identical to the previously biopsied lung mass (Fig. 3). Postoperatively, his severe peritonitis with sepsis persisted and multiple organ failure developed. In spite of intensive combined therapy, he expired 21 days later.
Case 2 A 39-year-old man with known adenocarcinoma of the lung with brain metastases presented with abdominal pain, anorexia, obstipation, and distension of I -week duration. His medications included dexamethasone, furosemide, laxatives, and narcotic analgesics. Physical examination revealed a nontender, tympanitic markedly distended abdomen. His leukocyte count was 6,600, without leftward shift. Abdominal radiographs showed dilated loops of bowel with multiple air-fluid levels and a large amount of stool in the rectum.
Fig. 2. Squamous cell carcinoma in ileal wall. a: Low-power view. b: High-power view.
A functional bowel obstruction due to narcotic ileus was suspected. Fourteen days later, the patient developed worsening distension, but remained pain free. Abdominal radiographs disclosed free air under the diaphragm. At laparotomy , diffuse purulent peritonitis, a phlegmonous mass of small bowel with multiple interloop ab-
Bowel Perforation and Lung Carcinoma
289
Fig. 4. Metastatic adenocarcinoma in bowel mucosa.
Fig. 3 . Case 1. Primary squamous cell carcinoma of the lung.
scesses, and several focal small bowel perforations were found. Hepatic metastases were present. The involved segment of small bowel was resected with jejunoileostomy reconstruction. Microscopic examination revealed rnultifocal deposits of metastatic adenocarcinoma extensively involving all layers of the intestine, mesentery, and omentum (Fig. 4). There was a malignant enterocolic fistula. The metastatic lesion was histologically identical to the previously biopsied lung mass (Fig. 5). Postoperatively, he had continuing severe sepsis with organ failure for 10 days prior to his demise.
Case 3 A 57-year-old man with known adenocarcinoma of the lung with brain metastases presented complaining of increasing lethargy and decreased level of consciousness. He had previously undergone left lower lobectomy and radiation therapy to the brain. Medications included phenytoin, dexamethasone, atenalol , and codeine. Physical examination revealed mild abdominal distension as well as diffuse rebound and guarding. Abdominal radiographs
Fig. 5 .
Case 2. Primary lung adenocarcinoma.
were unremarkable. The diagnosis of acute appendicitis was made. At laparotomy, a phlegmonous mass of jejunum was found. Two distinct foci of metastatic tumor of the jeju-
290
Gitt et al.
Fig. 6. Case 3. Metastatic squamous cell carcinoma. a: In jejunal wall. b: In jejunal rnucosa.
num had perforated. Segmental jejunectomy with jejunojejunostomy was performed. Microscopic examination revealed metastatic, poorly differentiated squamous cell carcinoma consistent with the primary lung (Fig. 6a,b). Postoperatively, the patient remained afebrile and was tolerating a regular diet at the time of his discharge on postoperative day number 10.
DISCUSSION Lung cancer is the most frequent malignancy as well as the commonest cause of cancer related death [ 11. Approximately one-half of all patients with lung carcinoma have metastases when first seen. However, acutely perforated viscus due to metastatic lung carcinoma is extremely rare. There have been only 24 previous cases reported [3-91. Four of these patients achieved satisfactory surgical palliation. The remaining 20 patients expired postoperatively [6-91. Among the 24 reported cases of bowel perforation due to metastatic lung carcinoma, nine primary lung tumors were iarge cell, seven squamous cell, six adenocarcino-
mas, and two were SCCA. The commonest locations of these metastatic deposits have been small bowel (22 patients) and cecum (2 patients). Woods and Koretz [7] reported 13 patients with metastatic lung cancer who underwent exploratory laparotomy. Eleven presented with complaints of abdominal pain, nausea, and vomiting. Only three of these patients presented with perforation, while 12 had enteric metastases. McNeil et al. [8] found occult small bowel metastases in 46 of 431 patients ( 1 1%) with primary lung cancer who underwent autopsy during an 1 1 -year period. During this same period, five clinical cases of small bowel perforation and one of small bowel obstruction due to metastatic lung cancer were encountered at their institution. Five of these six patients expired within 1 week. Enteric metastases may present as hemorrhage, obstruction, malabsorption, or perforation. While perforated viscus in the lung cancer patient may occur due to metastatic disease, the differential diagnosis should also include diverticular perforation, perforated peptic ulcer, perforated appendix, and perforated colonic carcinoma.
Bowel Perforation and Lung Carcinoma
291
CONCLUSIONS
REFERENCES
Perforated viscus due to metastatic lung cancer is a highly fatal event occurring in the latter phases of the disease. Despite the poor prognosis, early and aggressive intervention has occasionally yielded successful surgical palliation. A high degree of clinical suspicion coupled with rapid diagnosis and prompt intervention are of critical importance. Our experience with three cases of bowel perforation due to metastatic lung cancer further demonstrates its poor prognosis. Yet, as we have seen, mortality is, indeed, not uniform. We concur with Woods and Koretz [ 131, who noted that early diagnosis and aggressive surgical intervention for abdominal complaints and findings is needed to palliate and to improve short term survival. Late intervention is associated with near uniform early fatality.
1 . Silverberg E, Lubera J: Cancer statistics. CA 39(1):3-22, 1989. 2. Sternberg A, Giler S , Segal 1, Shmuter Z , Kott I: Small bowel perforation as the presenting symptom of squamous cell carcinoma of the lung. Clin Oncol6:181-186, 1980. 3. Line D, Deeley T: The necropsy findings in carcinoma of the bronchus. Br J Dis Chest 65:238-242, 1971. 4. Galluzzi S, Payne P: Bronchial carcinoma: A statistical study of 741 necropsies with special reference to the distribution of blood borne metastases. Br J Cancer 9:s 1 1-527, 1955. 5 . Gabot R: Primary carcinoma of the left bronchus with metastases to the adrenals, jejunum, appendix and mesentery. N Engl J Med 2 12: 1224-1 226, 1935. 6. Pang J, King W: Bowel haemorrhage and perforation from metastatic lung cancer. Report of three cases and a review of the literature. Aust NZ J Surg 57379-783, 1987. 7. Woods J, Koretz M: Emergency abdominal surgery for complications of metastatic lung carcinoma. Arch Surg 125:583-585, 1990. 8. McNeil P, Wagman L, Neifeld JP: Small bowel metastases from primary carcinoma of the lung. CA 59: 1486-1489, 1987. 9. Shirani S, Brackett J: Lung cancer presenting as small bowel perforation. Conn Med 53:455-456, 1989.
