BY. J. Dis. Chest (1976) 70, 121
SMALL INTESTINAL PERFORATION DUE TO SECONDARIES FROM BRONCHOGENIC CARCINOMA T.
RAMANATHAN,
HILARY
SKENE-SMITH,
S. University
Hospital,
DERVINDER
SINGH
AND
SIVANESAN
Kuala
Lumpur,
Malaysia
Bronchogenic carcinoma is a common disease and ‘metastasizes with great frequency, often widely and often at an early stage while the primary growth is still small and symptomless’ (Willis 1967). Many necropsy studies have been carried out to determine the distribution of the metastases (Engelman & McNamara 1954; Galluzzi & Payne 1955 ; d’ilbren et al. 1971). The common sites are mediastinal lymph nodes, liver, adrenals, brain, kidneys and bone. According to Sinclair and Gravelle (1967), who reviewed 4000 cases of bronchogenic carcinoma, involvement of the gastrointestinal tract was very uncommon. Hinson (1958) states that metastases to the bowel can occur and at times produce perforation.
Case Report A 50-year-old Indian male presented with a six-month history of chest pain, and four months of cough and hoarseness. He also had dysphagia with the sensation that food was sticking at the level of the suprasternal notch. Physical examination revealed no abnormality but the chest radiograph showed widening of the right superior mediastinum. Over the next three weeks he developed effort dyspnoea and swelling of his right arm, with prominent veins. His fingers became clubbed and enlarged lymph nodes were found in the right supraclavicular fossa. Bronchoscopy showed splaying of the carina and the right posterior basal bronchus was narrowed and occluded. A left supraclavicular lymph node was biopsied and the histological report was that ‘the entire lymph node is almost completely replaced by tumour tissue . . . metastatic carcinoma undifferentiated’. He was therefore referred for radiotherapy. Two months later he complained of left loin pain which progressively increased in severity and 12 days after the onset barium studies showed leak of contrast medium from the proximal jejunum into the peritoneal cavity (Fig. 1). A chest radiograph (Fig. 2) demonstrated subdiaphragmatic gas, marked mediastinal widening and cardiac enlargement. At laparotomy there was free intraperitoneal pus. Five ulcerating nodules of metastatic tumour were present in the wall of the small intestine, two of these had perforated, 30 cm and 120 cm from the duodenojejunal flexure (Fig. 3). The mesenteric lymph nodes were enlarged but the peritoneum and liver were free of tumour. Resection and end-to-end anastomosis were performed, but the patient had cardiac arrest immediately postoperatively and died. A limited autopsy revealed enlarged tracheobronchial and deep cervical lymph nodes. There was a tumour arising from the lower lobe of the right lung. The pericardial sac contained 600 ml of haemorrhagic fluid and whitish tumour infiltrate was present on the posterior and basal aspects of the heart. The liver, kidneys and adrenals were free of tumour. Histology showed an undifferentiated carcinoma composed of large cells with abundant eosinophilic cytoplasm and vesicular nuclei with prominent nucleoli (Fig. 4).
122
T. Ramanathan,
Fig. 1. Barium proximal
jejunum
Hilayy Skene-Smith, Dervinder Singh and S. Sivanesen
meal and follow through into the peritoneal cavity
showing
extravasation
of
contrast
medium
from
the
DISCUSSION
Metastatic spread to small bowel is rare, except as a preterminal event, and from a lung primary it is even rarer (Marshak et al. 1965). Engelman et al. (1954), in 234 consecutive necropsies on cases of bronchogenic carcinoma, found only 5 cases (2 %) where metastases had spread to bowel. A series from the Mayo Clinic (de Castro & Dockerty 1957) covering 50 years had no case, and another from the Cleveland Clinic (Farmer & Hawk 1964) had only one case where bronchogenic carcinoma had spread to small bowel. When small bowel metastases are present, perforation may be the presenting feature. We could find only one example where bronchogenic carcinoma had metastasized to ileum and caused perforation, localized abscess and fistula formation between loops of ileum (Tillotson & Douglas 1962). In our patient the perforations involved the jejunum and resulted in free peritoneal air and pus. As far as could be shown with a limited autopsy, the small bowel was the only organ involved by metastases. These lesions were small and only affected a segment of jejunum and, with resection, would not have adversely affected the prognosis.
Small Intestinal Perforation
Fig. 2. Chest
Fig. 3. Segment
of jejunum
with
radiograph
one
of
shows
the
123
subdiaphragmatic
secondary
deposits
gas
which
produced
perforation
124
Fig.
T. Ramanathan,
4. Histology
Hilary
of the secondary
Skene-Smith,
deposit
Dervinder Singh and 5’. Sivanesan
in the jejunum
showed
an undifferentiated
carcinima
ACKNOWLEDGEMENTS
We would like to thank Professor N. K. Yong and Professor K. Prathap for their help and advice, the Department of Medical Illustration for the prints and Miss Janet Low for her secretarial assistance. REFERENCES A. L., COLLIS, J. L. & CLARKE, D. B. (1971) A Practice of Thoracic Surgery, p. 219. London: Edward Arnold. DE CASTRO, C. A. & DOCKERTY, M. B. (1957) Metastatic tumours of the small intestine. D’ABREU,
3rd ed., Surgery
Gynec. Obstet. 105, 159. R. M. & MCNAMARA, W. L. (1954) Bronchogenic carcin0ma.A statistical review of 234 autopsies. J. thorac. Surg. 27, 227. FARMER, G. R. & HAWK, W. A. (1964) Metastatic tumours of the small bowel. Gastroenterology 47, 496. GALLUZZI, S. & PAYNE, P. M. (1955) Bronchial carcinoma. A statistical study of 741 necropsies with special reference to the distribution of blood-borne metastases. BY. J. Cancer 9, 511. HINSON, K. F. W. (19.58) In Monographs on Neoplastic Disease, Carcinoma of the Lung, vol. 1, ed. D. W. Smithers and J. R. Bignall, p. 141. Edinburgh and London: Livingstone. MARSHAK, R. H., KHILNANI, M. T., ELIASOPH, J. & WOLF, B. S. (1965) Metastatic carcinoma of 94, 385. the small bowel. Am. J. Roentgen. SINCLAIR, D. J. & DOUGLAS, R. G. (1962) Metastatic tumour of the small bowel. Am. ‘j. Roentgen 88, 702. WILLIS, R. A. (1967) Pathology of Tunaours, 4th ed., p. 369. London: Butterworths.
ENGLEMAN,
SMALL INTESTINAL PERFORATION DUE TO SECONDARIES FROM BRONCHOGENIC CARCINOMA T.
RAMANATHAN,
HILARY
SKENE-SMITH,
S. University
Hospital,
DERVINDER
SINGH
AND
SIVANESAN
Kuala
Lumpur,
Malaysia
Bronchogenic carcinoma is a common disease and ‘metastasizes with great frequency, often widely and often at an early stage while the primary growth is still small and symptomless’ (Willis 1967). Many necropsy studies have been carried out to determine the distribution of the metastases (Engelman & McNamara 1954; Galluzzi & Payne 1955 ; d’ilbren et al. 1971). The common sites are mediastinal lymph nodes, liver, adrenals, brain, kidneys and bone. According to Sinclair and Gravelle (1967), who reviewed 4000 cases of bronchogenic carcinoma, involvement of the gastrointestinal tract was very uncommon. Hinson (1958) states that metastases to the bowel can occur and at times produce perforation.
Case Report A 50-year-old Indian male presented with a six-month history of chest pain, and four months of cough and hoarseness. He also had dysphagia with the sensation that food was sticking at the level of the suprasternal notch. Physical examination revealed no abnormality but the chest radiograph showed widening of the right superior mediastinum. Over the next three weeks he developed effort dyspnoea and swelling of his right arm, with prominent veins. His fingers became clubbed and enlarged lymph nodes were found in the right supraclavicular fossa. Bronchoscopy showed splaying of the carina and the right posterior basal bronchus was narrowed and occluded. A left supraclavicular lymph node was biopsied and the histological report was that ‘the entire lymph node is almost completely replaced by tumour tissue . . . metastatic carcinoma undifferentiated’. He was therefore referred for radiotherapy. Two months later he complained of left loin pain which progressively increased in severity and 12 days after the onset barium studies showed leak of contrast medium from the proximal jejunum into the peritoneal cavity (Fig. 1). A chest radiograph (Fig. 2) demonstrated subdiaphragmatic gas, marked mediastinal widening and cardiac enlargement. At laparotomy there was free intraperitoneal pus. Five ulcerating nodules of metastatic tumour were present in the wall of the small intestine, two of these had perforated, 30 cm and 120 cm from the duodenojejunal flexure (Fig. 3). The mesenteric lymph nodes were enlarged but the peritoneum and liver were free of tumour. Resection and end-to-end anastomosis were performed, but the patient had cardiac arrest immediately postoperatively and died. A limited autopsy revealed enlarged tracheobronchial and deep cervical lymph nodes. There was a tumour arising from the lower lobe of the right lung. The pericardial sac contained 600 ml of haemorrhagic fluid and whitish tumour infiltrate was present on the posterior and basal aspects of the heart. The liver, kidneys and adrenals were free of tumour. Histology showed an undifferentiated carcinoma composed of large cells with abundant eosinophilic cytoplasm and vesicular nuclei with prominent nucleoli (Fig. 4).
122
T. Ramanathan,
Fig. 1. Barium proximal
jejunum
Hilayy Skene-Smith, Dervinder Singh and S. Sivanesen
meal and follow through into the peritoneal cavity
showing
extravasation
of
contrast
medium
from
the
DISCUSSION
Metastatic spread to small bowel is rare, except as a preterminal event, and from a lung primary it is even rarer (Marshak et al. 1965). Engelman et al. (1954), in 234 consecutive necropsies on cases of bronchogenic carcinoma, found only 5 cases (2 %) where metastases had spread to bowel. A series from the Mayo Clinic (de Castro & Dockerty 1957) covering 50 years had no case, and another from the Cleveland Clinic (Farmer & Hawk 1964) had only one case where bronchogenic carcinoma had spread to small bowel. When small bowel metastases are present, perforation may be the presenting feature. We could find only one example where bronchogenic carcinoma had metastasized to ileum and caused perforation, localized abscess and fistula formation between loops of ileum (Tillotson & Douglas 1962). In our patient the perforations involved the jejunum and resulted in free peritoneal air and pus. As far as could be shown with a limited autopsy, the small bowel was the only organ involved by metastases. These lesions were small and only affected a segment of jejunum and, with resection, would not have adversely affected the prognosis.
Small Intestinal Perforation
Fig. 2. Chest
Fig. 3. Segment
of jejunum
with
radiograph
one
of
shows
the
123
subdiaphragmatic
secondary
deposits
gas
which
produced
perforation
124
Fig.
T. Ramanathan,
4. Histology
Hilary
of the secondary
Skene-Smith,
deposit
Dervinder Singh and 5’. Sivanesan
in the jejunum
showed
an undifferentiated
carcinima
ACKNOWLEDGEMENTS
We would like to thank Professor N. K. Yong and Professor K. Prathap for their help and advice, the Department of Medical Illustration for the prints and Miss Janet Low for her secretarial assistance. REFERENCES A. L., COLLIS, J. L. & CLARKE, D. B. (1971) A Practice of Thoracic Surgery, p. 219. London: Edward Arnold. DE CASTRO, C. A. & DOCKERTY, M. B. (1957) Metastatic tumours of the small intestine. D’ABREU,
3rd ed., Surgery
Gynec. Obstet. 105, 159. R. M. & MCNAMARA, W. L. (1954) Bronchogenic carcin0ma.A statistical review of 234 autopsies. J. thorac. Surg. 27, 227. FARMER, G. R. & HAWK, W. A. (1964) Metastatic tumours of the small bowel. Gastroenterology 47, 496. GALLUZZI, S. & PAYNE, P. M. (1955) Bronchial carcinoma. A statistical study of 741 necropsies with special reference to the distribution of blood-borne metastases. BY. J. Cancer 9, 511. HINSON, K. F. W. (19.58) In Monographs on Neoplastic Disease, Carcinoma of the Lung, vol. 1, ed. D. W. Smithers and J. R. Bignall, p. 141. Edinburgh and London: Livingstone. MARSHAK, R. H., KHILNANI, M. T., ELIASOPH, J. & WOLF, B. S. (1965) Metastatic carcinoma of 94, 385. the small bowel. Am. J. Roentgen. SINCLAIR, D. J. & DOUGLAS, R. G. (1962) Metastatic tumour of the small bowel. Am. ‘j. Roentgen 88, 702. WILLIS, R. A. (1967) Pathology of Tunaours, 4th ed., p. 369. London: Butterworths.
ENGLEMAN,
