Small Bowel Perforation Caused by Metastasis from an Extra-Abdominal Malignancy: Report of Three Cases

Abstract

Small bowel perforation is rarely caused by metastasis from an extra-abdominal malignancy. This report describes three cases of small bowel perforation that occurred secondary to a metastatic tumor. The first case involved a 72-year-old man with malignant lymphoma of the larynx that had been treated with chemo- and radiation therapy; the second involved a 70-year-old man with rhabdomyosarcoma of the mediastinum that had been treated with radiation therapy; and the third involved a 41-year-old man with lung carcinoma that had been treated with surgery 10 months prior to perforation. Each patient presented with acute abdominal pain, had X-ray findings of free air in the abdomen, and underwent limited emergency surgery. Wedge resection and closure of the ileum was performed for the first patient and partial bowel resection with the creation of an intestinal stoma was performed for the second and third patients. In each case, the histologic findings of the resected specimens were consistent with the extra-abdominal primary tumors. Although the patients recovered sufficiently to begin eating and moving about, all three died of cancer or cancer-related complications within 45 days of surgery. We conclude that surgeons should be aware of the poor prognosis of such patients and perform only the minimal surgery required.

Spontaneous free perforation of the small intestine in adults

“…A further study of lymphoma in Chinese from Beijing revealed primary intestinal T-cell and NK-cell lymphomas were heterogeneous but not usually associated with celiac disease [72] . Instead, most were NK-cell type with a poor prognosis showing molecular evidence for a prior Epstein-Barr virus infection [73] . The small intestine may also perforate due to involvement with a secondary rather than primary malignancy, or metastatic disease, usually from an extra-abdominal site, including lymphoma [74] .…”

“…Often, metastatic tumors in the ileocecal region appear to have been developed through a hematogenous route from the primary lesion [75] . Other extra-intestinal causes of metastatic disease causing small intestinal perforation recently noted include rhabdomyosarcoma [73] , squamous cell carcinoma from the tongue [75] , breast carcinoma [76] , lung cancer [73] and pleural mesothelioma [77] . Cutaneous malignant melanoma has also been reported to cause intestinal perforation, even after years of apparently tumor-free follow-up [78] .…”

Small Bowel Perforation Secondary to Metastatic Lung Cancer: A Case Report with Literature Review

“…Several mechanisms of small bowel perforation secondary to lung cancer have been hypothesized in the literature. The majority of the authors have suggested an increase risk of perforation following treatment with chemotherapy, radiotherapy or combination radiochemotherapy [12][13][14][15]. In addition, increased intraluminal pressure secondary to mechanical obstruction, metastatic tumor emboli leading to bowel ischemia, and steroids may increase the risk of bowel perforation [15][16][17].…”

Small Intestinal Metastasis from Small Cell Lung Cancer

“…In contrast, squamous cell carcinoma was the most frequent histological type in other reported series (4,5). (3,5,8); all of these are serious and require emergency surgery (10)(11)(12)(13)(14) (15,16). Small bowel follow-through may show a mass lesion, mucosal defect, or intussusception, but it is often unremarkable, and has a sensitivity of 33% for detection of malignant small intestinal tumors (16).…”

“…The most common metastases to invade the small intestine are of gastrointestinal or gynecologic origin, such as those arising from the colon, uterine cervix, or ovaries (4). Small intestinal metastases from extra-abdominal malignancies have been previously reported mainly in cases of melanoma (6,7) and lung cancer (3,4,(8)(9)(10) (4,5,11). Antler et al (11) reported that large cell and small cell carcinoma lead to gastrointestinal metastases more often than other histological types.…”