Lung cancer metastasis to the gastrointestinal system: An enigmatic occurrence

Case Report: Recurrent colonic metastasis from lung cancer-diagnostic pitfalls and therapeutic challenge of a peculiar case

Lung cancer (LC) mortality exceeds 20%, and detecting metastases from LC is becoming a challenging step in understanding the real prognostic role of specific localization. We report a case of a patient with lung metastasis to the colon with local recurrence at the anastomosis after radical resection for metastasis. In both cases, the diagnosis was on oncological follow-up, and surgery was offered in consideration of reasonable life expectancy, good control of LC, and high risk of intestinal occlusion. A 67-year-old male, with a history of LC 18 months ago, was referred to our surgical unit after a positron emission tomography CT total body, where an area of intense glucose metabolism (SUV max: 35.6) at the hepatic colic flexure was reported. A colonoscopy revealed an ulcerated, bleeding large neoplasm distally to hepatic flexure, almost causing resulting total occlusion. Histologic examination revealed a tumor with complete wall thickness infiltration, which appears extensively ulcerated, from poorly differentiated squamous carcinoma (G3), not keratinizing, with growth in large solid nests, often centered by central necrosis. Two of the 30 isolated lymph nodes were metastatic. The omental flap and resection margins were free from infiltration. The malignant cells exhibited strong positive immunoreactivity only for p40. The features supported metastatic squamous carcinoma of lung origin rather than primary colorectal adenocarcinoma. After 8 months from surgery, intense Fluorodeoxyglucose (FDG) uptake of tissue was confirmed in the transverse colon. Colonoscopy evidenced an ulcerated substenotic area that involved ileocolic anastomosis on both sides. Reoperation consisted of radical resection of ileocolic anastomosis with local lymphadenectomy and ileotransverse anastomosis. The second histologic examination also revealed poorly differentiated squamous carcinoma (G3), not keratinizing, with positive immunoreactivity only for p40, suggesting the origin of LC. This case report confirmed that the possibility of colonic secondary disease should be part of the differential diagnosis in asymptomatic patients and those with a history of LC diagnosis. In addition, relapse of colonic metastasis is infrequent but should be considered during follow-up of LC. More studies on colonic metastasis of LC are required to better understand the clinical features and outcomes.

Metastasis to the stomach: a systematic review

Background: This study reviews the literature on gastric metastases (GM) in terms of diagnosis, treatment, and outcomes. The goal of this study was to provide clinicians with a reliable and beneficial source to understand gastric metastases arising from various primary tumors and to present the growing literature in an easily accessible form. Methods: Articles published in English language from implementation of MEDLINE and Cochrane databases until May 2022 were considered for the systematic review. Articles other than English language, letters to the editor, posters, and clinical images were excluded. Hematogenous and lymphogenic metastases were included whereas direct tumoral invasion and seeding were excluded. Articles and abstracts were analyzed and last selection was done after cross-referencing and by use of defined eligibility criteria. Results: In total 1,521 publications were identified and 170 articles were finally included totaling 186 patients with GM. The median age of patients was 62 years. Gynecologic cancer was the most common cancer type causing GM (67 patients), followed by lung cancer (33 patients), renal cancer (20 patients), and melanoma (19 patients). One of the main treatment methods performed for metastasis was resection surgery (n=62), sometimes combined with chemotherapy (ChT) or immunotherapy. ChT was the other most used treatment method (n=78). Also, immunotherapy was amongst the most preferred treatment options after surgery and ChT (n=10). Conclusions: As 172 case reports were screened in the systematic review from different journals, heterogeneity was inevitable. Some articles missed important information such as complete follow-up or clinical information. Moreover, since all of the included articles were case reports quality assessment could not be performed. Among 172 case reports reviewed, resection surgery was performed the most and was sometimes combined with ChT and immunotherapy. Further research about what type of treatment has the best outcomes for patients with gastric metastases is needed.

Small Bowel Perforation Due to Rare Metastasis From Stage IV Lung Adenocarcinoma

Lung adenocarcinoma commonly metastasizes to the lymph nodes, bone, nervous system, liver, respiratory system, and adrenal gland. Metastasis to the small bowel is extremely rare and the literature deals mostly with few published case reports. We present a case of a 70-year-old male with a previous history of stage IV lung adenocarcinoma with brain and liver metastases treated with radiotherapy and chemotherapy. He presented to the emergency department with peritonitis and sepsis due to bowel perforation. He underwent an emergency exploratory laparotomy and small bowel resection. Surgical pathology revealed metastatic lung adenocarcinoma as the cause of bowel perforation. He tolerated and recovered from surgery well and was discharged on postoperative day 7. On one-month follow-up as an outpatient, he was doing well and had no complications or complaints from his recent surgery.

Unique diagnostic challenge in surgery: hepatic abscess versus malignancy

A man in his 30s had presented with a history of abdominal pain, vomiting and high-grade fever. He had tender hepatomegaly with peritonism in the upper abdomen. Investigations revealed a neutrophilic leucocytosis, and contrast-enhanced CT had shown several well-defined peripherally enhancing thick-walled cystic lesions with non-enhancing centres throughout the liver suggestive of pyogenic liver abscess, treated initially with antibiotics. However, ultrasonography-guided fine needle aspiration revealed atypical neoplastic cells, and a trucut biopsy showed squamous cell carcinoma (SCC). He developed acute shortness of breath. CT pulmonary angiogram confirmed pulmonary thromboembolism (PTE). Incidentally, here we saw a solitary nodule in the right middle lobe, probably a neoplastic lesion. His condition deteriorated rapidly secondary to PTE and died. A pathological review was positive for CK7, p40, p63 and CK19 confirming SCC. We concluded the primary was a pulmonary SCC with multiple hepatic metastases. Hepatic metastases can mimic an abscess; trucut biopsy with immunohistochemistry was critical for a definitive diagnosis.

Colonic Metastasis of Primary Lung Cancer

The colon is an uncommon secondary site for metastasis of lung adenocarcinoma. Distinguishing primary colonic carcinoma from metastatic spread of lung carcinoma can be difficult. We present a case of a patient with lung adenocarcinoma who, on abdominal computed tomography scan examination, was found to have a sigmoid tumor that was thought to represent a synchronous primary colorectal adenocarcinoma. Histological examination of endoscopic sigmoid tumor biopsies confirmed this to be metastasis from the lung adenocarcinoma. The patient subsequently developed major rectal bleeding and deteriorated significantly. This case also illustrates the poor prognosis association with colorectal metastasis of lung cancer.

Early Gastrointestinal Progression to Immunotherapy in Lung Cancer: A Report of Two Cases

Intestinal and pancreatic metastases are rare and often challenging to recognize and manage. Lung cancer patients with enteric involvement usually display poor outcomes. Hyperprogression to immunotherapy represents a concern, even though there is currently no agreement on its exact definition. Gastrointestinal hyperprogression to immune checkpoint inhibitors has not been described so far. In these cases, distinguishing disease-related symptoms from immune-related adverse events may represent a diagnostic conundrum. Here, we report two cases of non-small-cell lung cancer experiencing a rapid pancreatic and colic progression to immunotherapy, respectively. While further investigations to identify biomarkers associated with hyperprogression are warranted, clinicians should be aware of the potential unusual clinical presentations of this phenomenon.

Serendipitous Discovery of Isolated Gastric Metastases From Adenocarcinoma of the Lung on Staging 18F-FDG PET-CT

Gastric metastasis from lung cancer is rare. We here present the case of a 59-year-old man with lung adenocarcinoma where isolated gastric metastases were discovered on staging F-FDG PET-CT, confirmed with endoscopy and biopsy.