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Metastatic squamous cell cancer of the lung presenting as a perforated cecal cancer

Metastatic squamous cell cancer of the lung presenting as a perforated cecal cancer Lung cancer is the leading cause of cancer deaths worldwide, with non-small cell lung cancer (NSCLC) accounting for 85% of diagnoses. Metastasis occurs in ~50% of cases but clinically evident isolated gastrointestinal (GI) metastasis is rare. We pre- sent a 78-year-old female who underwent an urgent right hemi-colectomy after cross-sectional imaging revealed a perfo- rated cecal mass. Final pathology demonstrated squamous cell cancer of lung origin. We review the literature on NSCLC with clinically evident metastases to the GI tract, as well as important diagnostic considerations. INTRODUCTION CASE REPORT Lung cancer is the leading cause of cancer deaths worldwide, A 78-year-old female presented with worsening abdominal with metastases detected in ~50% of cases [1–3]. Common pain over 1 week, with onset of symptoms occurring 3 months sites include lymph nodes, adrenal glands, liver, bone, brain prior. No history of recurrent fever or weight loss was elicited. and contralateral lung [2, 3]. While symptomatic gastrointes- There were no changes in bowel habits and she denied melena tinal (GI) metastasis of lung cancer is rare, occurring in or hematochezia. She endorsed a normal colonoscopy three 0.2–0.5% of cases, autopsy studies show metastatic disease to years prior. Of note, she was diagnosed with a biopsy proven the GI tract to be far more common [3–5]. The incidence of squamous cell cancer of her left lower lobe 4 months earlier isolated small bowel metastasis ranges from 7.5 to 19%, and (Fig. 1). A PET scan performed just three weeks prior to her that of isolated colonic metastasis from 2.5 to 5% [4, 5]. presentation demonstrated significant FDG uptake in the left Authors theorize that the attribution of symptoms to chemo- lower lobe as well as the cecum, with no convincing evidence therapy may contribute to under-diagnosing GI metastases in of regional nodal disease in the lungs (Figs 2 and 3). lung cancer patients [3]. Her past medical history was significant for coronary artery Nonetheless, symptomatic colonic metastasis of lung ori- disease with two previous MI’s, COPD, hypertension and type II gin remains a rare entity. We report the case of a primary diabetes mellitus. Past surgeries included an appendectomy, lung lesion with isolated colonic involvement presenting hysterectomy and laparoscopic cholecystectomy. She admits to with perforation. In addition, we discuss the complexity of a 20 pack-year smoking history with minimal alcohol intake. diagnostic considerations in this setting and the implications At presentation her vital signs were stable. Abdominal exam on management. revealed exquisite tenderness in the right lower quadrant, with Received: October 3, 2017. Accepted: January 5, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 I. Browne et al. Figure 1: Axial view of chest CT showing left lower lobe lesion. Figure 3: PET-CT showing FDG uptake in cecum. Figure 4: Abdominal CT scan showing annular cecal mass with evidence of perforation. days of IV antibiotics with transition to oral antibiotics on POD 4. Her JP drain was removed on POD 3 and she was discharged on Figure 2: PET-CT showing FDG uptake in left lower lobe. POD 5 without complication and with a prescription for oral anti- biotics. After extensive histopathology review, the cecal mass was confirmed to be an invasive squamous cell carcinoma of lung ori- no evidence of digital clubbing. Blood-work revealed an elevated gin (Fig. 6). Specimens were sent for immunohistochemical stain- WBC of 15.6. A CT scan demonstrated a 4.3 cm annular mass ing. Subsequent investigations included cystoscopy and urine within the cecum, suspicious for a primary colonic malignancy, cytology, which were negative for urogenital carcinoma. as well as an 8.6 × 8.2 cm lobulated gas-containing abscess with extension in to the lateral abdominal wall (Figs 4 and 5). Urgent exploratory laparotomy revealed a large cecal mass DISCUSSION invading the abdominal wall with perforation and localized abscess formation. A right hemi-colectomy was performed with Historically the esophagus has been thought to be the most irrigation and washout of the abdomen. Source control was common site of lung cancer metastasis within the GI tract, fol- achieved and a primary anastomosis was performed with no lowed by the small bowel [5]. Colonic involvement accounts for diversion. A Jackson-Pratt drain was left in situ. She received 3 <5% of GI metastases [5]. Clinically diagnosed metastatic Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Metastatic squamous cell cancer of the lung 3 The importance of establishing the right diagnosis is exem- plified in our case. Our patient was referred to a thoracic sur- geon for consideration of oncologic resection of her primary lesion. While the presence of a colonic primary certainly influ- ences the decision regarding management, the presence of metastatic disease to the GI tract negates curative resection and portends a poor prognosis. Of note, our patient demon- strated isolated colonic metastasis in the absence of regional nodal disease on PET-CT. The sensitivity of PET-CT in detecting mediastinal disease has been shown to be as low as 78%, likely influenced by a multitude of factors including tumor biology [6]. As such, an area of distant FDG-avid activity should be pre- sumed to represent metastatic disease, even in the absence of regional or mediastinal disease, until proven otherwise. Given the location of the colonic lesion, squamous cell can- cer of GI origin was deemed unlikely. A thorough pathology review by two independent pathologists was performed, which confirmed the suspicion of metastatic disease. Additionally, cystoscopy and urine cytology ruled out the presence of a uro- genital primary. Our patient’s disease was deemed incurable and palliative radiation was initiated. Her disease progressed rapidly and she succumbed to her illness 3 months after her presentation. In summary, GI metastasis from a primary lung carcinoma resulting in large bowel perforation is rare and signals a poor prognosis. Establishing the correct diagnosis is of utmost Figure 5: Coronal view of abdominal CT scan showing cecal mass with evidence importance in the setting of potentially curable disease. of perforation. Thorough histopathology review with appropriate adjuncts should be considered in all cases. Colonoscopy, cystoscopy and urine cytology are also of value. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Thomas KW, Gould MK, Finlay G.(2016). Overview of the Initial Evaluation, Diagnosis, and Staging of Patients With Suspected Lung Cancer, UpToDate. Retrieved 1 November 2016. http:// www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/overview- of-the-initial-evaluation-diagnosis-and-staging-of-patients- with-suspected-lung-cancer. 2. Weng MW, Wang HC, Chiou JC, Lin SL, Lai RS. Colonic metas- tasis from a primary adenocarcinoma of the lung presenting Figure 6: Carcinoma involving colonic serosa (image courtesy Dr Maisoun with acute abdominal pain: a case report. Kaohsiung J Med Sci Abdelbaqi, Department of Pathology, Red Deer Regional Hospital, Alberta, Canada). 2010;26:40–4. doi:10.1016/S1607-551×(10)70007-3. 3. Jevremovic V, Abboud A, Krauss S. Colonic metastasis with deposits to the GI tract are far less common than autopsy con- anemia leading to a diagnosis of primary lung adenocarcin- firmed lesions [3]. oma. Case Rep Oncol Med 2016;2016:5275043. doi: 10.1155/2016/ Accurate identification and characterization of GI metastasis 5275043. Epub 2016 Jan 27. is paramount to effective management. Imaging modalities such 4. McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases as CT or MRI are often inadequate for establishing the diagnosis from primary carcinoma of the lung. Cancer 1987;59:1486–9. [3]. As a result, accurate diagnosis relies heavily on immunohis- 5. Antler AS, et al. Gastrointestinal metastases from malignant tochemical staining. A pathology review was performed in this tumors of the lung. Cancer 1982;49:170–2. case and should always be considered in this setting. For our 6. Garg PK, Singh SK, Prakash G, Jakhetiya A, Pandey D. Role of patient, p16, TTF1, CK7, CK20, CDX2, PAX5 and NAPSIN A stain- positron emission tomography-computed tomography in ing were completed on both lung and colonic tissue samples. non-small cell lung cancer. World J Methodol 2016;6:105–11. Both samples were positive only for CK7, and the high degree of DOI:10.5662/wjm.v6.i1.105. correlation allowed for confirmation of the diagnosis. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Metastatic squamous cell cancer of the lung presenting as a perforated cecal cancer

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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2042-8812
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10.1093/jscr/rjx262
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Abstract

Lung cancer is the leading cause of cancer deaths worldwide, with non-small cell lung cancer (NSCLC) accounting for 85% of diagnoses. Metastasis occurs in ~50% of cases but clinically evident isolated gastrointestinal (GI) metastasis is rare. We pre- sent a 78-year-old female who underwent an urgent right hemi-colectomy after cross-sectional imaging revealed a perfo- rated cecal mass. Final pathology demonstrated squamous cell cancer of lung origin. We review the literature on NSCLC with clinically evident metastases to the GI tract, as well as important diagnostic considerations. INTRODUCTION CASE REPORT Lung cancer is the leading cause of cancer deaths worldwide, A 78-year-old female presented with worsening abdominal with metastases detected in ~50% of cases [1–3]. Common pain over 1 week, with onset of symptoms occurring 3 months sites include lymph nodes, adrenal glands, liver, bone, brain prior. No history of recurrent fever or weight loss was elicited. and contralateral lung [2, 3]. While symptomatic gastrointes- There were no changes in bowel habits and she denied melena tinal (GI) metastasis of lung cancer is rare, occurring in or hematochezia. She endorsed a normal colonoscopy three 0.2–0.5% of cases, autopsy studies show metastatic disease to years prior. Of note, she was diagnosed with a biopsy proven the GI tract to be far more common [3–5]. The incidence of squamous cell cancer of her left lower lobe 4 months earlier isolated small bowel metastasis ranges from 7.5 to 19%, and (Fig. 1). A PET scan performed just three weeks prior to her that of isolated colonic metastasis from 2.5 to 5% [4, 5]. presentation demonstrated significant FDG uptake in the left Authors theorize that the attribution of symptoms to chemo- lower lobe as well as the cecum, with no convincing evidence therapy may contribute to under-diagnosing GI metastases in of regional nodal disease in the lungs (Figs 2 and 3). lung cancer patients [3]. Her past medical history was significant for coronary artery Nonetheless, symptomatic colonic metastasis of lung ori- disease with two previous MI’s, COPD, hypertension and type II gin remains a rare entity. We report the case of a primary diabetes mellitus. Past surgeries included an appendectomy, lung lesion with isolated colonic involvement presenting hysterectomy and laparoscopic cholecystectomy. She admits to with perforation. In addition, we discuss the complexity of a 20 pack-year smoking history with minimal alcohol intake. diagnostic considerations in this setting and the implications At presentation her vital signs were stable. Abdominal exam on management. revealed exquisite tenderness in the right lower quadrant, with Received: October 3, 2017. Accepted: January 5, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 I. Browne et al. Figure 1: Axial view of chest CT showing left lower lobe lesion. Figure 3: PET-CT showing FDG uptake in cecum. Figure 4: Abdominal CT scan showing annular cecal mass with evidence of perforation. days of IV antibiotics with transition to oral antibiotics on POD 4. Her JP drain was removed on POD 3 and she was discharged on Figure 2: PET-CT showing FDG uptake in left lower lobe. POD 5 without complication and with a prescription for oral anti- biotics. After extensive histopathology review, the cecal mass was confirmed to be an invasive squamous cell carcinoma of lung ori- no evidence of digital clubbing. Blood-work revealed an elevated gin (Fig. 6). Specimens were sent for immunohistochemical stain- WBC of 15.6. A CT scan demonstrated a 4.3 cm annular mass ing. Subsequent investigations included cystoscopy and urine within the cecum, suspicious for a primary colonic malignancy, cytology, which were negative for urogenital carcinoma. as well as an 8.6 × 8.2 cm lobulated gas-containing abscess with extension in to the lateral abdominal wall (Figs 4 and 5). Urgent exploratory laparotomy revealed a large cecal mass DISCUSSION invading the abdominal wall with perforation and localized abscess formation. A right hemi-colectomy was performed with Historically the esophagus has been thought to be the most irrigation and washout of the abdomen. Source control was common site of lung cancer metastasis within the GI tract, fol- achieved and a primary anastomosis was performed with no lowed by the small bowel [5]. Colonic involvement accounts for diversion. A Jackson-Pratt drain was left in situ. She received 3 <5% of GI metastases [5]. Clinically diagnosed metastatic Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Metastatic squamous cell cancer of the lung 3 The importance of establishing the right diagnosis is exem- plified in our case. Our patient was referred to a thoracic sur- geon for consideration of oncologic resection of her primary lesion. While the presence of a colonic primary certainly influ- ences the decision regarding management, the presence of metastatic disease to the GI tract negates curative resection and portends a poor prognosis. Of note, our patient demon- strated isolated colonic metastasis in the absence of regional nodal disease on PET-CT. The sensitivity of PET-CT in detecting mediastinal disease has been shown to be as low as 78%, likely influenced by a multitude of factors including tumor biology [6]. As such, an area of distant FDG-avid activity should be pre- sumed to represent metastatic disease, even in the absence of regional or mediastinal disease, until proven otherwise. Given the location of the colonic lesion, squamous cell can- cer of GI origin was deemed unlikely. A thorough pathology review by two independent pathologists was performed, which confirmed the suspicion of metastatic disease. Additionally, cystoscopy and urine cytology ruled out the presence of a uro- genital primary. Our patient’s disease was deemed incurable and palliative radiation was initiated. Her disease progressed rapidly and she succumbed to her illness 3 months after her presentation. In summary, GI metastasis from a primary lung carcinoma resulting in large bowel perforation is rare and signals a poor prognosis. Establishing the correct diagnosis is of utmost Figure 5: Coronal view of abdominal CT scan showing cecal mass with evidence importance in the setting of potentially curable disease. of perforation. Thorough histopathology review with appropriate adjuncts should be considered in all cases. Colonoscopy, cystoscopy and urine cytology are also of value. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Thomas KW, Gould MK, Finlay G.(2016). Overview of the Initial Evaluation, Diagnosis, and Staging of Patients With Suspected Lung Cancer, UpToDate. Retrieved 1 November 2016. http:// www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/overview- of-the-initial-evaluation-diagnosis-and-staging-of-patients- with-suspected-lung-cancer. 2. Weng MW, Wang HC, Chiou JC, Lin SL, Lai RS. Colonic metas- tasis from a primary adenocarcinoma of the lung presenting Figure 6: Carcinoma involving colonic serosa (image courtesy Dr Maisoun with acute abdominal pain: a case report. Kaohsiung J Med Sci Abdelbaqi, Department of Pathology, Red Deer Regional Hospital, Alberta, Canada). 2010;26:40–4. doi:10.1016/S1607-551×(10)70007-3. 3. Jevremovic V, Abboud A, Krauss S. Colonic metastasis with deposits to the GI tract are far less common than autopsy con- anemia leading to a diagnosis of primary lung adenocarcin- firmed lesions [3]. oma. Case Rep Oncol Med 2016;2016:5275043. doi: 10.1155/2016/ Accurate identification and characterization of GI metastasis 5275043. Epub 2016 Jan 27. is paramount to effective management. Imaging modalities such 4. McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases as CT or MRI are often inadequate for establishing the diagnosis from primary carcinoma of the lung. Cancer 1987;59:1486–9. [3]. As a result, accurate diagnosis relies heavily on immunohis- 5. Antler AS, et al. Gastrointestinal metastases from malignant tochemical staining. A pathology review was performed in this tumors of the lung. Cancer 1982;49:170–2. case and should always be considered in this setting. For our 6. Garg PK, Singh SK, Prakash G, Jakhetiya A, Pandey D. Role of patient, p16, TTF1, CK7, CK20, CDX2, PAX5 and NAPSIN A stain- positron emission tomography-computed tomography in ing were completed on both lung and colonic tissue samples. non-small cell lung cancer. World J Methodol 2016;6:105–11. Both samples were positive only for CK7, and the high degree of DOI:10.5662/wjm.v6.i1.105. correlation allowed for confirmation of the diagnosis. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx262/4812594 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case Reports – Oxford University Press

Published: Jan 1, 2018

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