Eur J Cardiothorac Surg 2001;19:719-720
© 2001 Elsevier Science NL
Colonic metastases from primary squamous cell carcinoma of the lung
D. Carroll,
P.B. Rajesh
Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
Received 28 June 2000;
received in revised form 5 February 2001;
accepted 21 February 2001.
Corresponding author.
e-mail: danderosier{at}doctors.org.uk
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Abstract
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Lung cancer is the most common malignancy in the UK. Metastasis to the colon is very rare and only infrequently symptomatic. Here we report a case of squamous cell carcinoma of the lung which presented with symptoms from a colonic metastasis.
Key Words: Lung cancer • Colonic metastasis
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1. Introduction
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Lung cancer is the most common malignancy in the UK, however metastasis to the colon is very rare. In the past 20 years only 11 cases of symptomatic colonic metastases from lung malignancies of all types have been reported in the literature [1–5]. Here, we present a case in the literature of a symptomatic colonic metastasis from a squamous cell carcinoma of the lung.
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2. Case report
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A 68-year-old man was referred to the gastroenterology department by his general practitioner with a 4 month history of diarrhoea and weight loss. He complained of passing 12 stools per day with mucus but no frank blood loss, and also of losing almost 4 kg in weight. He had a significant previous smoking history of 50 pack years but had not smoked for many years.
Clinical evaluation, including rectal examination, was unremarkable. Routine biochemical and haematological profiles were within physiological limits. A routine chest X-ray was reported as normal. Colonoscopy revealed a polypoid lesion at 25 cm with a proximal stricture, which had macroscopic features of malignancy, however this was not confirmed on biopsy, and a preliminary diagnosis of stricture secondary to diverticulosis was made. The patient was scheduled to have elective laparotomy and large bowel resection.
Six weeks later, the patient was admitted as an emergency under the chest physicians with haemoptysis. He complained of exertional dyspnoea and a change in the character of his voice. Clinical evaluation revealed reduced air entry at the right base, with dullness to percussion and a monophonic wheeze. A chest radiograph showed an opacity in the right lower zone. Bronchoscopy was requested urgently and performed 4 weeks later. This yielded biopsies which were consistent with a squamous cell carcinoma. Computed tomography (CT), requested urgently was performed 4 weeks later. This confirmed a 4 cm mass in the right lower lobe, occluding the right lower lobe bronchus and associated with distal consolidation, with no evidence of mediastinal involvement (see Fig. 1). These appearances were consistent with an anatomically resectable lung lesion. Pulmonary function tests and the patients general condition were acceptable for pneumonectomy to be tolerated.
In view of his symptomatic colonic disease he underwent a sigmoid colectomy for resection of his presumed colonic diverticular mass 4 weeks later. All other organs were normal at the time of laparotomy, and he made an unremarkable post-operative recovery. The pathology specimen demonstrated diffuse diverticulosis with irregular mucosal thickening with a focal perforation and paracolic abscess. A grey nodule 1 cm in diameter was also seen, which contained poorly differentiated squamous cell carcinoma of the large cell non-keratinising pattern. All 10 lymph nodes sampled were free from tumour which had similar histology to the bronchial biopsy, i.e. a moderately differentiated squamous cell carcinoma demonstrating brisk stromal desmoplasia.
Two months later, he underwent a bronchoscopy and right lateral thoracotomy with a view to resection of his lung primary. He was bronchoscopically operable, however at thoracotomy the tumour was found to be adherent to the pericardium, invading the inferior pulmonary vein and there was an additional tumour in the right upper lobe, this represented T4 disease. A curative resection was not possible and he was referred to the local oncology service for further treatment. He received MIC chemotherapy, but eventually died 6 months later due to respiratory failure, from a combination of disease progression and a chest infection.
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3. Discussion
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In the UK lung cancer is the most common primary malignancy with approximately 35 000 new cases per year [7]. Around 50% of cases have demonstrable metastases at the time of presentation with the most commonly affected sites being the lymph nodes, adrenals, liver, bone and brain [1–3]. Unfortunately in this case there were long delays between each stage in patient assessment due to local problems which have since been addressed.
Gastrointestinal metastases are not an uncommon finding at post-mortem. Oschner and DeBakey noted gastrointestinal involvement in 4.3% of a series of 3047 autopsies [8], and Antler et al. [1] reported the incidence to be 14% when including tumours which had extended by direct spread into the oesophagus. Solitary metastases, however, were rare occurring in only three of 423 cases.
Colonic metastasis usually occurs late in the disease and typically present after the diagnosis of the primary lesion. Symptomatic colonic metastases have been reported previously but are rare [2–6]. Occasionally the lung primary and colonic lesion present synchronously [3,4]. A case presenting with symptoms from a solitary colonic metastasis has not been previously reported. They are usually associated with widespread metastasis. This case either represents a symptomatic colonic metastasis, or an incidental colonic metastasis in the presence of obstructing diverticular disease. The macroscopic appearance of the disease and the absence of other symptoms of diverticular disease favour the former.
The prognosis of lung cancer is related to the cell type, grade and stage. Small cell carcinoma has particularly poor results following surgery due to the aggressive biology of this tumour. Previous evidence suggests that squamous cell carcinoma of the lung has a tendency to invade locally and extrathoracic dissemination is less common. Other authors report a poor prognosis with intestinal metastasis with a mean survival of only 4–8 weeks [9]. This patient survived for a further 6 months following a course of MIC chemotherapy. This presents a dilemma in management. Which lesion should be treated first – the colonic metastasis of the lung primary? With a complicated colonic lesion (obstruction, bleeding or perforation), we advocate surgery to the colonic lesion and thorough assessment of the lung lesion. Surgery for colonic metastases from squamous cell carcinoma of the lung provides excellent palliation and does not affect survival adversely [2]. The primary lung lesion should be treated on its own merits. It should be noted that in the presence of distant metastases, the primary cancer is likely to be locally advanced.
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Abstract
1. Introduction
