|Ahead of print publication
Characteristics of gastrointestinal metastasis in lung cancer: Single-center experience from eastern India
Chaitanya Patil1, Shrikant Atreya2
1 Kolhapur Cancer Center, Kolhapur, Maharashtra, India
2 Department of Palliative Care and Psycho Oncology, Tata Medical Center, Kolkata, West Bengal, India
|Date of Submission||07-May-2020|
|Date of Decision||06-Oct-2020|
|Date of Acceptance||06-Oct-2020|
Tata Medical Center, 14th Main Arterial Road, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Lung cancer is one of the most common cancers associated with a poor prognosis. Gastrointestinal (GI) metastasis among lung cancer patients is often misdiagnosed or missed as a diagnosis. With a paucity of literature on this theme, we conducted a study to understand the clinicopathological characteristics of GI metastasis in lung cancer patients. Materials and Methods: A retrospective review of 793 primary lung cancer patients registered from January 2018 to December 2018 was done at a tertiary cancer hospital. The present study focused on lung cancer patients with an objective to find out the cases of GI metastasis. GI metastasis was confirmed on radiological imaging in the records and positron emission tomography, magnetic resonance imaging, or computed tomography scans. Quantitative variables were either expressed in terms of mean and standard deviation or categorized and expressed in percentages. Pearson's correlation coefficient was used to find the correlation between different symptom clusters in patients with GI metastasis in lung cancer. Results: Of the 793 lung cancer patients, 31 (3.9%) patients had metastasis to the GI tract, with as high as 70.97% (22/31) patients presenting with peritoneal/omental deposits. Of the 31 patients with GI metastasis, five (16.13%) patients were symptomatic, four patients had intestinal obstruction, and one had intestinal perforation. Due to advanced metastatic cancer and poor performance status, patients were provided palliative care and symptom management as they were deemed unfit for surgical intervention. Conclusion: With the advent of targeted and immunological therapies, patients with metastatic lung cancers are surviving longer. Palliative care specialists must work in close collaboration with oncologists to identify an impending GI complication at an early stage to direct specific interventions to avert the complication.
Keywords: Gastrointestinal metastasis, lung cancer, quality of life
|How to cite this URL:|
Patil C, Atreya S. Characteristics of gastrointestinal metastasis in lung cancer: Single-center experience from eastern India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=315790
| Introduction|| |
Lung cancer is one of the most common cancers and often portends a poor prognosis as patients often present in the advanced stage of the disease challenged by limited options for definitive treatment. Patients present in the advanced stage of the disease with bone, brain, liver, pleura, and the contralateral lung being the more common sites for metastases. The incidence of gastrointestinal (GI) metastasis is uncommon and is reported to be as low as 0.3%–1.7% based on clinical studies.,,, Contrary to clinical reporting of data, autopsy studies reveal a much higher proportion of GI metastases (>10%).,, The discrepancy in the clinical and autopsy findings could be attributed to asymptomatic metastasis to the GI tract which often leads to misdiagnosis and missed diagnosis. There are few reports of synchronous or metachronous lung cancer and GI malignancy and may often be difficult to diagnose considering that more than 50% patients with lung cancer present with metastasis.
The advent of newer modalities of treatment and introduction of targeted therapies has increased survival among patients with metastatic lung cancer. However, improved survival in the long run may harbor higher incidences of morbidities due to metastases. There is a paucity of literature on GI metastasis in lung cancer, and very little is known about the pattern of presentation and line of management in conditions with multiple metastatic deposits. In the current study, we reviewed the charts of patients with lung cancer and explored the clinicopathological factors associated with GI metastasis in lung cancer.
| Materials and Methods|| |
The present study was conducted by the Department of Palliative Care and Psycho-Oncology at Tata Medical Center, a tertiary cancer center in Eastern India. A retrospective review of 793 primary lung cancer patients registered from January 2018 to December 2018 was done. The data were extracted from the hospital management information system. We specifically focused on lung cancer patients with an objective to find out the cases of GI metastasis. GI metastasis was confirmed on radiological imaging in the records and positron emission tomography, magnetic resonance imaging, or computed tomography scans.,, For patients with symptomatic GI metastasis (intestinal obstruction, perforation, or bleeding) clinical history, examination supported by imaging studies was recorded.
All the data were entered and compiled in Microsoft Excel. The data were analyzed using Epi Info version 7.2 (Center for Disease Control, Atlanta, USA) and Statistical Package for the Social Sciences (SPSS) software version 20.00 (IBM). The qualitative variables were expressed in terms of percentages. Quantitative variables were either expressed in terms of mean and standard deviation or categorized and expressed in percentages. Pearson's correlation coefficient was used to find the correlation between different symptom clusters in patients. All the analyses were two-tailed, and the significance level was set at 0.05.
The waiver from the Institutional Ethics Committee was obtained for the study (The IRB waiver number is EC/WV/TMC/35/20).
| Results|| |
We included 793 records of primary lung cancer patients in our study [Figure 1].
The mean age of the participants was 62.11 ± 10.58 years with a male: female ratio of 3.45:1 [Table 1].
|Table 1: Demographic characteristics of primary lung cancer patients (n=793)|
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The GI metastasis was present in 3.90% (31/793) patients [Figure 1]. Of the 31 cases with GI metastasis, (5/31) 16.13% were symptomatic. We found four cases with features of intestinal obstruction and one case of perforation.
The mean age of the patients was 59.90 ± 10.54 with male preponderance (78.26%). The most common site of metastasis was the peritoneum (70.97%) followed by the large intestine. The most common histopathological type associated with GI metastasis was adenocarcinoma (58.06%) [Table 2].
|Table 2: Characteristics of patients with gastrointestinal metastasis in lung cancer (n=31)|
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Although a small number but there was definite reduction in survival among patients who were symptomatic. Symptomatic patients survived for an average of 16.6 days. Patients with symptoms had an average of 3.2 visits to the emergency followed by admission before death [Table 3].
|Table 3: Clinicopathological profile of patients with symptomatic gastrointestinal metastasis|
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Respiratory cluster had a moderate negative significant correlation with neuropsychiatric cluster in the present study. Although there was no correlation found between respiratory clusters and GI clusters, patients did have significant burden where they co-existed [Table 4].
| Discussion|| |
With the introduction of newer modalities of treatment and targeted therapies, over all life expectancy of patients with lung cancers has increased. This may have an implication on symptom management and as time progresses; oncologists and palliative care physicians may be faced with the challenges of treating multitude of complex symptoms. GI metastasis in lung cancer, although infrequent, has been reported in case reports and small case series as an incidental finding in lung cancer patients. The definitive treatment for GI metastasis is often challenged by disease progression, complex symptoms affecting quality of life, and limited treatment choices. Suspecting GI pathology in a case of primary lung cancer is often missed or misdiagnosed.,
Our study inferred that GI metastasis was more common among the elderly individuals (average age at manifestation was 60.10 years) with male preponderance. These findings were consistent with studies conducted by Taira et al., Huang et al., and Rossi et al. GLOBOCAN 2018 statistics and Indian Center for Medical Research statistics for lung cancer have reported that the occurrence of lung cancers increases with age and is more common among males., This may explain the reason for higher occurrence of GI metastasis in the elderly lung cancer population. The most common histological type was adenocarcinoma in our patients. Studies have reported equivocal findings on the histological variant in relation to GI metastases.,,, The higher incidence of adenocarcinoma in patients could be attributed to a high prevalence of adenocarcinoma in lung cancer patients as reported by the Indian statistics on lung cancer., About 3.9% of our patients with lung cancer had GI metastasis. Our study has reported a higher incidence of GI metastases as compared to the other studies.,,,,, Among the GI metastatic sites, the common sites of metastasis was the peritoneum (80.43%) followed by the large intestine (10.85%) and small intestine (8.68%), and symptomatic GI metastases were the highest among patients with peritoneal deposits (4/5; 80%). Few authors have reported small intestine to be the common site for metastasis while a few have reported gastric metastasis in their studies.,,,,,,
The clinical presentation varies from ileus, perforation, obstruction, and bleeding through the tumor site. The most common complication in our patients was intestinal obstruction (n = 4; 12.90%) followed by perforation (n = 1;3.2%). The probability and intensity of the complication depend on the incubation period and luminal diameter. Studies with metastasis to the small intestine have reported obstruction and perforation to be the most common complication and in patients with gastric metastasis hemorrhage as a common complication. Four patients from our study had intestinal obstruction, and one patient had perforation. Although a surgical opinion was sought for these patients, they were deemed inoperable in view of poor general health condition. The patients were provided symptom management and approached conservatively. The occurrence of adverse event in GI metastases depends on the luminal diameter and flexibility for the bowel wall. Whereas the tumor in the stomach could have a larger margin of growth wherein as they invade through the bowel wall can penetrate the vasculature leading to hemorrhage, the intestinal lumen has less space to accommodate the growing tumor burden and thus manifest as obstruction or perforation. Treatment-associated complications cannot be overlooked. For example, chemotherapy may also induce necrosis of metastatic tumor and lead to intestinal perforation or bleeding. These extreme complications are usually preceded by a period of nonspecific symptoms (abdominal pain, weight loss, or weakness); the latter may camouflage the clinical manifestations often leading to missed diagnosis. The route of GI spread of lung cancer may be attributed to either hematogenous or lymphatic spread of tumour cells. The cancer cells enter into blood stream and then implant in and gradually replace the bowel wall to cause various complications. However, a study revealed that squamous cell carcinoma has higher predilection for lymphatic invasion resulting in metastasis to serosa and sub mucosa of the intestine.,
Treatment for symptomatic GI metastases is debatable in literatures with ambivalence about the best treatment approach; surgical versus conservative approach. Goh et al. suggested that adequate selection of patients for surgical intervention may help improve the survival outcome and one must account for the extraintestinal metastases, general condition/performance of the patient and complications such as bleeding/perforation which may influence the decision-making process, overall survival and post-surgical recovery. Our study was a retrospective design, wherein we could not capture the quality of life data using a standard scale. However, we looked at certain surrogate factors such as symptom burden, emergency visits, and number of admissions for symptomatic patients as an indirect indicator of quality of life. Often patients with lung cancer have a progressive disease at presentation that compromises the quality of life, perhaps, unaware of the progressing disease. The latter could also be the reason for high symptom burden at presentation to the physician. High symptom burden that include pain, dyspnea, fatigue and symptoms of obstruction as in our study can threaten the quality of life of patients. There is very little known or studied about the psychological and emotional impact of the disease burden but empirical data reveal that patients with lung cancer do suffer from psychological distress. The disease extent can impact the patient's psychological well-being as patients become physically dependent on others, have compromised activities of daily living, and are unable to eat food of their choice, experience change of role function in the family, lose control over the situation, and lose autonomy in decision-making.
The present study had some limitations. This being a retrospective record-based study, there is high likelihood of selection bias. However, since we included all the lung cancer patients in 1-year study period, this could have reduced the probability of selection bias. The study did not record quality of life using standard data; however, the authors used some of the surrogate indicators that determined poor quality of life.
| Conclusion|| |
We found a higher proportion of GI metastases in our study. Peritoneum/omentum was the most common location for metastasis associated with intestinal obstruction. With the advent of targeted therapies and immunotherapies, the survival of patients with advanced lung cancer may increase with resultant complex symptom burden. There in, oncologists and palliative care specialists have to keep a constant vigil of such patients such that symptoms are identified at an early stage to direct definitive treatment options before the advent of complications.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]