LETTERS TO THE EDITOR

 

Intestinal obstruction due to metastasis in mesentery from squamous cell lung carcinoma

Obstrucción intestinal por metástasis en mesenterio de un carcinoma epidermoide de pulmón

 

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Key words: Mesenteric metastasis. Lung carcinoma. Surgery.

Palabras clave: Metástasis mesentérica. Carcinoma de pulmón. Cirugía.

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Dear Editor,

The first cause of mortality due to cancer in Spanish men is the lung neoplasm. Over 70% of cases are diagnosed in advanced stadium, being the curative treatment of them unusual. Despite the chemo-radiotherapy, in most cases the disease progresses, metastases occur at other levels, more frequently in lymph nodes, liver, adrenal glands, bone and brain (1). Not only the intestinal spread is rare, being the squamous cell carcinoma the most frequent (1), but our patient with mesenteric metastasis has unprecedented case. A comprehensive bibliography search (PubMed^®), including studies of intestinal metastases and soft tissues in the last 26 years, did not make any reference. The clinical manifestations of these metastases are uncommon (2): bleeding, malabsortion, intestinal perforation (3) and obstruction, the most common thing (1-3).

 

Case report

A 69 year-old male patient with the following antecedents: ex-smoker, infrarenal aortic aneurysm (7.5 cm), pulmonary embolism, and non small cell lung carcinoma (T3aN2M0 in left upper lobe) with pathology of epidermoid type. Surgical treatment was contraindicated and then he was subjected to 4 cycles of chemo-theraphy (cisplatin-vinorelbin) and chest radiotherapy, with moderate response. Six months after diagnosis, the patient was admitted because of diffuse abdominal pain of six days of evolution and occasional vomiting. The patient showed hypoalbuminemia and mild anemia (haemoglobin: 6.5 g/dl), abdominal CT reported a mass which embraced several mesenterium intestine loops. The ultrasound revealed a fistulous tract between bowel loops and a small area with extraluminal gas bubbles, so antibiotic treatment was instituted. At 5^th day, he developed an acute abdominal pain with intestinal obstruction and he underwent laparotomy. An abdominal mass (15 cm in diameter) in the mesentery at the level of the promontory and close to the aneurysm was found. This includes the small intestine (two loops of jejunum, ileum of a 30-cm-cecal valve) and sigmoid colon over a length of 10 cm. We proceeded to segmental resection of the sigmoid colon and loops included in the mesenteric tumor, reconstructing with three small bowel latero-lateral anastomosis and another one end-to-end sigmoidea. The histopathology revealed infiltration of the mesenteric fat and its extension to the wall of the bowel loops, mucosal-reaching, encompassing, with areas of abscess and fistula. Postoperative recovery was without incidents - oral intake and intestinal transit were recovered - until the 8^th day when he presented a feverish peak. The CT scan showed a collection of 8 cm and minimal dehiscence of sigma which was drained radiologically. With normal bowel function, was discharged. In the following weeks, he experienced a rapid deterioration of general condition and progression of tumor disease. Not being able to start a second course of chemotherapy, he died one month and a half after surgical resection of the abdominal metastasis.

 

Discussion

The diagnosis of intestinal lesion is done by CT-oral or intravenous contrast (sensitivity: 87%) (4). The existence of multiple intestinal lesion adversely affects the prognosis of lung disease (1). Even advanced neoplasms have greater risk of mortality and morbidity due to the fact that they can present themselves like intestinal obstruction, perforation or bleeding. The excision of the mass and loops involved in the intestinal obstruction is an aggressive intervention, only justified by the inability to perform a more conservative treatment. In our patient, due to the involvement of proximal jejunum was not possible ileostomy. Only in cases of perforation or massive bleeding is indicated emergency surgery (5). The other option was to abstain. In any case, the survival of this procedure, it is not more than 16 weeks (6), other authors note that 15% survived to 8 months after surgery (2).

 

Discussion

As far as we know, this is the first case published of mesentery metastasis from non small cell lung cancer. CT showed its accuracy in the diagnosis of this unusual disease. The prognosis is gloomy.

 

Z. Meneses-Grasa, A. Coll-Salinas¹, J. A. Macias-Cerrolaza², J. L. Aguayo-Albasini¹, A. Campillo-Soto¹ and M. P. Guillén-Paredes¹

School of Medicine. University of Murcia. Departments of ¹General and Digestive Surgery, and ²Hematology and Oncology.
General University Hospital Morales Meseguer. Murcia, Spain

 

References

1. McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer 1987; 59: 1486-9.        [ Links ]

2. Berger A, Cellier C, Daniel C, Kron C, Riquet M, et al. Small bowel metastases from primary carcinoma of the lung: Clinical findings and outcome. Am J Gastroenterol 1999; 94: 1884-7.        [ Links ]

3. Gómez JA, Sánchez C, Torres MI. Carcinoma primitivo de pulmón con afectación intestinal secundaria: 3 casos de una serie de 420 pacientes. Arch Bronconeumol 2007; 43(8): 472-4.        [ Links ]

4. Kanemoto K, Kurishima K, Ishikawa H, Shiotani S, Satoh H, et al. Small intestinal metastasis from small cell lung cancer. Intern Med 2006; 45: 967-70.        [ Links ]

5. Hillenbrand A, Strater J, Henne-Bruns D. Frequency, symptoms and outcome of intestinal metastases of bronchopulmonary cancer. Case report and review of the literature. Int Semin Surg Oncol 2005; 6: 2-13.        [ Links ]

6. Leidich RB, Rudolf LE. Small bowel perforation secondary to metastatic lung carcinoma. Ann Surg 1981; 193: 67-9.        [ Links ]