Scand J Thor Cardiovasc Surg 26: 161-162, 1992
CARCINOSARCOMA OF THE LUNG WITH GASTROINTESTINAL METASTASIS Case Report
Jibah Eng and Sabaratnam Sabanathan From the Departments of Thoracic Surgery, Bradford Royal Infirmary, Bradford, England
Scand Cardiovasc J Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
(Accepted for publication January 9, 1992)
Abstract. An unusual case of carcinosarcoma of the lung with metastasis to the gastrointestinal tract causing intussusception is presented. The clinical, radiologic and histopathologic features are reviewed with reference to relevant literature. Key words: intussusception, metastatic carcinosarcoma.
Carcinosarcoma of the lung is rare, with less than 60 cases hitherto reported in the available literature (7). Distant metastasis tends to occur especially from the sarcomatous component of peripheral tumours ( 1 3). Metastasis from primary bronchial malignancy to the small bowel causing intussusception is unusual (7, 8, 11). We report recent experience of such a case. CASE REPORT A 60-year-old man presented with a 3-month history of cough and haemoptysis. Chest radiography (Fig. 1) showed a large tumour of the right lung. Computed tomographic (CT) scan (Fig. 2) confirmed the tumour, with no evidence of mediastinal involvement.
Fig. 1. Chest radiograph showing large tumour of the right lung.
Fig. 2. C T scan shows a large, well circumscribed tumour posteriorly in the right lower lobe.
Bronchoscopy and mediastinoscopy revealed no abnormality. Histologic study of a percutaneous needle biospy under CT guidance showed carcinosarcoma. Respiratory function studies, bone scan and general work-up did not preclude surgical treatment. An intrapericardial right pneumonectomy was performed and the patient recovered uneventfully. Histologic examination of the resected lung confirmed the diagnosis. There was no extrapulmonary extension and no involvement of mediastinal lymph nodes. No adjuvant therapy was given. The patient remained well for 18 months, but then presented with intermittent vomiting and abdominal discomfort. At gastroscopy the stomach, pylorus and duodenum were grossly dilated. A barium meal (Fig. 3) confirmed proximal small-bowel obstruction. At laparotomy the obstruction was found to have resulted from intussusception of the proximal jejunum distal to the ligament of Treitz. The apex of the intussusceptum was a polypoid tumour. Resection of the obstructed bowel with end-to-end anastomosis was performed and recovery was smooth. Histologic sections showed the large polyp to be composed of a proliferation of spindle cells with a high mitotic rate and numerous bizarre multinucleated giant cells. The tumour appeared to extend into the muscular layer of the bowel wall. In one of the five
Fig. 3. Barium meal demonstrating obstruction of the proximal small bowel and gastric and duodenal dilation.
Scand J Thoracic 26
162
J. Eng and S. Sabanathan
Scand Cardiovasc J Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
identified mesenteric lymph nodes there was tumour involvement. Histologically the picture was similar to the sarcomatous component of the tumour found in the right lung. The patient survived for 6 more months, after which he died of cerebral metastasis.
CONCLUSIONS Metastatic lesions of the small bowel are rare. Reported origins are cervical, renal or ovarian cervical carcinoma and malignant melanoma (5, 8). Small-bowel metastasis from primary pulmonary neoplasm is rarely detected clinically, although incidence at autopsy has been reported as 4.7% (1) and 10.7% (12). In most of these cases there are multiple metastases (12). Metastasis to the small bowel may present as perforation, obstruction, malabsorption or haemorrhage ( 12). Perforation occurs at sites where mural replacement by tumour cells has resulted in necrosis. A submucosal lesion may develop a pseudopedicle and then present as an intraluminal polypoid mass which may cause intussusception (8). Indeed, intussusception is the most common finding in melanoma patients with symptoms of intestinal obstruction (9). Intussusception secondary to squamous cell carcinoma of the lung was recently reported (7). As in that case, resection with end-to-end anastomosis gave satisfactory palliation in our patient. Carcinosarcoma may originate in the uterus, hypopharynx, oesophagus and lung (3). Bronchopulmonary carcinosarcoma may appear as a central endobronchial lesion or a peripheral invasive process (14), with the latter tending to be more aggressive (2). Carcinosarcoma has been reported to constitute 0.2% (4) or 0.27% (6) of primary pulmonary malignancies, mainly occurring in the upper lobes (2,4). Polypoid endobronchial central lesions produce symptoms of bronchial obstruction, whereas peripheral tumours tend to be relatively asymptomatic until a late stage, often with metastasis, and thus larger when detected (13). Distant metastases, as in our case, will eventually occur in more than 40 % of patients. The pathogenesis of pulmonary carcinosarcoma is not clear (2, 7). It may arise by sarcomatous transformation of the stroma or as a ‘collision tumour’ (6). The carcinomatous component is mostly (70 O/o) epidermoid, sometimes Scand J Thoracic 26
(20%) adenomatoid, and in a few cases (10%) undifferentiated (2). The mesenchymal portion is mostly of spindle cell type and may contain foci of leiomyosarcoma, fibrosarcoma, chondrosarcoma, osteosarcoma or an immature form of cells (7). For true carcinosarcoma, both components must be malignant (3). The carcinomatous part tends to metastasize to regional lymph nodes and the sarcomatous part to give rise to distant metastasis (7). The roles of radiotherapy (7) and chemotherapy (4)are uncertain. Resection should be performed whenever possible. REFERENCES 1. Antler AS, Ough Y, Pitchumoni CS, Davidian M, Thelmo W. Gastrointestinal metastases from malignant tumors of the lung. Cancer 1982; 49: 170-1 72. 2. Cabarcos A, Dorronsoro MG, Beristain JLL. Pulmonary carcinosarcoma: A case study and review of the literature. Br J Dis Chest 1985; 79: 83-94. 3. Chaudhuri MR. Bronchial carcinosarcoma. J Thorac Cardiovasc Surg 1971; 61: 319-323. 4. Davis MP, Eagan RT, Weiland LH, Pairolero PC. Carcinosarcoma of the lung: Mayo clinic experience and response to chemotherapy. Mayo Clin Proc 1984; 59: 598-603. 5 . De Castro CA, Dockerty MB, Mayo CW. Metastatic tumors of the small intestine. Surg Gynecol Obstet 1957; 105: 159-165. 6. Diaconita G. Bronchopulmonary carcinosarcoma. Thorax 1975; 30: 682-686. 7. Engel AF, Groot G, Bellot S. Carcinosarcoma of the lung. A case-history of disseminated disease and review of the literature. Eur J Surg Oncol 1991; 17: 94-96. 8. Farmer RG, Hawk WA. Metastatic tumors of the small bowel. Gastroenterology 1964; 47: 496-504. 9. Gupta TKD, Brasfield RD. Metastatic melanoma of the gastrointestinal tract. Arch Surg 1964; 88: 969-973. 10. Leidich RB, Rudolf LE. Small bowel perforation secondary to metastatic lung carcinoma. Ann Surg 1981; 193: 67-69. 11. Listrom MB, Davis M, Lowry S, Williams WW, Monsein LH, Kleinman R, Gogel HK. Intussusception secondary to squamous carcinoma of the lung. Gastrointest Radio1 1988; 13: 224-226. 12. McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer 1987; 59: 1496-1497. 13. Meade P, Moad J, Fellows D, Adams CW. Carcinosarcoma of the lung with hypertrophic pulmonary osteoarthropathy. Ann Thorac Surg 1991; 51: 488-490. 14. Moore T. Carcinosarcoma of the lung. Surgery 1961; 50: 886-893.
CARCINOSARCOMA OF THE LUNG WITH GASTROINTESTINAL METASTASIS Case Report
Jibah Eng and Sabaratnam Sabanathan From the Departments of Thoracic Surgery, Bradford Royal Infirmary, Bradford, England
Scand Cardiovasc J Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
(Accepted for publication January 9, 1992)
Abstract. An unusual case of carcinosarcoma of the lung with metastasis to the gastrointestinal tract causing intussusception is presented. The clinical, radiologic and histopathologic features are reviewed with reference to relevant literature. Key words: intussusception, metastatic carcinosarcoma.
Carcinosarcoma of the lung is rare, with less than 60 cases hitherto reported in the available literature (7). Distant metastasis tends to occur especially from the sarcomatous component of peripheral tumours ( 1 3). Metastasis from primary bronchial malignancy to the small bowel causing intussusception is unusual (7, 8, 11). We report recent experience of such a case. CASE REPORT A 60-year-old man presented with a 3-month history of cough and haemoptysis. Chest radiography (Fig. 1) showed a large tumour of the right lung. Computed tomographic (CT) scan (Fig. 2) confirmed the tumour, with no evidence of mediastinal involvement.
Fig. 1. Chest radiograph showing large tumour of the right lung.
Fig. 2. C T scan shows a large, well circumscribed tumour posteriorly in the right lower lobe.
Bronchoscopy and mediastinoscopy revealed no abnormality. Histologic study of a percutaneous needle biospy under CT guidance showed carcinosarcoma. Respiratory function studies, bone scan and general work-up did not preclude surgical treatment. An intrapericardial right pneumonectomy was performed and the patient recovered uneventfully. Histologic examination of the resected lung confirmed the diagnosis. There was no extrapulmonary extension and no involvement of mediastinal lymph nodes. No adjuvant therapy was given. The patient remained well for 18 months, but then presented with intermittent vomiting and abdominal discomfort. At gastroscopy the stomach, pylorus and duodenum were grossly dilated. A barium meal (Fig. 3) confirmed proximal small-bowel obstruction. At laparotomy the obstruction was found to have resulted from intussusception of the proximal jejunum distal to the ligament of Treitz. The apex of the intussusceptum was a polypoid tumour. Resection of the obstructed bowel with end-to-end anastomosis was performed and recovery was smooth. Histologic sections showed the large polyp to be composed of a proliferation of spindle cells with a high mitotic rate and numerous bizarre multinucleated giant cells. The tumour appeared to extend into the muscular layer of the bowel wall. In one of the five
Fig. 3. Barium meal demonstrating obstruction of the proximal small bowel and gastric and duodenal dilation.
Scand J Thoracic 26
162
J. Eng and S. Sabanathan
Scand Cardiovasc J Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
identified mesenteric lymph nodes there was tumour involvement. Histologically the picture was similar to the sarcomatous component of the tumour found in the right lung. The patient survived for 6 more months, after which he died of cerebral metastasis.
CONCLUSIONS Metastatic lesions of the small bowel are rare. Reported origins are cervical, renal or ovarian cervical carcinoma and malignant melanoma (5, 8). Small-bowel metastasis from primary pulmonary neoplasm is rarely detected clinically, although incidence at autopsy has been reported as 4.7% (1) and 10.7% (12). In most of these cases there are multiple metastases (12). Metastasis to the small bowel may present as perforation, obstruction, malabsorption or haemorrhage ( 12). Perforation occurs at sites where mural replacement by tumour cells has resulted in necrosis. A submucosal lesion may develop a pseudopedicle and then present as an intraluminal polypoid mass which may cause intussusception (8). Indeed, intussusception is the most common finding in melanoma patients with symptoms of intestinal obstruction (9). Intussusception secondary to squamous cell carcinoma of the lung was recently reported (7). As in that case, resection with end-to-end anastomosis gave satisfactory palliation in our patient. Carcinosarcoma may originate in the uterus, hypopharynx, oesophagus and lung (3). Bronchopulmonary carcinosarcoma may appear as a central endobronchial lesion or a peripheral invasive process (14), with the latter tending to be more aggressive (2). Carcinosarcoma has been reported to constitute 0.2% (4) or 0.27% (6) of primary pulmonary malignancies, mainly occurring in the upper lobes (2,4). Polypoid endobronchial central lesions produce symptoms of bronchial obstruction, whereas peripheral tumours tend to be relatively asymptomatic until a late stage, often with metastasis, and thus larger when detected (13). Distant metastases, as in our case, will eventually occur in more than 40 % of patients. The pathogenesis of pulmonary carcinosarcoma is not clear (2, 7). It may arise by sarcomatous transformation of the stroma or as a ‘collision tumour’ (6). The carcinomatous component is mostly (70 O/o) epidermoid, sometimes Scand J Thoracic 26
(20%) adenomatoid, and in a few cases (10%) undifferentiated (2). The mesenchymal portion is mostly of spindle cell type and may contain foci of leiomyosarcoma, fibrosarcoma, chondrosarcoma, osteosarcoma or an immature form of cells (7). For true carcinosarcoma, both components must be malignant (3). The carcinomatous part tends to metastasize to regional lymph nodes and the sarcomatous part to give rise to distant metastasis (7). The roles of radiotherapy (7) and chemotherapy (4)are uncertain. Resection should be performed whenever possible. REFERENCES 1. Antler AS, Ough Y, Pitchumoni CS, Davidian M, Thelmo W. Gastrointestinal metastases from malignant tumors of the lung. Cancer 1982; 49: 170-1 72. 2. Cabarcos A, Dorronsoro MG, Beristain JLL. Pulmonary carcinosarcoma: A case study and review of the literature. Br J Dis Chest 1985; 79: 83-94. 3. Chaudhuri MR. Bronchial carcinosarcoma. J Thorac Cardiovasc Surg 1971; 61: 319-323. 4. Davis MP, Eagan RT, Weiland LH, Pairolero PC. Carcinosarcoma of the lung: Mayo clinic experience and response to chemotherapy. Mayo Clin Proc 1984; 59: 598-603. 5 . De Castro CA, Dockerty MB, Mayo CW. Metastatic tumors of the small intestine. Surg Gynecol Obstet 1957; 105: 159-165. 6. Diaconita G. Bronchopulmonary carcinosarcoma. Thorax 1975; 30: 682-686. 7. Engel AF, Groot G, Bellot S. Carcinosarcoma of the lung. A case-history of disseminated disease and review of the literature. Eur J Surg Oncol 1991; 17: 94-96. 8. Farmer RG, Hawk WA. Metastatic tumors of the small bowel. Gastroenterology 1964; 47: 496-504. 9. Gupta TKD, Brasfield RD. Metastatic melanoma of the gastrointestinal tract. Arch Surg 1964; 88: 969-973. 10. Leidich RB, Rudolf LE. Small bowel perforation secondary to metastatic lung carcinoma. Ann Surg 1981; 193: 67-69. 11. Listrom MB, Davis M, Lowry S, Williams WW, Monsein LH, Kleinman R, Gogel HK. Intussusception secondary to squamous carcinoma of the lung. Gastrointest Radio1 1988; 13: 224-226. 12. McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer 1987; 59: 1496-1497. 13. Meade P, Moad J, Fellows D, Adams CW. Carcinosarcoma of the lung with hypertrophic pulmonary osteoarthropathy. Ann Thorac Surg 1991; 51: 488-490. 14. Moore T. Carcinosarcoma of the lung. Surgery 1961; 50: 886-893.
