simultaneous solitary metastatic lesion in stomach: a case report with the
review of literature
Çiğdem ÖZDİLEKCAN1, Necla SONGÜR2, Leyla MEMİŞ3, Nazan BOZDOĞAN1, Aydın Şeref KÖKSAL4, Uğur OK1
1 SB Ankara Onkoloji Eğitim ve Araştırma Hastanesi, Göğüs Hastalıkları Bölümü, Ankara,
2 Süleyman Demirel Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, Isparta,
3 Gazi Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı,
4 29 Mayıs Tıp Merkezi, Gastroenteroloji Bölümü, Ankara.
ÖZET
Midede izole, eş zamanlı metastatik lezyon ile seyreden akciğer kanseri: Literatür eşliğinde olgu sunumu
Mideye ait metastatik tümörler oldukça nadirdir. Pek çok doku neoplazmının mideye metastaz yapabileceği bildirilmiş ol- sa da, akciğer kanseri nadir bir metastaz nedenidir. Burada, ilk başvuru bulgusu vena kava sendromu olan 46 yaşındaki erkek olguyu sunmayı amaçladık. Primer akciğer tümörün histopatolojisi bilgisayarlı tomografi eşliğinde alınan biyopsi ile küçük hücreli dışı akciğer kanseri olarak rapor edildi. Takipleri sırasında gastrik yakınmaları olan hastaya üst gastrointes- tinal sistem endoskopisi uygulandı. Endoskopi bulguları primer skuamöz hücreli kanserin metastazını teyit etti ve yapılan taramaları da farklı uzak organ metastazının olmadığını, gastrik bölgenin tek bir metastaz odağı olduğunu işaret etti.
Anahtar Kelimeler: Akciğer kanseri, mide metastazı.
SUMMARY
Lung cancer associated with a single simultaneous solitary metastatic lesion in stomach: a case report with the review of literature
Çiğdem ÖZDİLEKCAN1, Necla SONGÜR2, Leyla MEMİŞ3, Nazan BOZDOĞAN1, Aydın Şeref KÖKSAL4, Uğur OK1
Yazışma Adresi (Address for Correspondence):
Dr. Aydın Şeref KÖKSAL, 29 Mayıs Tıp Merkezi, Gastroenteroloji Bölümü, ANKARA - TURKEY
e-mail: serefkoksal@gmail.com
Lung cancer is the major cause of death all over the world. Approximately 40 percent of patients have metastatic disease at the time of presenta- tion (1). The most common site of extrapulmo- nary spread include liver (35%), bones (25%), adrenals (22%), kidneys (10-15%) and heart- pericardium (20%) (2). However, a metastasis to the stomach is uncommon; hence, it’s rarely di- agnosed during the patients life time. Although these patients are often asymptomatic, gastric metastasis mark advanced disease and poor prognosis.
We report a case of lung cancer associated with a single simultaneous solitary metastatic lesion in the stomach with a review of the literature about this rare entity.
CASE REPORT
A 46-years-old male patient admitted to hospi- tal with a two months’ history of shortness of breath, cough, night sweats and weight loss. His chest radiography revealed an appearance of mass lesion and atelectasis in the right middle zone.
He had a history of smoking (20 package-year) and quitted just two months before hospitalizati- on. His father has died because of lung cancer at age of 58.
Physical examination findings were edema in the face and neck region, formation of collateral ve- ins in chest wall suggesting vena cava syndrome (VCS). Oscultation findings were cracles in the
lower lung areas. Also during oscultation breath sounds in the right upper lobes of chest was dec- reased.
X-ray film of the chest showed volume loss of right lung with tracheal deviation to the right. In the right upper lobe mass lesion is observed ne- ar to the assending aorta (Figure 1).
Computed tomography (CT) scan of lung sho- wed vascular invasion of mass lesion with ate- lectatic areas in the right upper lobe. A large trombus was observed in internal jugular and subclavian vein. There were also multiple medi- astinal enlarged lymph nodes and thickening of pericardium with minimal pericardial effusion (Figure 2).
He was undertaken bronchoscopic examination.
Bulging of main carina and obstruction of right upper lobe bronchus with submucosal lesion is observed pathological examination of the speci- men obtained from tumor by transbronchial bi- opsy was non-diagnostic. Patient refused se- cond bronchoscopic procedure.
Because of patient’s poor general condition ur- gent palliative radio theraphy was performed for VCS findings. Mediastinal and right lung region was radiated totally with dose of 3600 cGy for two weeks period. By the improvement of his general condition after radiation theraphy, CT- guided transthorasic fine needle biopsy was per- formed as a second diagnostic procedure. Histo- logical examination of biopsy specimen was consistent with the diagnosis of non-small cell
1 Department of Chest Diseases, Ankara Oncology Training and Research Hospital, Ankara, Turkey,
2 Department of Chest Diseases, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey,
3 Department of Pathology, Faculty of Medicine, Gazi University, Ankara, Turkey,
4 Department of Gastroenterology, 29 Mayis Medical Center, Ankara, Turkey.
Metastatic tumors of the stomach are rare. Although neoplasms from almost every tissue have been reported to metastasi- ze to the stomach, lung cancer is a rare cause. We report the case of 46-years-old man presented with superior Vena Cava syndrome. Histopathological diagnosis was non-small cell lung cancer with computed tomography-guided needle biopsy of lung. Since gastric symptoms occured during follow up of patient, upper gastrointestinal endoscopy performed. Upper gastrointestinal endoscopy and biopsy showed metastasis of stomach secondary to primary squamous cell lung cancer and additionally lack of another distant site metastasis indicated that gastric region was the single site of tumor spread.
Key Words: Lung cancer, gastric metastasis.
lung cancer. Immunohistochemical stainings for Pan CK and CK 7 were positive but negative for CK 20 and CEA (Figure 3).
Distant site metastasis including abdomen and cranium were investigated and no patological spread was observed. After radio therapy, che- motherapy was planned; however just before the initiation of chemotherapy the patient had a complaint of disphagia and epigastric pain. Up- per gastrointestinal endoscopy (UGIE) revealed a giant ulcer with central ulceration located in the lesser curvature of the gastric body which was assessed as a malignant ulcerative lesion
macroscopically by the endoscopist. Histopat- hological examinations of gastric specimens showed a low differentiated malignant infiltration of the stomach. The histopathological result of gastric specimen was reported as “low-differen- tiated malignant infiltration of tumor”. Tumor cells were positively stained with CK 7 and CK 5/6 which was diagnosed as metastasis of gast- ric region secondary to primary squamous cell lung cancer (Figure 4). Gastric region was the only metastatic site obtained in our patient.
Figure 1. X-ray view of the chest showing volume loss of right lung with tracheal deviation, and mass lession in the right upper lobe.
Figure 2. CT scan of lung with mass lesion and ate- lectasis in the right upper lobe. Mediastinal enlarged lymph nodes are remarkable.
Figure 3. Histological view of transthoracic needle biopsy specimen of lung. Tumor composed of atypi- cal cells (cell block). Hematoxylin & Eosin x100 (re- ported as non-small cell lung cancer).
Figure 4. Histopathological view of gastric specimen showing squamous carcinoma cells infiltrating wall of stomach (HE).
RENKLİ
RENKLİ
The patient’s survival was only one month after the diagnosis.
DISCUSSION
Lung cancer has been shown to metastasize to almost anywhere within the gastrointestinal tract. The esophagus has been described as the most common sites largely secondary to local extension of the primary lung tumor (1). The he- matogenous spread of lung cancer to stomach is extremely rare, but recent reports suggest that they may be more frequent than previously tho- ught, because they are rarely symptomatic (3).
The gastrointestinal tract has been reported throughout the literature as a site of metastatic lung cancer with an estimated incidence of 4 to 12 percent (4,5). But only 0.2-1.7% of them are detected as gastric metastasis during autopsy findings (6). The presence of gastric metastasis suggests poor prognosis (Table 1).
Metastatic disease to stomach can occur with breast, melanoma, ovary, liver, colon and testi- cular cancer with breast cancer being the most frequent (7). Other rare tumors that can involve stomach include Kaposi’s sarcoma, schwanno- ma and glomus tumors (7,8).
Only 51 cases of lung carcinoma metastasis to gastrointestinal tract have been reported in the literature since 1961 (seven cases with stomach metastasis, 37 cases with small bowel metasta- sis, three cases with colon metastasis, two cases with anus metastasis, and two cases with duode- num metastasis) (3). The most frequent site of metastasis was reported as small bowel and per- foration in gastrointestinal tract was observed among 55.1% of all cases (3).
Patients with gastric metastases from any types of malignancy are often asymptomatic unless the metastases invade the gastric mucosa or se- roza, or occupy the gastric lumen. However, further evaluation of gastric intestinal truct is un- likely to be performed because the symptoms, such as nausea and vomiting, are usually regard as side effect of chemotheraphy or a involve- ment of the central nervous system (6). For our patient, complaint of dysphagia was considered as to be local invasion of the primary tumor to
esophagus or as a complication of radio therapy.
However, UGIE revealed only a malignant ulce- rative lesion located in the corpus of the sto- mach.
The most common symptoms and complicati- ons according to gastrointestinal tract metasta- sis are gastrointestinal bleeding, abdominal pa- in, perforation and peritonitis (6). Up to date three cases were reported with perforation due to stomach metastasis and one of the perforati- on occurred during application of chemotherapy (9-11). For this reason, gastrointestinal symp- toms observed during chemotherapy need care- ful management.
Maeda et al. and Casella et al. reported two ca- ses with small cell carcinoma of lung metastasi- zed to stomach (12,13). In our case histopatho- logical type of tumor was squamous cell cancer and did not have gastric symptoms until advan- ced stage of his disease. For this reason, there was a diagnostic delay both for his primary dise- ase and metastatic procedure.
Some mechanisms of gastric metastasis are considered as follows;
1. Direct invasion such as pancreatic cancer or esophageal cancer,
2. Disseminated involvement of peritoneum such as in ovarian cancer,
3. Hematogeneous metastasis most often occur- ring in lung cancer (12,14,15).
Although the stomach receives plenty of blood supply, both the mechanism of gastric metasta- sis and the reason of rarity of metastasis to sto- mach from lung cancer could not be explained up to now. Recently, it is suspected that some types of cytokines may affect the organ specifity in hematogenous metastasis. Recently, it is sus- pected that some types of cytokines may affect the organ specifity in hematogenous metastasis (12). Hematogeneous metastatic tumor cells to the stomach are situated in the submocosal la- yer and develop into submucosal tumors (12).
Endoscopically nearly all the metastatic cases present submucosal tumors with bridging folds and small ulcerations at the top which is named
“volcano-like ulcers’’(3,6,12,13,17,18).
Table 1. The review of previously reported gastric metastatic cases from primary lung carcinoma. Metastasis StomachlocalisationTimeSurvival ClinicalDiagnosticGITbiopsy/LungPulmonary(except GIS)intervalafter Age/Sexpresentationprocedurelocalisationbiopsy (HP)localisationpositive(months)*diagnosis Wu et al.82/MMelenaGastroscopyCardiaAdenocarcinomaIndeterminedLocation not108Indetermined (2007) (20)reported positive 73/MMelenaGastroscopyCardiaSquamous cellIndeterminedLocation not5Indetermined carcinomareported positive 70/MEpigastric painGastroscopyGastricAdenocarcinomaIndeterminedLocation not5Indetermined corpusreported Casella et al.63/MEpigastric painGastroendoscopyGastricSmall cell/smallLeft upperBrain +The1 month (2006) (13)corpuscelllobe +liversame pleurisytime Altintas et al.55/MMelena +GastroendoscopyGreaterAdenocarcinoma/?IndeterminedBrain +123 weeks (2006) (16)hematemesiscurvature ofbone +skin stomach Yamamato et al.Epigastric painGastroendoscopyUpperAdenocarcinoma/LeftlowerBrain?18 months (2002) (3)80/Mstomachadenocarcinomalobe Suzaki et al.45/MEpigastralgia +GastroendoscopyGreaterAdenocarcinoma/RightNo76 days (2002) (9)gastriccurvature ofadenocarcinomamiddle lobemetastasis perforationstomach Kim et al.66/MEpigastric painGastroendoscopyUpper bodySmall cell/?Left upperNo-Indetermined (1993) (19)+ weakness+fundus oflobemetastasis stomach Kim et al.68/MPolydipsia +GastroendoscopyGreaterSquamous cell/Left upperBrainTheIndetermined (1993) (19)headachecurvaturesquamous celllobe(diabetissame side ofinsipidus)time mid-body Maeda et al.60/FNausea +GastroendoscopyWholeSmall cell/smallRigt upperSkin4Indetermined (1992) (12)voimitingstomachcell-lower lobe * Time between primary tumour diagnosis andGIS metastasis. M: Male, F: Female, GIS: Gastrointestinal system, GIT: Gastrointestinal tract, HP: Histopathology.
As observed in Table 1 which is the review of ca- ses in literature, all of the patients with gastric metastasis was symptomatic and diagnostic procedure was gastroendoscopy for all of the cases. Upper lobe localization was pre-dominant among all cases just like our case. It has also been reported that a high percentage of gastric metastases are localized in the fundus and car- dias, but in our experience, the lesions were pre- sent in the gastric corpus region which is in ag- reement with Casella et al. and Kadakia et al.
(3,19). In clinicopathological study of Ming- Hsun Wu et al., the sites of metastasis in the sto- mach were solitary for 94.4% of patients and only 5.6% developed multiple lesions in the sto- mach (20). In previous reports as shown in Tab- le 1, most of the lung cancer patients with gast- ric metastasis were associated with other organ metastasis when the diagnosis of gastric metas- tasis was established. In our patients, stomach was found to be a single site of metastasis with careful review of imaging studies.
Because of advanced improvement in chemot- herapy and supportive care in lung cancer and extending life expectancy, we may come across an increasing number of this kind of metastatic tumor in the future. Therefore, we should pay more attention to these GI metastatic signs inc- luding gastro-intestinal bleeding, epigastric pa- in, nausea, vomiting, acute abdominal pain or less commonly ileus. Cases with new develop- ment of gastrointestinal symptoms after che- motherapy, should be carefully managed beca- use of the possibility of chemotherapy induced perforation or ulceration. Chemotherapy may be beneficial to the improvement of the survival ra- te in individual cases (6). The definite role of FDG-PET in the diagnosis of gastrointestinal metastasis from lung cancer is still controversial because of the few cases and lack of enough cli- nical data (6).
Therefore since the stomach metastases of lung cancer is rarely seen, commonly lethal and pre- emptive diagnosis of the metastatic disease af- fect survival; gastroendoscopy which is the gold standard diagnostic procedure is not recom- mended as a routine screening test unless the patients are symptomatic. The suitable time for endoscopy can be before initiation of chemothe-
rapy or as soon as the gastric symptoms are ob- served. When patients with lung cancer present with gastrointestinal symptoms like bleeding and obstructive symptoms semi elective surgery should be considered.
This case and review of literature support that the prevalence of gastric metastasis in patients with lung cancer is very low. The clinician sho- uld be aware of the possibility of gastric metas- tasis. During the follow up of lung cancer, gast- rointestinal symptoms should be questioned and gastroscopy associated with biopsy should be performed especially in symptomatic patients.
Unfortunately, the diagnosis of metastasis in a symptomatic patient signifies a late diagnosis which a stage that renders any treatment proce- dure ineffective. Further research is required to clarify the timing of gastroscopy in patients with lung cancer.
REFERENCES
1. Garwood RA, Sawyer MD, Ladesma EJ, et al. A case and review of bowel perforation secondary to metastatic lung cancer. The American Surgeon 2005; 71: 110-6.
2. The guideline of lung cancer diagnosis and treatment.
Turkish Thoracic Journal 2006; (Suppl 2): 1-29.
3. Yamamoto M, Matsuzaki, Kusumoto H, et al. Gastric me- tastasis from lung carcinoma: Case report. Hepato-Gast- roenterology 2002; 49: 363-5.
4. Stenbygaard LE, Sorensen JB, Larsen H, et al. Metastatic patern in non-resectable non-small cell lung cancer. Ac- ta Oncol 1999; 38: 993-8.
5. McNeill P, Wagman LD, Neifeld JP. Small bowel metasta- ses from primary carcinoma of the lung. Cancer 1987;
59: 1486-9.
6. Yang CJ, Hwang JJ, Kang WY, et al. Gastrointestinal me- tastasis of primary lung carcinoma: Clinical presentati- ons and outcome. Lung Cancer 2006; 54: 319-23.
7. Caravelli JF, Sklarin NT, Panicek DM, et al. Metastatic lo- bular carcinoma of the breast: Patterns of spread in the chest, abdomen and pelvis on CT. Am J Roentgenol 2000; 175: 795-800.
8. Blecker D, Abraham S, Furth E, et al. Melanoma in the gast- rointestinal tract. Am J Gastroenterol 1999; 94: 3427-33.
9. Suzaki N, Hiraki A, Ueaka H, et al. Gastric perforation due to metastasis from lung carcinoma of the lung. Anti- cancer Research 2002; 22: 1209-12.
10. Fletcher MS. Gastric perforation secondary to metastatic carcinoma of the lung: A case report. Cancer 1980; 46:
1879-82.
11. Schmidt G. Gastric perforation secondary to metastatic bronchogenic carcinoma: A case report. Hepatogastroen- terol 1985; 32: 103-5.
12. Maeda J, Miyake M, Tokita K, et al. Small cell lung can- cer with extensive cutaneus and gastric metastases. In- ternal Medicine 1992; 31: 1325-8.
13. Casella G, Di Bella C, Cambareri AR, et al. Gastric metas- tasis by lung small cell carcinoma. World Journal Gast- roenterology 2006; 12: 4096-7.
14. Radin DR, Halls JM. Cavitating metastases of the sto- mach and duodenum. Comput Tomogr 1987; 11: 83-7.
15. Lunch P, Green L, Jordan PH. Hepatocellular carcinoma metastatic to the stomach presenting as bleeding multip- le craterogenic ulcers. Am J Gastoenterol 1989; 84: 653-5.
16. Altintas E, Sezgin O, Uyar B. Accute upper gastrointesti- nal bleeding due to metastatic lung cancer: An unusual case. Yonsei Med J 2006: 276-7.
17. Kadakia SC, Parker A, Canales L. Metastatic tumors to the upper gastrointestinal tract endoscopic experience.
Am J Gastroenterol 1992; 87: 1418-23.
18. Kim HS, Jang WI, Hong HS, et al. Metastatic involvement of the stomach secondary to lung carcinoma. Journal Korean Medical Science 1993; 8: 24-9.
19. Green LK. Hematogenous metastases to the stomach. A review of 67 cases. Cancer 1990; 65: 168-71.
20. Wu MH, Lin MT, Lee PH. Clinicopathological study of gastric metastases. World J Surg 2007; 31: 132-6.
