Diagnostic laparoscopy for intussusception secondary to metastatic lung cancer

May 25, 2007
Weesam Alkhatib, MD

Surgical Rounds, September 2006, Volume 0, Issue 0

Weesam Alkhatib, Surgical Resident, Department of Surgery; Michael Moncure, Associate Professor of Surgery, Department of Surgery; Rosane Achcar, Pathology Resident, Department of Pathology, University of Kansas Medical Center, Kansas City, KS

This case report highlights the unusual complication of lung carcinoma metastasizing to the small bowel and causing intestinal obstruction and intussusception. Although the initial laparoscopic diagnosis and treatment were successful, the patient experienced additional complications and died. The occurrence of lung cancer metastasizing to the intestine is rare, and the prognosis is extremely poor. Intussusception in adults is usually treated differently than in infants, with resection of the intussuscepted segment being the mainstay of treatment. Reduction is generally not recommended because of concern of malignancy and the risk of contamination if a lesion is perforated. Using a minimally invasive approach in these patients can be beneficial since they are so frail.

Thomas Gadacz, MD Series Guest Editor Professor and Chairman Department of Surgery Medical College of Georgia Augusta, GA

Intussusception occurs when one part of the intestine telescopes into another, causing obstruction. The condition is seen primarily in the pediatric population, generally in children between 3 months and 3 years of age. Only 5% of reported cases involve adults.1 Intussusception presents differently in adults than in children, with adults typically reporting chronic colicky abdominal pain, distention, nausea, and vomiting of more than 1 month's duration. Children usually present with acute changes in bowel habits and a palpable mass. Bowel obstruction may also occur and lead to edema and vascular compromise, causing ischemia, necrosis, gastrointestinal bleeding, and perforation of the bowel in both children and adults.

Weesam Alkhatib, MD

Surgical Resident

Department of Surgery

Michael Moncure, MD

Associate Professor of

Surgery

Department of Surgery

Rosane Achcar,MD

Pathology Resident

Department of

Pathology

University of Kansas

Medical Center

Kansas City, KS

Likely causes of adult intussusception include benign and malignant neoplasms, Meckel's diverticulum, postoperative factors, and inflammatory diseases. Most cases are caused by neoplasms such as primary and metastatic bowel cancer, lymphoma, polyps, or lipomas. Colonic intussusception is normally caused by a primary colonic adenocarcinoma, whereas small bowel intussusception is usually the result of a benign tumor, although malignant lesions have also been noted. The most common primary small bowel tumor to cause intussusception is leiomyosarcoma, followed by metastatic tumors such as malignant melanoma and Kaposi's sarcoma. Lung cancer rarely metastasizes to the small bowel but can cause various symptoms, including obstruction, hemorrhage, peritonitis, perforation, and intussusception. We report a case of small bowel obstruction caused by intussusception in a woman with a history of lung carcinoma and review the literature regarding this rare condition.

Case report

A 56-year-old white woman with a history of T2 N0 M0 lung cancer presented to our institution reporting a 1-week history of nausea and bilious vomiting. She also noted diffuse abdominal pain, upper abdominal bloating, and severe constipation with no bowel movements for over 1 week. The patient had undergone curative resection of her giant cell variant of large cell lung cancer approximately 1 year earlier and had done well. In consultation with the oncology service, the patient underwent cisplatin-based therapy and received her last dose about 1 week before her current admission to the hospital.

Physical examination revealed a soft but diffusely tender and tympanic abdomen with no peritoneal signs on palpation and normal bowel sounds on auscultation. The remainder of the patient's physical examination, including vital signs and laboratory evaluations, was unremarkable. A diagnosis of small bowel obstruction was made, and she was admitted to the medical service. Intravenous fluid hydration was initiated, and a nasogastric tube was placed, which drained 1.5 to 2.5 L of dark, bilious fluid daily. An abdominal radiograph showed multiple dilated loops of bowel with air-fluid levels. An upper gastrointestinal barium swallow study revealed mild small bowel dilation but no discrete strictures, masses, or other abnormalities (Figure 1). Computed tomography (CT) scans of the abdomen and pelvis were taken but were of poor quality because of residual contrast from the upper gastrointestinal barium swallow study. Colonoscopy and upper endoscopy were normal.

Since the etiology of the small bowel obstruction could not be determined, the patient was taken to the operating room for diagnostic laparoscopic exploration. A distended proximal small bowel and a nondistended large bowel were observed (Figure 2). Further exploration revealed an enteroenteric intussusception of the distal small bowel (Figure 3). This portion of the bowel was reduced laparoscopically, and an approximately 20-cm segment of small bowel was resected and primarily anastomosed. The segment was first isolated by stapling both ends with an endoscopic linear cutting stapler, and intestinal continuity was established with an extracorporeal, hand-sewn, two-layer anastomosis.

The patient recovered well from the procedure and was discharged from the hospital on postoperative day 5. Pathology evaluation of the small bowel revealed a 6.0 x 3.0 x 2.5-cm, metastatic, poorly differentiated, non?small cell carcinoma, which was a giant cell variant of large cell cancer consistent with lung origin (Figure 4). The tumor was seen invading the bowel wall and beginning to encroach into the mucosa. Low-power magnification revealed multiple inflammatory cells. The high-power magnification showed giant tumor cells surrounded by multiple types of inflammatory cells (Figure 5). The margins were free of tumor.

The patient was readmitted to the hospital approximately 3 months later for small bowel obstruction due to metastatic lung disease. Open exploration with small bowel resection and primary anastomosis was performed. Although the procedure was successful in relieving the obstruction, the patient developed anemia, hypotension, tachycardia, atrial fibrillation, and abdominal distention. The abdomen was re-explored, which revealed diffuse bleeding despite normal coagulation parameters. The bleeding was attributed to diffuse metastasis of the patient's primary lung cancer. The patient's family was informed of her poor prognosis and decided on minimal supportive care. The patient died 7 days later, approximately 98 days after her initial procedure.

Discussion

Lung cancer may aggressively metastasize by directly invading surrounding tissues or by hematogenous or lymphatic spread. Lung cancer has been commonly found to invade the chest wall, diaphragm, pulmonary vessels, and pericardium, but it can also involve other structures of the thorax, such as the esophagus. In cases of lymphatic metastasis, the most likely location of disease spread is the pulmonary and mediastinal lymph nodes. The pattern of spread first involves the ipsilateral hilar lymph nodes and then the mediastinal lymph nodes. Hematogenous spread often involves the brain but can also include the liver, bones, adrenal glands, and kidneys. When lung cancers spread hematogenously, they are generally found within 2 years of lobectomy or pneumonectomy.

Our patient's lung cancer metastasized to the small bowel and caused intussusception. A review of the literature from 1981 to the present revealed only 7 similar cases. Reports of lung cancer metastasizing to the small bowel have noted obstruction, peritonitis, small bowel perforation, and hemorrhage in addition to intussusception.2,3 Autopsy studies of lung cancer patients have shown that even asymptomatic patients had metastasis to the small bowel, which indicates that lung cancer may metastasize to the gastrointestinal tract more often than anticipated.

Of the subtypes of lung cancer, the large cell variety is the one that most frequently invades the small bowel. Our patient's case was unique because she had a giant cell variety of large cell cancer invade the mucosa of the small bowel. This is a rare occurrence because the giant cell variety of large cell cancers accounts for only 0.8% of all lung cancers.4

Ryo and colleagues reviewed the incidence of lung cancer metastasizing to the gastrointestinal tract (excluding the esophagus) and found 30 such cases among the 1,635 lung cancer patients admitted to their institution during a 17-year period.5 The diagnosis was made before death in 7 patients and on autopsy in 23 patients. Large cell carcinoma was the most common tumor, followed by adenocarcinoma, small cell carcinoma, and squamous cell carcinoma. Metastasis occurred most often to the small intestine, followed by the colon and the stomach. Occult blood was positive in 9 of the cases diagnosed on autopsy, and only 3 of those patients had symptoms while they were alive. The most frequent manifestations of lung cancer metastasizing to the small bowel included melena, ileus, perforation, and intussusception.

The only other large-scale series of lung cancer metastasizing to the bowel was by Berger and associates.2 This study included 1,544 patients with lung cancer, of which 1,399 underwent surgery. Seven patients had symptomatic small bowel metastasis, all found within 2 years of their primary tumor resection. Clinically, 2 patients presented with peritonitis, 3 with obstruction, and 2 with gastrointestinal bleeding. Jejunal metastasis was found in 2 patients, ileal metastasis in 3 patients, and both sites were affected in 2 patients. After resection of the metastasis, 6 of these patients died within 8 months and 1 patient was alive 22 months after resection. This study demonstrates the rarity of lung cancer metastasizing to the small bowel and the poor prognosis for such patients.

Yoshida and colleagues reported a poor prognosis for a patient whose primary lung cancer metastasized to the small bowel and resulted in intussusception.6 After palliative small bowel resection, their patient died within 1 month due to disease. This correlates to the mean survival period of 49 days noted in the study by Ryo and associates.5

The most commonly used modality for diagnosing intussusception is CT scanning, which generally has a high enough sensitivity and specificity for allowing an accurate diagnosis; however, it may not always elucidate intussusception as the cause of small bowel obstruction for reasons such as residual contrast in the bowel from an upper gastrointestinal barium swallow study. Endoscopy, colonoscopy, and upper gastrointestinal barium swallow studies are not cost-effective and may not identify intussusception. Laparoscopic exploration may be helpful in lung cancer patients who have intestinal obstruction because it can help establish the cause and is less traumatic than exploratory laparotomy.

Although intussusception may be caused by multiple etiologies, malignancy must be assumed in adults; thus, bowel resection should be performed.7 This procedure would only be palliative since these patients have such a poor prognosis.

Conclusion

The giant cell type of large cell tumors make up only 0.8% of all lung cancers; thus, this variant metastasizing to the small bowel and causing intussusception is rare.4 Although all histologic types of lung cancer can metastasize to the small intestine, the large cell variety is the most common. Along with intussusception, reported symptoms include hemorrhage, obstruction, perforation, and peritonitis. CT scanning should be the first imaging modality used to evaluate lung cancer patients presenting with abdominal pain. If the CT scan is inadequate, exploratory laparoscopy may be used. Once diagnosed, the bowel containing the mass may be resected laparoscopically.

References

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Am J Gastroenterol

2. Berger A, Cellier C, Daniel C, et al. Small bowel metastases from primary carcinoma of the lung: clinical findings and outcome. . 1999; 94(7):1884-1887.

J Clin Gastroenterol

3. Issa K, Mullen KD. Large-cell carcinoma of the lung. With major bleeding and intussusception. . 1992; 15(2):142-145.

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4. Ginsberg SS, Buzaid AC, Stern H, et al. Giant cell carcinoma of the lung. . 1992; 70(3):606-610.

Nihon Kyobu Shikkan Gakkai Zasshi

5. Ryo H, Sakai H, Ikeda T, et al. Gastrointestinal metastasis from lung cancer [in Japanese]. . 1996; 34(9): 968-972.

Nihon Kokyuki Gakkai Zasshi

6. Yoshida J, Ishimaru T, Ekimura M. Non-small cell lung cancer metastatic to the stomach and the jejunum causing intussusception: a case report [in Japanese]. . 1998; 36(3):268-272.

Am Fam Physician

7. Prater JM, Olshemski FC. Adult intussusception. . 1993; 47(2):447-452.

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