International Journal of Surgery Case Reports 109 (2023) 108599

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Small intestinal perforation secondary to metastasis from skin squamous

cell carcinoma: A case report and literature review
Maxence Emmanuel Reynard, Titika-Marina Strati, Bernhard Egger *
Department of Surgery, HFR Fribourg – Cantonal Hospital, Chemin des Pensionnats 2-6, 1752 Villars-sur-Glâne, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Primary and metastatic carcinoma of the small intestine are rare. While most of these
Intestinal perforation malignancies are adenocarcinomas, squamous cell carcinoma (SCC) of the gastrointestinal tract is uncommon.
Metastatic squamous cell carcinoma We present a case report of a rare occurrence of skin SCC metastasizing to the ileum, highlighting diagnostic
Diagnostic challenges
challenges and clinical implications.
Clinical implications
Case presentation: An 83-year-old female had a history of cutaneous SCC excision in the right temporal region two
Literature review
Case report years prior to the current emergency department visit, followed by metastatic recurrence in a right intra-parotid
lymph node treated with radiotherapy. The patient exhibited septic shock and an acute abdomen, and an
abdominal computed tomography scan revealed signs of intestinal perforation. Emergency exploratory lapa­
rotomy confirmed purulent peritonitis and perforation of the terminal ileum. Subsequently, a 20 cm intestinal
resection was performed. Histopathological examination of the resected specimen revealed a 4 cm perforated
SCC of the small intestine (pT4 pN0 L0 V1 Pn0 R0).
Clinical discussion: Metastases of the small intestine are rare. The primary sites for these metastases are typically
the uterus, cervix, colon, lung, breast, or melanoma. SCC of the small intestine is particularly rare and poses
challenges in diagnosis owing to non-specific symptoms. The prognosis for SCC of the small intestine is generally
poor, and the potentially aggressive behavior of some skin SCC emphasizes the need for increased awareness and
vigilance in managing such cases.
Conclusion: This case report underscores the importance of considering metastatic disease in the small bowel of
patients with a history of skin SCC who present with new-onset abdominal symptoms.

1. Introduction tumor (GIST), adenocarcinoma, and metastatic carcinomas of the hy­

Intestinal perforation is a life-threatening condition that is
commonly encountered in visceral surgery. The primary treatment
approach involves emergency surgery, including damage control sur­
gery or intestinal resection with definitive repair. The leading causes of
perforation in industrialized countries are bowel obstruction and in­
flammatory bowel disease whereas infectious causes of intestinal per­
forations are more common in developing countries [1]. Early
recognition and prompt treatment are crucial to prevent the high mor­
tality rates associated with peritonitis. The most common malignancies
found after histopathologic examination of perforated small bowel
specimens include lymphoma, leiomyosarcoma, gastrointestinal stromal
popharynx, cervix, and lung [2].
Primary and metastatic squamous cell carcinomas (SCC) of the small
intestine are extremely rare. Fewer than 30 cases of primary SCC of the
small intestine have been reported in the literature. Although there are
few references of SCC metastasis in the small intestine, only in four case
reports, the skin is the primary site [3–6].
Cutaneous squamous cell carcinoma (cSCC) is the second most
prevalent form of skin cancer after basal cell carcinoma (BCC) [7]. Early
diagnosis and treatment of cSCC generally lead to an excellent prognosis
[8]. A recently published epidemiologic cohort study suggested that the
incidence rate of cSCC continues to increase, especially among female
patients. Furthermore, the occurrence of multiple cSCCs in a single

Abbreviation: cSCC, cutaneous squamous cell carcinoma; BCC, basal cell carcinoma; INR, International Normalized Ratio; aPTT, Activated Partial Thromboplastin
Time; KDIGO, Kidney Disease Improving Global Outcomes; SCARE, Surgical Case Report; GIST, Gastrointestinal Stromal Tumor; ENT, Ear, Nose, and Throat; PET,
Positron emission tomography; PPI, Proton pump inhibitors; P16, cyclin-dependent kinase inhibitor 2A.
* Corresponding author at: HFR Fribourg – Cantonal Hospital, Chemin des Pensionnats 2-6, 1752 Villars-sur-Glâne, Switzerland.
E-mail address: bernhard.egger@h-fr.ch (B. Egger).

https://doi.org/10.1016/j.ijscr.2023.108599
Received 23 June 2023; Received in revised form 25 July 2023; Accepted 27 July 2023
Available online 2 August 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M.E. Reynard et al.
patient significantly contributes to the current and future burden on
dermatologic healthcare, which requires additional resources for diag­
nosis and treatment [9].
Herein, we present an extremely rare case of a patient admitted to
Cantonal Swiss Hospital in an emergency setting with ileum perforation,
identified as a metastasis of cSCC through histopathological examina­
tion. The case report was conducted in accordance with the SCARE
(Surgical CAse REport) criteria [10].
2. Case presentation
An 83-year-old woman was transported to the Emergency Depart­
ment by ambulance because of worsening abdominal pain, hema­
tochezia, and asthenia that had been present for several weeks. The
detailed history revealed one episode of hematochezia two days before
admission and abdominal pain for the last 5 days.
Her personal medical history was marked 2 years prior to the current
emergency department visit by a total excision of cutaneous squamous
cell carcinoma (cSCC) in the right frontotemporal region, staged as pT1
uN0 cM0 G2. The tumor extended into the subcutis, the greatest vertical
tumor thickness was 5 mm, the lateral extension <2 cm and the excision
margin >5 mm (R0). One year later, she presented with a recurrence of
squamous cell carcinoma in the metastatic form of the right parotid
gland. Radiation therapy was initiated and was well tolerated. Subse­
quent sonography and CT follow-up revealed a persistent heterogeneous
lesion within the right lobe of the right parotid gland, which was sus­
pected of either recurrence or post-radiation alterations. Furthermore, a
rounded hypodense structure of 3 cm in the pelvic cavity and in contact
with the small intestine showed in the CT scan was difficult to interpret
because of artifacts due to prosthetic material of the right hip. No further
investigations were conducted regarding these findings, and a clinical
and radiological follow-up of 3 months was decided. Chronological
events associated with this disease are summarized in Fig. 1.
The patient also had a history of insulin-dependent type 2 diabetes,
hypertension, rhythmic and valvular heart disease, chronic renal failure
(KDIGO stage G3a), and polymyalgia rheumatica. Her surgical history
included cholecystectomy for symptomatic cholelithiasis, hysterectomy
for heavy monthly bleeding, oophorectomy for a benign ovarian cyst,
and minor orthopedic surgeries.
Her current medication consisted of metoprolol, apixaban, and
prednisone 5 mg once daily.
In the clinical setting, the patient’s initial vital signs revealed a low
blood pressure of 85/35 mmHg in both arms, and a regular pulse rate of
66 beats per minute. Physical examination revealed guarding and
rebound tenderness of the lower abdomen. The digital rectal examina­
tion was unremarkable, with an empty rectal ampulla, and no blood was
found.
Laboratory tests showed a plasma creatinine level of 240 umol/l,
white blood cell count of 15 G/l, hemoglobin level of 86 g/l, C-reactive
protein level of 68 mg/l and hyperlactatemia of 4.5 mmol/l.
An abdominal CT scan without contrast revealed numerous extra­
luminal air bubbles, fat stranding opposite the right colonic angle, and
intra-abdominal free fluid, compatible with intestinal perforation
(Fig. 2). The location of this lesion corresponded to that identified on the
CT scan performed three months earlier after the completion of radio­
therapy (Fig. 3).
The patient was promptly resuscitated with fluids and received high-
dose proton pump inhibitor (PPI) therapy (80 mg bolus followed by 8
mg/h) and antibiotic treatment (piperacillin-tazobactam). Blood cul­
tures were collected for further analyses.
An emergency exploratory laparotomy revealed generalized puru­
lent peritonitis. Approximately 20 cm from the ileocecal valve, a short
loop of the ileum with a 4 cm perforation in the middle was identified,
surrounded by local fecal peritonitis (Fig. 4). Abdominal exploration
revealed no macroscopic peritoneal or hepatic metastases. Segmental
resection of the affected ileum (20 cm) was performed. Due to
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International Journal of Surgery Case Reports 109 (2023) 108599
intraoperative hemodynamic instability and considering the patient’s
comorbidities, medication, and suspected malignancy, a damage control
surgical approach was decided, and the two intestinal stumps were left
closed intra-abdominal. A second-look laparotomy was scheduled
within 24–48 h.
Small bowel tissue was sent for histological analysis and reported an
approximately 4 cm (~ 1.5 in) outbreak of a non-keratinizing squamous
cell carcinoma, acantholytic variant, P16[− ], in the small intestinal
wall, which was perforated and associated with fibrinoleukocytic peri­
tonitis. Other findings included the presence of venous invasion and one
lymph node identified in the mesenteric adipose tissue without
malignancy.
Blood cultures obtained before surgery were positive for Klebsiella
pneumoniae. The peritoneal fluid collected during the operation showed
positive results for Klebsiella pneumoniae, Escherichia coli and some spe­
cies of Bacteroides, such as Bacteroides sp., Bacteroides thetaiotaomicron,
and Bacteroides vulgatus.
The patient was admitted postoperatively to the Intensive Care Unit.
She suffered from severe septic shock and underwent aggressive fluid
resuscitation, continuous norepinephrine support up to 0.5 micrograms/
kg/min., broad-spectrum antibiotic (Piperacillin-Tazobactam followed
by Meropenem) and corticoid administration. Despite this treatment,
the patient remained in shock, requiring high norepinephrine doses.
Because of the severity of the illness and the expressed wishes of the
patient, as reported by her relatives, it was decided not to pursue further
treatment, and a second-look laparotomy was not performed. The pa­
tient peacefully died shortly thereafter.
3. Discussion
Primary and metastatic carcinomas of the small bowel are rare, with
an incidence of approximately 2 in 100,000 individuals [11]. Metastases
account for approximately 10 % of cases, most often arising from pri­
mary tumors in the uterus, cervix, colon, breast, lung, or melanoma. In
most cases, primary malignancies are adenocarcinomas [12]. Squamous
cell carcinoma (SCC) of the small bowel, either primary or metastatic, is
rare. Interestingly, only four case reports have documented skin as the
primary site of secondary tumors of the small intestine [3–6]. They are
summarized in Table 1.
Cutaneous squamous cell carcinoma (cSCC) is characterized by the
abnormal and accelerated growth of squamous cells [7,8]. Although in
the greater part it has a good prognosis and low rates of metastasis, there
are certain risk factors and features associated with more aggressive
behavior [7]. Gastrointestinal involvement in cSCC is extremely rare
and metastasis is believed to occur primarily via lymphatic spread.
Secondary lesions found in the small bowel indicate an advanced stage
and poor prognosis. Furthermore, when they manifest with a compli­
cated course such as perforation, mortality is even higher [13,14].
Overall, small-bowel malignancies have a poor prognosis, partly due
to frequent delays in diagnosis, as symptoms are mainly vague and
nonspecific. Acute presentations vary, including obstruction, intussus­
ception, bleeding, or perforation. Furthermore, even under the suspicion
of a secondary small-bowel lesion, radiologic detection is difficult.
Different modalities, such as small-bowel endoscopy, contrast studies,
and CT scans, can be helpful. However, only 18F-2-fluoro-2-deoxy-D-
glucose-positron emission tomography (FDG PET)/CT and capsule
endoscopy have shown some early success in the diagnosis of small-
bowel metastatic tumors [4,15].
In cases of primary or secondary SCC bowel lesions, surgical treat­
ment is a validated approach and may be unavoidable in emergencies.
Wide local surgical resection of the tumor and lymph node-bearing
mesentery could be considered the surgical treatment of choice. How­
ever, in the case of secondary lesions or in an emergency setting, which
corresponds to an advanced stage disease, surgical treatment has a
palliative role, and complex resections are not recommended. In both
cases, the outcome was poor.
M.E. Reynard et al. International Journal of Surgery Case Reports 109 (2023) 108599

Fig. 1. Course of events related to cSCC.

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M.E. Reynard et al.
Fig. 2. Subject to hardening artifacts of the right hip prosthesis, presence of a pelvic mass, with foamy content and suspicion of fistula with a small bowel loop (white
arrow) on CT-Scan.
Although the majority of patients with cSCC present an excellent
prognosis after adequate surgical resection, a subset of patients carry an
increased risk of lymph node metastasis, local recurrence, and disease-
specific death [7,9,14]. High-risk features include tumor diameter ≥
2 cm, tumor thickness ≥ 2 mm, anatomic tumor site (face, ear, pre/post
auricular area, genitalia, hands, and feet), poor histological differenti­
ation, certain histological subtypes, evidence of perineural invasion,
immunosuppression, and the presence of parotid metastases [3,7,16].
In our case and in concordance with the literature, our patient pre­
sented with an aggressive form of cSCC, the acantholytic variant, which
had already led to parotid and level II lymph node metastases soon after
the primary diagnosis and surgical treatment. Furthermore, immuno­
suppression, with great mention to transplant patients, should always be
considered, presenting a higher risk of both cSCC development and a
worse disease course [2,10]. Our patient was in long-term medical
treatment with corticoids because of rheumatic polymyalgia, probably
contributing to a more aggressive tumor behavior but also influencing to
a certain degree, along with the patient’s hemodynamic instability,
emergency surgical treatment, and the decision to perform a damage
control surgery without proceeding to anastomosis creation.
Finally, we would like to outline the difficulty in detecting these
secondary small bowel lesions, firstly because of their rarity and because
they lack specific characteristics, they often remain unidentifiable until
they reach an advanced stage or become complicated [12]. In our case,
the diagnosis of metastatic cSCC was confirmed only after pathological
examination results were obtained. Additionally, it is noteworthy that a
previous follow-up CT scan described a round hypodense structure of
approximately 3 cm in the pelvic area, in contact with the small bowel,
but it was not interpreted due to artifacts from the prosthetic material in
the right hip (Fig. 3). The examination was carried out in a patient
believed to have a total response to radiotherapy. These facts, together
with the rarity of a small intestinal metastasis from a cSCC, did not lead
to further investigations. It further highlights the challenges in diag­
nosing these lesions and raises questions about the need for further
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International Journal of Surgery Case Reports 109 (2023) 108599
screening and investigation, even in the presence of nonspecific and rare
findings in otherwise nonaggressive tumors that rarely metastasize to
the abdominal cavity.
There are only four case reports in the literature concerning sec­
ondary cutaneous SCC of the small bowel [3–6]. Known as a disease of
late adulthood, with the exception of appearance at a younger age in
immunocompromised patients, in these four case reports, the youngest
patient was 53 years old and the oldest was 71 years old. It is of great
interest that, as in our case, three of these four patients were treated
surgically in an emergency setting without their metastatic small bowel
SCC being already known. Bowel perforation was the cause in two cases
and obstruction in the one. In the last case, the small bowel lesion was
incidentally found preoperatively during elective sigmoid resection
because of an already proven cSCC metastasis in a colonic diverticulum.
However, in one of these four cases, perforated metastatic small bowel
SCC was the first acute presentation of the disease, resulting in further
investigations and subsequent detection of the primary cutaneous site.
Of the four cases, only one small bowel metastasis was located in the
ileum, while all three others were identified in the jejunum. All patients
were treated surgically and small bowel resection was performed. In
three case reports, the outcome was poor, with death occurring 8 weeks
to 7 months post-operatively. In only one case, the last follow-up, six
months after the operation, did not show any other metastatic disease or
recurrence. All four case reports stress the rarity of metastatic small
bowel cSCC and their presentation usually in an emergency setting with
poor prognosis.
4. Conclusion
Most cases of cSCC are limited to the skin and are successfully
managed with local therapy. However, distant metastases occur with an
annual incidence in up to 4 %, leading to increased mortality [7].
Therefore, early diagnosis and detection are important. However, non-
specific symptoms and imaging findings, as well as the lack of
M.E. Reynard et al.
Fig. 3. CT-Scan of a round hypodense structure (~3 cm) in the pelvic area (white arrow), in contact with the small bowel, subject to artifacts from the pros­
thetic material.
awareness of this very low but existing proportion of tumors, result in a
considerable delay in diagnosis and a poor outcome. Surgeons should be
alerted in cases of acute abdominal pain or no specific abdominal
symptoms when there is a history of cancer, even in cases where the
primary tumor rarely metastasizes in the gastrointestinal tract.
However, as the incidence of cSCC continues to increase [8,9], these
rare metastatic sites might also become more apparent, making aware­
ness of this entity even more important.
Increased awareness, vigilance, and comprehensive evaluation are
key to identifying this subset of cases and providing timely interventions
for improved patient management, in light of the growing prevalence of
SCC.
Consent
Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Ethical approval
This study involves human participants but was not approved by an
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International Journal of Surgery Case Reports 109 (2023) 108599
Ethics Committee(s) or Institutional Board(s).
Our institution does not require ethical approval for reporting indi­
vidual cases or case series.
Funding
All authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
Guarantor
The guarantor for this statement is Dr. med. Maxence Emmanuel
Reynard. He can be reached at any time under reynard.maxence@gmail.
com.
Registration of research studies
This study is not a “First in Man” study.
CRediT authorship contribution statement
All authors contributed to the design, data collection, analysis and
interpretation of this protocol. All authors contributed read and
M.E. Reynard et al. International Journal of Surgery Case Reports 109 (2023) 108599

Fig. 4. Ileal perforation.

Table 1
Overview of the reviewed sources.
Author Year Patient demography Primary localisation Metastasis localisation Complication Outcome

N. Hitchen et al. 2016 70-year-old woman Back Jejunum Perforation with peritonitis Death 8 weeks after surgery
R. Li et al. 2014 71-year-old man Hand Ileum Small bowel obstructions Death 4 months after surgery
B. Schwartz et al. 2016 65-year-old male Chest Jejunum None n.e.
H. Zheng et al. 2010 53-year-old man Scalp Jejunum Perforation with peritonitis Death 7 months after surgery

approved the final manuscript. identification is low.

References
Declaration of competing interest
All authors declare no competing interests.
Data availability
Dataset will be available from the corresponding author at reynard.
maxence@gmail.com. The presented data are anonymised and risk of
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