Mohan M John, MD, Harish Nirujogi, MD, Visweshwar Haresh, MD, Vellore Parithivel, MD, Masooma Niazi, MD. Bronx Lebanon Hospital Center, Bronx, NY.
One half of lung cancer patients have metastatic disease at the time of presentation. The commonest sites of metastases are lymph nodes and the liver(1). Small bowel metastasis from lung cancer is rare and is invariably a marker of advanced disease. We report a case of metastatic small bowel obstruction managed successfully at our institution using the minimally invasive approach.
A 69 year old male presented to our institution with recurrent colicky abdominal pain , nausea, and inability to tolerate oral diet for 3 weeks. He had history of stage IIIB squamous cell cancer of the lung which was treated with chemotherapy and radiation in the year prior to presentation. He had had no abdominal surgery in the past. On examination, the abdomen was distended with hyperactive bowel sounds. Computerized tomography of the abdomen showed high grade small bowel obstruction with a transition point in the left lower quadrant. The patient was resuscitated and bowel decompressed with a nasogastric tube. At diagnostic laparoscopy, he was found to have an 2 x 2 cm obstructing mass in the ileum 4 feet from the ileocecal junction. The rest of the peritoneal cavity was free from gross metastatic disease. The umbilical incision was extended vertically by 1cm on either side and the affected segment of bowel delivered into the incision. Small bowel resection with a stapled anastomosis was performed. The patient made a steady recovery and was discharged on post-operative day 3. He was well at follow up in clinic 2 weeks later. Histopathological examination of the lesion was reported as metastatic squamous cell carcinoma. The tissue demonstrated CK7+/ CK20- immunoprofile, indicating origin from the lung.
The incidence of small bowel metastasis from a lung primary ranges from 0.4-0.5%(2). These metastases most commonly originate from squamous or large cell carcinoma of the lung(3). The initial presentation may be non-specific; but progression to intestinal obstruction, bleeding or perforation necessitates surgical intervention. Surgical resection offers the best palliation; but long term outcome remains poor. As demonstrated in this case, the laparoscopic-assisted approach is a viable option in these high-risk patients, with quick recovery time and minimal morbidity.
(1) McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer. 1987;59:1486–1489.
(2) Lee PC, Lo C, Lin MT, Liang JT, Lin BR. Role of surgical intervention in managing gastrointestinal metastases from lung cancer. World J Gastroenterol. 2011 Oct 14;17(38):4314-20.
(3) Hillenbrand A, Sträter 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 Jun 6;2:13.