Long-term survival in two cases of resected gastric metastasis of pulmonary pleomorphic carcinoma. J Thorac Oncol. 2008;3:796-799. [PMID: 18594328 DOI: 10.1097/jto.0b013e31817c925c]

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.

A rare case of gastric metastasis originating from primary lung adenocarcinoma: a case report

Unlike liver and lung, the stomach is rarely a metastatic location for cancers. We report a case of a 62-year-old man known to have lung adenocarcinoma poorly differentiated presented with melena 1 month after diagnosis. Upper endoscopy revealed an ulcerated tumor in the prepyloric antrum. The diagnosis of gastric metastasis from pulmonary cancer was confirmed by the immunohistochemical staining for the thyroid transcriptional factor-1 and the pattern cytokeratine CK7+/CK20-. In conclusion, gastric metastasis from primary lung cancer is a rare phenomenon that every clinician must keep in mind.

[Duodenal bleeding due to metastasis from lung adenocarcinoma controlled by radiotherapy: A case report and literature review]

INTRODUCTION

Gastrointestinal (GI) metastases in lung cancer rarely occur.

CASE REPORT

We report here the case of a 43-year-old male active smoker who was admitted to our hospital for cough, abdominal pain and melena. Initial investigations revealed poorly differentiated adenocarcinoma of the superior-right lobe of the lung: positive for thyroid transcription factor-1 and negative for protein p40 and for antigen CD56, with peritoneal, adrenal and cerebral metastasis, as well as anemia requiring major transfusion support. Over 50% of cells were positive for PDL-1, and ALK gene rearrangement was detected. GI endoscopy showed a large ulcerated nodular lesion of the genu superius with active intermittent bleeding, as well as an undifferentiated carcinoma with positivity for CK AE1/AE3 and TTF-1, and negativity for CD117, corresponding to metastatic invasion originating from lung carcinoma. Palliative immunotherapy with pembrolizumab was proposed, followed by targeted therapy with brigatinib. Gastrointestinal bleeding was controlled with a single 8Gy dose of haemostatic radiotherapy.

CONCLUSION

GI metastases are rare in lung cancer and present nonspecific symptoms and signs but no characteristic endoscopic features. GI bleeding is a common revelatory complication. Pathological and immunohistological findings are critical to diagnosis. Local treatment is usually guided by the occurrence of complications. In addition to surgery and systemic therapies, palliative radiotherapy may contribute to bleeding control. However, it must be used cautiously, given a present-day lack of evidence and the pronounced radiosensitivity of certain gastrointestinal tract segments.

Gastric Metastasis of Primary Lung Cancer: Case Report and Systematic Review With Pooled Analysis

Background

Gastric metastasis from lung cancer (GMLC) is a rare occurrence. The clinicopathological characteristics, outcomes, and prognostic factors remain largely elusive.

Methods

We conducted a systematic review on case reports and case series of GMLC by scanning MEDLINE, Embase, and ISI Web of Knowledge. Data involving the clinicopathological features, treatment, and outcomes were extracted and analyzed. Survival analysis was performed using Kaplan–Meier method. The Cox proportional hazards regression model was used to identify potential prognostic factors associated with survival. Furthermore, a case of metastatic gastric adenocarcinoma of pulmonary origin with epidermal growth factor receptor (EGFR) L858R+T790M mutation was also described and included.

Results

Seventy-eight records involving 114 cases (including ours) were finally included. The median age on admission was 65 years with a male predominance of 79.8%. Lung adenocarcinoma (42.1%), located in the right upper lobe (30.3%), was the most frequent primary tumor. Bleeding (36.7%) and abdominal pain (35.8%) were the two most common symptoms. Endoscopically, gastric lesions were typically presented as elevated lesions with or without volcano-like ulceration, or ulcerative lesions, mostly involving the gastric corpus. The median overall survival time and survival time after diagnosis of metastatic cancer were 11 months [95% confidence interval (CI): 7–14] and 4.5 months (95% CI: 3–9), respectively. The survival analyses revealed that surgical interventions (including lung surgery and/or abdominal surgery) and systemic therapy (including chemotherapy, radiotherapy, and/or targeted therapy) seemed to be positive prognostic factors for both overall survival and survival after diagnosis of metastatic cancer.

Conclusions

Clinicians should be alerted to the occurrence of gastric metastasis in lung cancer patients. Comprehensive evaluation and appropriate treatment for specific patients may improve the survival rate of GMLC patients.

Pulmonary Pleomorphic Carcinoma Mimicking Primary Sarcoma of the Neck: A Case Report and Literature Review

We describe our challenge in diagnosing an unusual and rapidly progressing case of pulmonary pleomorphic carcinoma (PPC)—a rare, poorly differentiated, or undifferentiated non-small-cell carcinoma that can metastasize locally or distantly and has a poor prognosis. Our patient was an elderly man with a one-month history of abdominal pain, anorexia, and weight loss, diagnosed with atrophic gastritis via endoscopy, and treated medically without improvement. A week later, this patient developed pain in the head, neck, and shoulder area, and further examination revealed a thickening of his left neck and shoulder, with no palpable lymph nodes. Computed tomography (CT) of the neck, chest, and abdomen led us to believe that we might be dealing with primary sarcoma of the neck since no lung mass was evident. Further investigation could not be performed because the patient’s status deteriorated rapidly. An autopsy revealed that soft tissue in the left neck and the mesentery was invaded by poorly differentiated polymorphic malignant cells, which were also seen in the lung lesion. Immunohistochemically, these malignant cells were all positive for AE1/AE3, CAM5.2, TTF-1, Napsin-A, and Vimentin. The cells were also positive for programmed death-ligand 1 staining with a low level of tumor proportion score (over 1%). The final diagnosis was PPC with metastases to soft tissues in the left neck and the mesentery. A review of previous case reports of PPC revealed that soft tissue is an uncommon site for metastasis, and that our CT findings were rather unusual. We hereby present our case and review of published case reports, with the hope that an awareness of the heterogeneous features of PPC could prompt timely biopsy and histological diagnosis.

Resected case of stage IV pleomorphic carcinoma of the lung with long-term survival

Background

No established treatments for pulmonary pleomorphic carcinoma exist because of its rarity, and the prognosis is poorer than that of other non-small cell lung cancers.

Case report

We present a case of stage IV pleomorphic carcinoma; the patient was a 66-year-old male. He was referred to our hospital because of a right adrenal hemorrhage and a lung tumor. A systemic examination revealed that the lung tumor was a primary lung cancer and that the adrenal hemorrhage was due to a metastatic cancer. We performed an adrenalectomy and resection of the lung tumor and obtained a diagnosis of pleomorphic carcinoma with adrenal metastasis. The patient has remained recurrence-free for 6 years since the surgery.

Conclusions

We report a patient with stage IV pleomorphic carcinoma of the lung and an oligometastasis in whom a complete resection enabled a good outcome. Additional reports are needed to clarify definite prognostic factors and the optimal treatment for pleomorphic carcinoma.

A case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment

Background

Generally, primary pulmonary pleomorphic carcinoma is resistant to treatment and has a poor prognosis. We report a case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment.

Case presentation

A 74-year-old man with a history of emphysema, pneumoconiosis, and chronic bronchitis presented with left lung nodule and left adrenal tumor based on computed tomography. We suspected clinical T1bN0M1b, stage IVB lung cancer. Adrenalectomy of the left adrenal tumor yielded a definitive diagnosis of pleomorphic carcinoma. Chemotherapy was performed despite the spontaneous regression of lung lesions. Since lung lesions re-enlarged 11 months after adrenalectomy, the left lower lobe was partially resected followed by chemotherapy. The lung lesion was the primary lesion of the adrenal tumor. There was no recurrence 100 months after the lung resection.

Conclusions

The patient experienced long-term survival after multidisciplinary treatment. Both multidisciplinary treatment and immunological mechanisms caused spontaneous regression of the primary lesion.

Approaches to Tumor Classification in Pulmonary Sarcomatoid Carcinoma

Pulmonary sarcomatoid carcinoma (PSC) is a heterogeneous category of primary lung cancer accounting from 0.3% to 3% of all primary lung malignancies. According to the most recent 2015 World Health Organization (WHO) classification, PSC includes several different variants of malignant epithelial tumors (carcinomas) histologically mimicking sarcomas showing or entirely lacking a conventional component of non-small cell lung cancer (NSCLC). Thus, this rare subheading of lung neoplasms includes pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, pulmonary blastoma, and carcinosarcoma. A diagnosis of PSC may be suspected on small biopsy or cytology, but commonly requires a surgical resection to reach a conclusive definition. The majority of patients with PSC consists of elderly, smoking men with a large, peripheral mass characterized by well-defined margins. However, presentation with a central, polypoid endobronchial lesion is well-documented, particularly in pleomorphic carcinoma and carcinosarcoma showing a squamous cell carcinoma component. As expected, PSC may pose diagnostic problems and immunohistochemistry is largely used when pathologists deal these tumors in routine practice. Indeed, PSC tends to overexpress molecules associated with the epithelial-to-mesenchymal transition, such as vimentin, but the panel of immunostains also includes epithelial markers (cytokeratins, EMA), TTF-1, p40 and negative markers (e.g., melanocytic, mesothelial and sarcoma-related primary antibodies). Although rare, PSC has increased their interest among oncologist community for different reasons: a. identification of the epithelial-to-mesenchymal phenomenon as a major mechanism of secondary resistance to tyrosine kinase inhibitors; b. over-expression of PD-L1 and effective treatment with immunotherapy; c. identification of c-MET exon 14 skipping mutation representing an effective target to crizotinib and other specific inhibitors. In this review, the feasibility of the diagnosis of PSC, its differential diagnosis and novel molecular findings characterizing this group of lung tumor are discussed.

Gastrointestinal metastasis of primary lung cancer: An analysis of 366 cases

The gastrointestinal (GI) tract is not a common site of metastasis in primary lung cancer. The aim of the present study was to reveal the clinical and prognostic characteristics of gastrointestinal metastases of lung cancer (GMLC). Information on 366 cases of GMLC was collected and factors that affect severe GI complications were analyzed. Univariate and multivariate survival analyses were performed using the Cox proportional hazards model. Of the cases analyzed, the small intestine (59.6%) and colorectum (25.6%) were the two organs where lung cancer was most likely to metastasize in the GI tract. Squamous cell carcinoma (28.5%), adenocarcinoma (27.6%) and large cell carcinoma (20.9%) were the three most common histological types. However, compared with the histological distributions of primary lung cancer, patients with large cell carcinoma exhibited the highest elevated risk of GMLC [relative risk (RR), 4.07; P<0.001] and those with adenocarcinoma exhibited the lowest risk (RR, 0.58; P<0.001). Differences in organ involvement and in histological type led to varying GI complications. It was also indicated that chemotherapy was associated with a decreased risk of hemorrhage (P=0.006), but there was no reduction in the risk of hemorrhage associated with perforation and obstruction (P>0.05). The median overall survival time of GMLC patients was 2.8 months (range, 0–108 months). The survival analyses revealed that perforation and extra-GI metastasis were negative prognostic factors but abdominal surgery was identified a positive prognostic factor. In conclusion, the histological distribution of GMLC differed from that of primary lung cancer. Sufficient and careful patient evaluation, targeted surgeries and systemic therapies for specific patients are able to increase patient survival rate and improve the quality of life.

A rare case of advanced lung cancer presenting as a symptomatic gastric tumor

Although gastric metastases have been estimated to occur in less than 2% of cancer patients, an increased use of upper digestive tract endoscopy allows for a higher detection of secondary gastric tumors. We describe the case of a 66-year-old male patient presenting with mild pain in the sternum and upper abdominal area. Physical examination revealed a right parietal skull tumor, with no other significant clinical changes. Upon exclusion of an acute coronary syndrome, upper digestive tract endoscopy was performed, showing the presence of an ulcerated tumor located in the gastric fundus. Histopathologic examination of the biopsy sample and immunohistochemical tests suggested a pulmonary origin of the gastric tumor. Whole body computer tomography showed the presence of tumors in the gastric fundus, left lung, liver, kidneys, bones and brain. Transbronchial biopsy of the lung tumor certified the diagnosis of non-small cell lung cancer, with the same immunohistochemical profile as the gastric tumor. Hence, it was considered the origin of the metastases. Biopsy of the skull tumor also had the identical tumor histology. Whole brain radiotherapy was performed for the brain metastases and subsequent chemotherapy was administered. Although non-specific, gastrointestinal signs and symptoms occurring in lung cancer patients should alert the clinicians as to the possibility of gastrointestinal metastases and prompt endoscopic evaluation.

Pleomorphic carcinoma of the lung mimicking synchronous pulmonary adenocarcinoma and small bowel sarcoma

Pulmonary pleomorphic carcinoma is defined as a nonsmall cell lung carcinoma (NSCLC) that contains at least 10% sarcomatoid components. We report a case of pulmonary pleomorphic carcinoma of which only the sarcomatoid component metastasized to the small bowel and adenocarcinoma was identified on percutaneous transthoracic needle biopsy (PTNB). We suggest that if an NSCLC is diagnosed by PTNB and a sarcoma is found at another site, or vice versa, pulmonary pleomorphic carcinoma with a single metastasis should be considered as a differential diagnosis to establish the best effective treatment plan.

Squamous cell lung carcinoma presenting as melena: a case report and review of the literature

Lung cancer has a predilection to widely metastasize to the liver, bone, brain and adrenal glands. Metastasis of primary lung tumors to the stomach is infrequent, with only sporadic cases reported. Most cases are asymptomatic and diagnosed post-mortem on autopsy. The incidence of symptomatic gastrointestinal metastases is extremely rare. Herein, we describe a case of gastric metastasis by squamous cell lung carcinoma, presenting as melena and diagnosed by esophagogastroduodenoscopy. To the best of our knowledge, only twenty other cases in the English literature have reported symptomatic gastric metastasis of lung cancer diagnosed by endoscopic biopsy. A brief review of the literature shows gastric metastasis of lung cancer to have a predilection to occur most frequently in male smokers with the most common type of tumor likely to be squamous cell carcinoma.

Stage IV pleomorphic carcinoma of the lung without recurrence for 6 years: a case report

Background

Pleomorphic carcinoma is a rare primary lung carcinoma that occurs at a rate of about 0.3%. Even with complete resection, the tumor usually recurs aggressively, resulting in a poor prognosis. Herein, we report a case of advanced pleomorphic carcinoma of the lung who had a long survival time after resection of the primary and metastatic sites.

Case presentation

A 48-year-old man was admitted to our hospital due to abdominal pain. Systemic examination revealed a lung mass on the right and a tumor in the jejunum. Surgical resection of both tumors revealed pleomorphic carcinoma of the lung with metastasis to the jejunum. Follow-up after 6 years showed that the patient remained recurrence-free, without the need for additional postoperative treatment.

Conclusions

A vigorous treatment strategy that included surgery had the potential to offer long-term survival, despite an advanced pleomorphic carcinoma with distant metastasis to other organs. Reports on more similar cases are needed to evaluate the value of this treatment option.

Targeted therapy of multiple liver metastases after resected solitary gastric metastasis and primary pulmonary adenocarcinoma

Gastric metastases from lung adenocarcinoma are rare and usually asymptomatic. A 61-year-old woman was referred to our department because of a right lower pulmonary mass found on a chest X-ray film in August 2012. Right lower lobectomy was performed for pulmonary adenocarcinoma. Four months later, she developed epigastric discomfort. A fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) scan showed a malignancy at the cardias of the stomach. A biopsy diagnosed poorly differentiated carcinoma and a gastric carcinoma was suspected. She underwent a subtotal gastrectomy and part of esophagectomy. The histologic diagnosis was metastasis from the pulmonary adenocarcinoma. She visited us again for her increasing level of carcinoembryonic antigen (CEA) after two months. FDG-PET/CT showed multiple malignant lesions in her liver, considering metastases from pulmonary origin. As she harbored activating epidermal growth factor receptor (EGFR) mutation, she received erlotinib from April, 2013. She survives 4 years after the lung resection and is still on erotinib treatment with complete response. Although gastric metastasis from lung cancer is considered a late stage of the disease, a radical resection might provide survival in solitary metastasis. Moreover, systemic therapy was emphasized after local treatment in some late stage cases.

Surgical resection of solitary omental metastasis from non-small cell lung cancer: Report of three cases

In the present study we report three cases of solitary omental metastasis from non-small cell lung cancer, which had been surgically resected at our institute. The primary site was resected in one patient (case 1) and the other two patients were treated with chemotherapy and demonstrated complete response (cases 2 and 3). The omental metastasis appeared 4 months after pneumonectomy in case 1. Two metachronous omental tumors appeared 55 and 79 months after the initial chemotherapy in case 2. In Case 3, an omental tumor appeared 6 months after chemotherapy. Case 1 succumbed to recurrence 8 months after the resection of the omental tumor. Case 2 survives with recurrent disease 8 months after resection of the second omental metastasis, and case 3 survives 6 months after resection of the omental tumor. Although omental metastasis from non-small cell lung cancer is extremely rare, it should be considered when a patient with history of lung cancer has a tumor around the stomach.

Clinicopathological features and outcome of gastric metastases from primary lung cancer: A case report and systematic review

Primary lung cancer is the fourth most frequently diagnosed cancer, but gastric metastasis from lung cancer is extremely rare. Little is known about its clinicopathological features, prognosis and optimal treatment strategy. The present study reports a case of primary lung cancer that metastasized to the stomach and to the best of our knowledge, is the first to identify discordance in epidermal growth factor receptor (EGFR) mutation status between the primary tumor and gastric metastasis. The study also systematically searched the Medline database for similar cases to provide a literature review. Data concerning the clinicopathological features, treatment strategies and outcomes were extracted and analyzed. In total, 22 eligible cases were identified from 16 studies. The average age at presentation was 67.3 years and there was a male predominance of 90.9%. Epigastric pain (45.5%) was the most common chief complaint, followed by melena (22.7%), nausea/vomiting (13.6%) and hematemesis (9.1%). Three patients were asymptomatic. Five patients sought the initial consultation for gastrointestinal symptoms. The median time between the primary lung cancer diagnosis and the confirmation of gastric metastasis was five months. Endoscopically, gastric lesions were described as polypoid masses or volcano-like ulcers, mostly involving the gastric corpus, which were identified in 62.5% of the 16 cases in which information regarding the site of metastasis was available. Gastric metastases were reported from adenocarcinoma, squamous cell carcinoma, small cell lung cancer and pleomorphic carcinoma of the lung. The median survival following comprehensive treatment strategies was four months, and the one-year post-metastasis survival rate was 35.3%. In conclusion, although primary lung cancer metastasis to the stomach is rare, clinicians should be aware of the possibility of its occurrence. Comprehensive and personalized treatment may be beneficial to patients. EGFR tyrosine-kinase inhibitor therapy may be the treatment of choice for non-small cell lung carcinoma patients harboring an activating EGFR mutation in the metastatic lesion.

Gastric metastasis of lung cancer mimicking an adrenal tumor

Lung cancer is one of the leading causes of cancer deaths worldwide. Metastatic spreads of lung cancer are often found in the adrenal glands, bone, liver, brain and kidneys; the gastrointestinal tract is less commonly involved. However, according to some reports in the literature, the incidence of gastrointestinal metastases, most of them asymptomatic, might be as frequent as 11% in autopsy studies of lung cancer, which suggests that this condition is not as rare as it was previously considered. We report a very rare case of small cell lung cancer with a solitary gastric metastasis mimicking an adrenal tumor which was belatedly diagnosed due to its unusual presentation and treated actively with surgery and chemotherapy, achieving a relatively favorable outcome.

Pleomorphic carcinoma showing rapid growth, multiple metastases, and intestinal perforation

Pleomorphic carcinoma is a rare and very aggressive subtype of lung cancer that tends to grow rapidly and invade adjacent structures. Here we report a case of pleomorphic carcinoma with rapid growth, multiple metastases, and intestinal perforation. A 46-year-old man was admitted to our hospital because of lung abscess. Several antibiotics were administered for 2 weeks, but his condition did not improve. F18-fluorodeoxyglucose positron emission tomography revealed high uptake in the right lung, stomach, and pancreas. CT-fluoroscopic lung biopsy was performed, and a diagnosis of pleomorphic carcinoma was made. His performance status worsened each day, and the lung tumor grew within 1 month. In addition, sudden severe abdominal pain and tenderness developed 10 days after lung biopsy. He was diagnosed with gastrointestinal perforation, and he underwent surgery. However, he died 2 weeks after the surgery. Autopsy revealed the presence of an enormous tumor in the right lung and multiple metastases in the stomach, duodenum, intestine, bilateral kidneys, pancreas, gallbladder, right adrenal gland and thyroid.

Surgically resected gastric metastasis of pulmonary squamous cell carcinoma

Gastric metastasis of pulmonary carcinoma has been reported to range from 0.19%-5.1%. An autopsy review of cancer disclosed 1.7%-29.6% of gastric metastases, primarily from breast cancer, lung cancer and melanoma. A 71-year-old man was referred to our department because of persistent cough, sputum and sweating for 20 d. Chest posteroanterior view and chest computed tomography scan demonstrated an irregular tumor mass measuring 5.8 cm with central necrosis at the right lower lung. Bronchoscopic biopsy revealed pulmonary squamous carcinoma. Esophagogastroduodenoscopy revealed a huge bleeding ulcer at the body of the stomach and a biopsy diagnosed a metastatic lesion. We performed a palliative total gastrectomy, splenectomy and distal pancreatectomy. The patient did not receive any adjuvant chemotherapy due to his refusal. He was controlled conservatively and survived for 11 mo after surgery. Surgical resection may provide an option for safe palliative treatment. Although gastric metastasis from lung cancer is associated with dismal outcomes, a longer survival or more favorable outcome has been demonstrated in patients undergoing palliative surgical resection of the metastatic site. Considerable improvements in the understanding of metastatic diseases and therapeutic strategies are needed to improve the clinical outcome.

Solitary gastric metastasis from primary lung adenocarcinoma: a rare site of extra-thoracic metastatic disease

Lung cancer metastasizing to gastrointestinal (GI)-tract is a rare event. Gastric metastasis is usually asymptomatic but when mucosal in location it may cause symptoms as demonstrated in the current case. This report describes a 60-year old male who was admitted for evaluation of a left upper lobe lung mass with associated bilateral nodular opacities and mediastinal lymphadenopathy. After thorough work-up the diagnosis of advanced lung adenocarcinoma was made. During hospitalization period and prior to starting chemotherapy, he exhibited upper gastrointentinal bleeding. Esophagogastroduodenoscopy revealed an ulcerative lesion in the gastric corpus representing metastasis of the primary lung carcinoma that ensued from immunohistochemical analysis. Clinical, pathological and therapeutic aspects of this uncommon site of extrathoracic metastatic disease are discussed, emphasizing the importance of the immunohistochemistry in the differential diagnosis of lung carcinomas whether primary or secondary to the lung.

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma: Report of a case

INTRODUCTION

Gastric metastases from lung adenocarcinoma are rare and usually associated with disseminated disease. The great majority is asymptomatic and in few cases discovered during autopsy studies. Reports of single metachronous metastases during the lifetime are anecdotal. We describe a case of solitary gastric metastasis 5 years after lung surgery.

PRESENTATION OF CASE

A 68-year-old male submitted in 2006 to right lobectomy for lung adenocarcinoma was referred at Emergency Room department in 01/2011 because of chronic epigastric pain. Radiologic and endoscopic evaluation showed a bulky lesion inside the stomach, originating from the muscular layer, suspected for GIST. He underwent a subtotal gastrectomy and the pathologic examination revealed an undifferentiated adenocarcinoma, positive for Thyroid Transcriptional Factor-1, Cytokeratin 7, AE 1/3 and CEA, confirming the pulmonary origin.

DISCUSSION

At the time of diagnosis about 50% of lung cancer are metastatic, with survival rates of 1% at 5-year. Gastric metastasis is very rare; autopsy studies report an incidence of 0.2-0.5%. They develop in the submucosa, usually without any symptom and the diagnosis is incidental during the staging of primary cancer or the follow-up. There are no guidelines about surgical treatment; however few cases of long-term survival following the operation were reported. Pathologic diagnosis is difficult, but the immunohistochemical staining helps to recognize the primary origin.

CONCLUSION

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma is an exceptional event, but it could happen during the follow-up. It seems that a radical resection, in absence of systemic implants, might provide survival benefits in selected patients.

Metastatectomy for extra-cranial extra-adrenal non-small cell lung cancer solitary metastases: systematic review and analysis of reported cases

BACKGROUND

Although patients with stage IV non-small cell lung cancer (NSCLC) have a poor prognosis, a subset of patients with solitary brain or adrenal metastasis have more favorable outcome following surgical resection. Nevertheless, the outcome and predictive factors for survival following metastatectomy for patients with other metastatic sites are not well defined.

METHODS

We performed a systematic review using PUBMED database for all articles which included patients with NSCLC and solitary metastasis to sites other than the adrenal gland or the brain who had undergone resection of their metastasis and definitive treatment of the primary lung cancer. Potential prognostic factors on survival including age, sex, histology, T and N stage of the primary tumor, synchronous vs. metachronous presentation, visceral vs. non-visceral metastasis and the use of perioperative chemotherapy were analyzed using multi-variable Cox proportional hazard model.

RESULTS

62 cases were eligible for the analysis. The 5-year survival rate was 50% for the entire cohort. Mediastinal lymph node involvement was independently predictive of inferior outcome; 5-year survival rate 0% vs. 64% in favor of no involvement, p<0.001. Similarly, patients with intra-thoracic stage III disease had an inferior outcome compared to patients with stage II and stage I disease: 5-year survival rate 0% vs. 77% and 63%, respectively, p<0.001. Other factors have no effect on outcome.

CONCLUSION

Selected patients with distant metastatic NSCLC can achieve long term survival following metastatectomy and definitive treatment of the primary tumor. Mediastinal lymph node involvement is associated with poor prognosis.

Review article: pulmonary sarcomatoid carcinomas: a practical overview

Pulmonary sarcomatoid carcinomas (PSCs) are currently defined as poorly differentiated non-small-cell carcinomas containing a component with sarcoma or sarcoma-like (spindle and/or giant cell) features. They consist of 5 major histological variants, namely pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. The segregation of PSCs into a distinct clinicopathologic entity seems justified on the basis of morphologic, behavioral, and genotypic/phenotypic attributes. As a group, PSCs generally run an aggressive clinical course and may cause major difficulties in the differential diagnosis with other primary and secondary malignancies of the lung. At present, PSCs are believed to represent a family of carcinomas "in transition," in which diverse pathways of clonal evolution account for histological differences of a common ancestor lesion. The sarcomatous or sarcomatoid component of these tumors is thought to derive from carcinoma cells during the progression of carcinogenesis through the activation of an epithelial-mesenchymal transition program leading to sarcomatous transformation or metaplasia (conversion paradigm). Conceivably, targeting the epithelial-mesenchymal transition program could become a valid therapeutic strategy for these life-threatening tumors, whose sensitivity to current medical manipulation is disappointing.