Surgical Treatment of Intraperitoneal Metastases From Lung Cancer

Two Case Reports and a Review of the Literature

Simone Sibio; Giuseppe Sigismondo Sica; Sara Di Carlo; Maurizio Cardi; Alessandra Di Giorgio; Bianca Maria Sollazzo; Paolo Sammartino


J Med Case Reports. 2019;13(262) 

In This Article

Cases Presentation

Patient 1

In March 2013, a 44-year-old Caucasian man, a non-smoker of tobacco, was referred to our department as an emergency with 3 days' history of bowel obstruction. His family history was negative for cancer. His past medical history included a right pneumonectomy in 2009 for a T2, N1, M0 G3, stage IIB lung adenocarcinoma. Immunohistochemistry was positive for cytokeratin 7 and negative for thyroid transcription factor 1 (TTF-1), caudal type homeobox transcription factor 2 (CDX2), cytokeratin 20, protein S100, thyroglobulin, the anti-melanosome clone, human melanoma black 45 (HMB-45), and the anti-melanoma, melanoma antigen recognized by T cells 1 (MART-1). After surgery, he underwent four cycles of adjuvant chemotherapy with cisplatin (100 mg/m2) and paclitaxel (175 mg/m2); he then received two cycles of gemcitabine (1000 mg/m2) after the fourth cycle of cisplatin and paclitaxel for a grade 4 toxicity to paclitaxel. On admission in our department, he was off any treatment, and 1 month previously he had negative magnetic resonance imaging (MRI) for brain metastases. His vital signs were normal. Performance status assessed by the Eastern Cooperative Oncologic Group (ECOG)[7] was 1. He had been vomiting and his bowel had been obstructed for 24 hours. A clinical examination revealed a tender distended abdomen. Blood tests were normal except for neutrophilic leukocytosis: white blood cells (WBC) 14,000/mm3. Neuron-specific enolase and cytokeratin-19 fragment (CYFRA 21–1) levels were normal (respectively 121 ng/ml and < 3 ng/ml). A total body contrast-enhanced computed tomography (CT) scan showed a distended large bowel with air-fluid levels and multiple neoplastic implants involving the right colon, greater omentum, spleen, and the sigmoid colon, ranging from 0.5 to 10 cm. (Figure 1). No other pathological findings were disclosed and a chest examination was negative except for the outcomes of the previous thoracic surgery (Figure 2).

Figure 1.

Coronal two-dimensional image showing huge implants (arrows) of peritoneal metastases located near colonic splenic flexure providing a compression of the lumen and in Morison pouch between right kidney and right liver

Figure 2.

Axial two-dimensional image obtained after intravenous administration of iodinated contrast agent, showing outcomes of right pneumonectomy (arrow)

Considering his young age, the absence of lung recurrence and of any other distant metastasis, palliative surgery was considered in order to treat bowel obstruction. At laparotomy there was no ascites, and three gross neoplastic implants were found in the greater omentum, right colonic flexure, transverse colon, and left colon. Extensive cytoreductive surgery was performed and surgical procedures included subtotal colectomy with ileosigmoid anastomosis, splenectomy, and greater omentectomy (Figs. 3 and 4). At the end of the procedure no residual macroscopic disease was left, reaching a completeness of cytoreduction score (CCS) of 0.

Figure 3.

Intraoperative picture showing gross neoplastic implants on greater omentum, transverse colon, and left colon (arrows)

Figure 4.

Final surgical specimen showing gross neoplastic implants involving right side of colon, transverse colon, left colon, greater omentum, and splenic flexure (arrows)

Pathology showed complete infiltration of the colonic wall and spleen by adenocarcinoma nodules with lymph node metastases in the mesocolon.

Immunohistochemistry evaluation showed the same staining as the previous lung adenocarcinoma, confirming the lung origin of the peritoneal metastases.

His postoperative course was complicated by fever (38.5 °C) and dyspnea on postoperative day 9. A chest X-ray showed a "ground glass" picture of left lung and bloodstream and expectorate cultures were positive for Candida albicans species. Intravenously administered anidulafungin treatment was started with rapid improvement of our patient's general condition and gradual resolution of sepsis. He was discharged on postoperative day 20 and subsequently he underwent six cycles of adjuvant chemotherapy with cisplatin (100 mg/m2). Considering the previous toxicity to paclitaxel no other drug was used. A follow-up protocol included clinical evaluation (1 month after surgery, then every 3 months), blood tests with tumor marker levels every 3 months, and total body CT scan 1 month after surgery, then every 3 months for the first year and every 6 months for the next 2 years. Yearly, a brain MRI was scheduled. He was alive and disease free 3 years after surgery. In September 2016 he was lost to follow-up.

Patient 2

In September 2011, a 59-year-old Caucasian man, a heavy tobacco smoker, presented to our department as an emergency with abdominal pain and vomiting. His past medical history included a left upper lobectomy for a T1N1M0, G3 stage IIB lung adenocarcinoma (3 years before) followed by six cycles of systemic chemotherapy (carboplatin + paclitaxel 175 mg/m2). His family history was positive for cancer (a 39-year-old brother died of colon cancer). Two days before admission, abdominal distension and bowel obstruction occurred and progressively worsened. His WBC count was 18,000/mm3. A total body CT scan showed a large mass involving the distal ileal loops with obstruction and distension of the proximal bowel, with a small amount of ascites in his pelvis.

He underwent explorative laparoscopy that confirmed the CT scan findings, showing no other peritoneal seeding. Ascites was taken for cytological examination, and a laparoscopic ileocolic resection with ileotransverse anastomosis was performed, reaching a CCS of 0. His postoperative course was uneventful and he was discharged on postoperative day 4. Pathology confirmed the diagnosis of metastasis from adenocarcinoma; ascites was found to be negative for neoplastic cells. At immunohistochemistry, cancer cells were positive for cytokeratin 7 and TTF-1 confirming the origin of peritoneal metastases from the lung cancer. He was followed by medical oncologists and, due to his poor general condition, he underwent a second-line adjuvant chemotherapy with gemcitabine only (1000 mg/m2). He was disease free for 2 years. Subsequently, brain metastases occurred and in February 2014 he died (Table 1).