Ileal metastases from oesophageal carcinoma causing intestinal obstruction

RS Neve, SS Qureshi, Rajesh C Mistry 
 Department of Thoracic Services, Tata Memorial Hospital, Parel, Mumbai - 400012, India

Correspondence Address:
Rajesh C Mistry
Department of Thoracic Services, Tata Memorial Hospital, Parel, Mumbai - 400012
India

Full Text

Sir,

A 56-year-old male presented with dysphagia. Endoscopy revealed an ulcerative lesion in the lower oesophagus, extending from 30 cm to 35 cm. At surgery, the tumour involved the oesophagus without infiltration of the adjacent structures. A transthoracic oesophagectomy was performed and a tube of the stomach was anastomosed to the oesophagus to restore gastrointestinal continuity. Histopathological examination revealed a squamous carcinoma of the oesophagus with involvement of the paraesophageal and perigastric lymph nodes (pT3N1M0). He received 54 Gray of radiotherapy to the mediastinum postoperatively.

Eight months later, the patient presented with abdominal distension. X-rays of the abdomen suggested small bowel obstruction. A computed tomogram scan of the abdomen showed an ill-defined bowel mass in right sub-hepatic region, with minimal ascites. The liver did not reveal any metastasis. These findings prompted a laparotomy that showed a well-localized abscess in the right paracolic gutter. After draining the abscess and separating the adhered bowel loops, a mass was noticed in the ileum, approximately 6 to 7 cm proximal to the ileocaecal junction, with adhesions to the adjacent small bowel and caecum. This mass was causing stenosis of the ileum here, with proximally dilated bowel. A perforation was also present at the site of the mass. There was no other gross evidence of intra-abdominal disease. The mass was excised and a diverting ileostomy with distal ileal mucous fistula was fashioned in view of the peritoneal contamination and poor nutritional status.

Histopathological examination of the excised mass revealed keratinized squamous carcinoma involving the full thickness of the ileal wall [Figure:1]. The suspicious omental areas which were resected showed non-specific inflammation, and the peritoneal fluid revealed pus cells and Escherichia coli on culture; however, no malignant cells were seen.

In view of the metastatic disease and the poor general condition of the patient, no further adjuvant treatment was offered. At an eight-month follow-up, the patient is alive and asymptomatic and has learnt to manage his ileostoma well.

While the small intestine accounts for nearly 75% of the total length of the GI tract and more than 90% of the mucosal surface area, less than 25% of all alimentary tract neoplasms and less than 2% of all malignant tumours originate from the small intestine.[1] This could be due to the relatively rapid transit time, liquid content of stools, low bacterial population, and a high concentration of IgA within the lumen.[1] Metastatic tumours of the small bowel outnumber the primary tumours and usually occur as part of generalised peritoneal carcinomatosis.[2] Rarely are these metastatic tumours solitary. The different mechanisms postulated for isolated small bowel metastasis include retrograde lymphatic spread following blockade of paraaortic or mediastinal lymph nodes, lymphatic embolisation, haematogenous spread or peritoneal seeding, including direct implantation.[2] The ileum is the commonest site of metastatic lesions in the small intestine, probably because of the large number of Peyer's patches, which make it the best trapping zone for hematogenic metastasis.[3]

Ileal metastasis of squamous carcinoma may arise from the cervix, lung and other sites, but metastasis from oesophageal carcinoma is rare.[4] Although equally uncommon, the possibility of a primary squamous cell carcinoma of the ileum was excluded since these usually arise in the presence of bowel duplication, and more importantly, the patient already had a primary tumour in the oesophagus.[1],[5]

Despite the inevitable concern of finding generalised abdominal carcinomatosis, laparotomy is indicated to relieve intestinal obstruction, either by a palliative intestinal resection or by a bypass surgery.[2],[3] Although the overall prognosis is poor, significant palliation or occasionally, long-term survival may be achieved in the absence of disseminated disease.[2],[3]

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