Metastatic involvement of the stomach secondary to lung carcinoma

Small cell lung carcinoma metastatic to the stomach: Commonly overlooked, limited treatment options

Small cell lung carcinoma metastatic to the stomach, whether synchronous or metachronous, is a rare phenomenon accounting for < 0.5% of lung cancers. Hence it can be overlooked by clinicians resulting in delayed diagnosis. This manuscript comments on Yang et al's article which reported 3 such cases. The main diagnostic features are based on routine morphology comprised of small cells with hyperchromatic nuclei, scant cytoplasm, brisk mitoses and necrosis. This can be supplemented by immunohistochemistry demonstrating positivity for cytokeratin, thyroid transcription factor-1 and neuroendocrine markers as well as a high Ki-67 labelling index. Imaging modalities such as positron emission tomography/contrast computed tomography help to confirm lung origin and rule out the possibility of extra-pulmonary small cell carcinoma. The predominant mechanism of spread is most likely hematogeneous. Prognosis is generally poor since this represents stage 4 disease but survival can be improved by chemo/radiotherapy and palliative surgery in select cases. Though outcomes have not changed much in the last several decades, the recent Food and Drug Administration approval of immune checkpoint inhibitors was a significant milestone as was the delineation of small cell lung carcinoma molecular subtypes. Liquid biopsies are increasingly being used for biomarker studies in clinical trials to assess treatment response and prognosis.

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.

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.

A Rare Presentation of Poorly Differentiated Lung Carcinoma with Duodenal Metastasis and Literature Review

Lung cancer is a common malignancy which is frequently found to metastasize to distant sites including bone, liver, and adrenal glands. There are rare reports of metastases to the gastrointestinal (GI) tract, with the duodenum being the most uncommon. We present a rare case of a poorly differentiated lung carcinoma metastasizing to the duodenum. This case enhances the medical literature as it provides additional distinct features to the clinical and histological presentation of metastatic lung carcinoma to the GI tract. A 61-year-old male with a history of poorly differentiated lung carcinoma presented with worsening dizziness, fatigue, and early satiety. He had extensive workup done in the past for hemoptysis including a computerized tomography scan of the chest which showed a new lobulated, apical lesion and hilar lymphadenopathy. He ultimately had a transthoracic fine-needle aspiration (FNA) of the mass and was later diagnosed with poorly differentiated lung carcinoma. On examination, the patient was noted to be pale, tachycardic, and hypotensive. The patient was noted to have an acute drop in his hemoglobin requiring fluid resuscitation, multiple blood transfusions, and evaluation with an esophagogastroduodenoscopy. He was found to have an oozing ulcer in the third portion of the duodenum whose biopsies showed poorly differentiated carcinoma with areas of neuroendocrine differentiation, similar to his lung biopsy results, which was consistent with metastatic lung carcinoma.

Primary lung squamous cell carcinoma and its association with gastric metastasis: A case report and literature review

Nearly 50% of primary lung carcinoma patients present with distant metastasis at their first visit. However, gastrointestinal tract (GIT) metastasis is an infrequent impediment. Herein, we report a case of progressive dysphagia and epigastralgia as an initial manifestation of recurrence as gastric metastasis of primary lung squamous cell carcinoma (SCC) after curative surgery. A 64-year-old man was diagnosed with primary lung SCC of the right lower lobe, and underwent thoracoscopic lower lobectomy. One year after lobectomy, computed tomography (CT) scan showed a gastric fundal mass located in the gastric cardia which measured 5 cm. Endoscopic biopsies and histopathology subsequently confirmed that tumor was SCC. The patient then underwent proximal gastrectomy with resection of the diaphragmatic crus. Following surgery, histopathological examination revealed gastric metastasis from primary lung SCC. KEY POINTS: Gastric metastasis of primary lung carcinoma is one of the rarest phenomena. Gastrointestinal symptoms should raise suspicion of the presence of advanced metastatic disease with poor prognosis.

Pathological diagnosis and treatment outcome of gastric metastases from small cell lung cancer: A case report

Small cell lung cancer (SCLC) is a type of lung cancer characterized by a rapid disease progression and poor prognosis. Its diagnosis is often accompanied by distant metastasis. A literature review revealed that metastases to the stomach from breast, lung and esophageal cancer are frequently reported. While SCLC is a common pathological subtype of lung cancer, literature on SCLC with gastric metastases is sporadic. The present study reviewed the literature using databases, including PubMed, WanFang Data and China National Knowledge Infrastructure, to analyze the clinicopathological features and outcome of patients with gastric metastases from SCLC. A total of 11 case reports and 6 retrospective studies comprising of 19 cases were compared and analyzed. In addition to the aforementioned studies, a case study describing a patient who survived for 10 months following a diagnosis of SCLC with gastric metastases is presented. The aim of the present study was to increase the understanding regarding the diagnosis and treatment of SCLC gastric metastasis.

Gastric metastasis from small cell lung cancer: A case report

Small cell lung cancer (SCLC) represents a group of highly malignant tumors that give rise to early and widespread metastases at the time of diagnosis. The preferential metastatic sites are the brain, liver, adrenal glands, bone, and bone marrow. However, metastases of the gastrointestinal system, especially the stomach, are rare; most cases of stomach metastasis are asymptomatic and, as a result, are usually only discovered at autopsy. We report a case of gastric metastasis originating from SCLC. The patient was a 66-year-old man admitted to our hospital due to abdominal pain. He underwent gastroscopy, with the pathological report of the tissue biopsy proving it to be a small cell cancer. Immunohistochemistry was positive for CD56, synaptophysin, and pan-cytokeratin. These results confirmed the diagnosis of gastric metastasis of a neuroendocrine small cell carcinoma from the lung.

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.

[Adenocarcinoma of lung cancer with solitary metastasis to the stomach]

Although hematogenous metastasis of cancer to the gastrointestinal track is rare, it sometime has been reported in patients with malignant melanoma and breast cancer. However, it is extremely rare for lung cancer to metastasize to the stomach, not to mention solitary gastric metastasis. Herein, the authors report a case of a 69-year-old man who was initially diagnosed with lung cancer with synchronous primary gastric cancer which proved to be lung cancer with solitary gastric metastasis after the operation.

Gastric and duodenal squamous cell carcinoma: metastatic or primary?

Either metastatic or primary squamous cell carcinoma in the gastrointestinal tract is extremely rare, with very few cases reported in the literature. In this paper, we report a case in which the patient presented with dysphagia during the course of radiotherapy for recurrent lung cancer in a mediastinal lymph node. Although the dysphagia mimicked radiation esophagitis, the ultimate cause proved to be gastric and duodenal metastases from primary lung squamous cell carcinoma. Taking into account the value of identification of metastatic or primary SCC in the stomach and duodenum on the prognosis and treatment options, it is imperative that the correct diagnosis be established. This report is followed by a discussion of the differential diagnosis between metastatic and primary squamous cell carcinoma in the stomach and duodenum.

Uncommon mucosal metastases to the stomach

BACKGROUND

Metastases to the stomach from an extra-gastric neoplasm are an unusual event, identified in less than 2% of cancer patients at autopsy. The stomach may be involved by hematogenous spread from a distant primary (most commonly breast, melanoma or lung), or by contiguous spread from an adjacent malignancy, such as the pancreas, esophagus and gallbladder. These latter sites may also involve the stomach via lymphatic or haematogenous spread. We present three cases of secondary gastric malignancy.

METHODS/RESULTS

The first is a 19-year-old male who received a diagnosis of testicular choriocarcinoma in September 2004. Metastatic malignancy was demonstrated in the stomach after partial gastrectomy was performed to control gastric hemorrhage. The second is a 75-year-old male, generally well, who was diagnosed with adenocarcinoma of the lung in September 2005. Poorly differentiated adenocarcinoma of the lung was demonstrated in a subsequent biopsy of "gastric polyps". The third is an 85-year-old man with no known history of malignancy who presented for evaluation of iron deficiency anemia by endoscopy in February 2006. Biopsies of the colonic and gastric mucosa demonstrated moderately differentiated invasive colonic adenocarcinoma with metastatic deposits in the stomach.

CONCLUSION

While the accurate recognition of these lesions at endoscopy is fraught with difficulty, pathological awareness of such uncommon metastases in the gastric mucosa is essential for accurate diagnosis and optimal patient management.

Primary lung cancer presenting with gastrointestinal tract involvement: clinicopathologic and immunohistochemical features in a series of 18 consecutive cases

BACKGROUND

Lung cancer initially manifesting as gastrointestinal (GI)-tract metastasis is exceedingly rare, representing a diagnostic challenge and a late-stage disease sign. The clinicopathologic characteristics of the largest series of lung carcinomas initially presenting with GI involvement were described, focusing on differential diagnosis and therapeutic options.

METHODS

Eighteen consecutive cases of lung cancer (11 surgical specimens and 7 biopsies) initially diagnosed on GI histologic samples were identified during routine pathologist practice. All cases were immunostained with thyroid transcription factor-1 (TTF-1), caudal-related homeobox 2 (CDX2), and cytokeratins 7 (CK7) and 20 (CK20). Clinical and radiological data were obtained in all cases.

RESULTS

There were 10 women and 8 men with a mean age of 68.5 years. The small bowel was the most common GI involved site (12 cases), followed by the stomach (four) and large intestine (two). Only half of cases were correctly diagnosed on GI biopsies. Fourteen patients died shortly from disease (mean follow-up, 3 months); two are still alive with multiple metastases, and two patients with the GI tract as the unique site of metastasis underwent pulmonary lobectomy and chemotherapy and are alive without evidence of disease. At morphology, there were 10 large cell undifferentiated carcinomas and eight adenocarcinomas. All cases were immunostained for CK7 and 89% for TTF-1, whereas CK20 and CDX2 were completely negative.

CONCLUSION

Lung cancer presenting as GI-tract metastasis is probably more frequent than expected, and pathologists should always keep in mind this possibility when dealing with undifferentiated GI carcinoma. Immunostaining with TTF-1, CDX2, CK7, and CK20 is helpful in highlighting lung primary. Although GI metastasis from lung cancer is associated with dismal outcomes, pulmonary resection coupled with chemotherapy might represent a therapeutic option in selected patients with a solitary GI-tract metastasis.

Primary lung cancer presenting with gastrointestinal tract involvement: clinicopathologic and immunohistochemical features in a series of 18 consecutive cases

BACKGROUND

Lung cancer initially manifesting as gastrointestinal (GI)-tract metastasis is exceedingly rare, representing a diagnostic challenge and a late-stage disease sign. The clinicopathologic characteristics of the largest series of lung carcinomas initially presenting with GI involvement were described, focusing on differential diagnosis and therapeutic options.

METHODS

Eighteen consecutive cases of lung cancer (11 surgical specimens and 7 biopsies) initially diagnosed on GI histologic samples were identified during routine pathologist practice. All cases were immunostained with thyroid transcription factor-1 (TTF-1), caudal-related homeobox 2 (CDX2), and cytokeratins 7 (CK7) and 20 (CK20). Clinical and radiological data were obtained in all cases.

RESULTS

There were 10 women and 8 men with a mean age of 68.5 years. The small bowel was the most common GI involved site (12 cases), followed by the stomach (four) and large intestine (two). Only half of cases were correctly diagnosed on GI biopsies. Fourteen patients died shortly from disease (mean follow-up, 3 months); two are still alive with multiple metastases, and two patients with the GI tract as the unique site of metastasis underwent pulmonary lobectomy and chemotherapy and are alive without evidence of disease. At morphology, there were 10 large cell undifferentiated carcinomas and eight adenocarcinomas. All cases were immunostained for CK7 and 89% for TTF-1, whereas CK20 and CDX2 were completely negative.

CONCLUSION

Lung cancer presenting as GI-tract metastasis is probably more frequent than expected, and pathologists should always keep in mind this possibility when dealing with undifferentiated GI carcinoma. Immunostaining with TTF-1, CDX2, CK7, and CK20 is helpful in highlighting lung primary. Although GI metastasis from lung cancer is associated with dismal outcomes, pulmonary resection coupled with chemotherapy might represent a therapeutic option in selected patients with a solitary GI-tract metastasis.

Acute upper gastrointestinal bleeding due to metastatic lung cancer: an unusual case

There have been several published reports on metastatic lesions in the stomach, but the number of cases have been limited due to the low frequency of the condition. Metastatic lesions in the stomach are usually asymptomatic. A 55-year-old man with known metastatic lung adenocancer exhibited epigastric pain, hematemesis, and melena. A bleeding, ulcerated gastric metastasis was found and treated with endoscopic therapy and omeprazole.

Percutaneous endoscopic gastrostomy associated gastric metastasis

An interesting case of gastric metastasis of head and neck cancer after percutaneous endoscopic gastrostomy (PEG) placement is presented. Gastric metastases may appear in 3 morphologic varieties endoscopically. They may be multiple nodules of varying size, submucosal tumor masses with tip ulceration, or nonulcerated masses. Histologically, they may be seen as microscopic infiltration, a gross nodule, gross ulceration, or a gross hypertrophied wall. A case of PEG associated gastric metastasis has been reported almost every year since 1989. Even then, PEG placement by pull method continues to be a common procedure for patients diagnosed with head and neck cancer. The mechanism of gastric metastasis in patients with PEG is unclear. Seeding as well as hematogenous and lymphatic spread to traumatized tissue may be the cause.