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World J Gastroenterol. Oct 21, 2026; 32(39): 119719
Published online Oct 21, 2026. doi: 10.3748/wjg.119719
Alarm from the peritoneum: Gastrointestinal perforations in cancer patients, with a focus on perforations of unknown origin
Manlio Monti, Bianca Ceredi, Nicolò Paganelli, Roberto Vespignani, Alice Andalò, Paolo De Angelis, Nicola Gentili, Ilaria Massa, Andrea Roncadori, Valentina Danesi, William Balzi
Manlio Monti, Bianca Ceredi, Nicolò Paganelli, Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola 47014, Emilia-Romagna, Italy
Roberto Vespignani, Department of Servizio Informatico, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola 47014, Emilia-Romagna, Italy
Alice Andalò, Paolo De Angelis, Nicola Gentili, Department of Data Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola 47014, Emilia-Romagna, Italy
Ilaria Massa, Andrea Roncadori, Valentina Danesi, William Balzi, Department of Outcome Research, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola 47014, Emilia-Romagna, Italy
Author contributions: Monti M, Massa I, Balzi W, Roncadori A and Danesi V participated in the conception and design of the study and in the interpretation of data; Roncadori A was involved in the analysis; Monti M wrote the manuscript with the assistance of Danesi V; Vespignani R, Balzi W, Andalò A, De Angelis P and Gentili N were involved in the acquisition and access of data; Ceredi B and Paganelli N verified the study data; all authors critically reviewed and provided final approval of the manuscript; and all authors were responsible for the decision to submit the manuscript for publication.
AI contribution statement: An AI-assisted tool was used only for language polishing and editing for response to reviewers. It was not used for data analysis, study design, interpretation of results, or image generation.
Supported by Ricerca Corrente by the Italian Ministry of Health.
Institutional review board statement: This investigation was approved by the Comitato Etico della Romagna (Romagna Ethics Committee; Approval No. 1517).
Informed consent statement: This was a retrospective single-center study based on secondary use routinely collected clinical data. No informed consent was obtained in accordance with article 110-bis of the Italian Data Protection Code.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
Corresponding author: Valentina Danesi, PhD, Department of Outcome Research, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via Piero Maroncelli, 40, Meldola 47014, Emilia-Romagna, Italy.
valentina.danesi@irst.emr.it
Received: February 5, 2026
Revised: March 16, 2026
Accepted: May 21, 2026
Published online: October 21, 2026
Processing time: 214 Days and 9.1 Hours
BACKGROUND
Gastrointestinal perforation is a rare but potentially life-threatening complication in cancer patients, often occurring in a complex clinical setting characterized by advanced disease, comorbidities, and ongoing systemic treatments. Despite its clinical relevance, data describing the characteristics, prognosis, and underlying causes of gastrointestinal perforation in oncologic populations remain limited, particularly for events not clearly attributable to tumor involvement or treatment-related factors. We hypothesized that gastrointestinal perforations in cancer patients represent a heterogeneous condition and that cases without an identifiable cause constitute a distinct subgroup with specific clinical characteristics and prognostic implications.
AIM
To characterize cancer patients with gastrointestinal perforation and to estimate overall survival (OS) and associated prognostic factors.
METHODS
This single-center retrospective observational study included adult cancer patients who experienced gastrointestinal perforation between October 2007 and October 2023 at IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori” of Meldola, Italy. Cases were identified through electronic health records and manually validated. Perforations were classified as cancer-related, cancer-unrelated, or of unknown cause based on a review of clinical records, radiological findings, recent procedures, and, when available, surgical and histopathological data. OS and prognostic factors were analyzed using Kaplan-Meier estimates and Cox regression models.
RESULTS
Among 72143 cancer patients, 119 (0.16%) experienced gastrointestinal perforation: 80 (67.2%) cancer-related, 28 (23.6%) cancer-unrelated, and 11 (9.2%) of unknown cause. Colorectal cancer predominated in cancer-related cases (41.3%), while breast (17.9%) and lung cancer (14.3%) in cancer-unrelated perforations; kidney and lung cancers in unknown-cause perforations (27.3% each). The colon (27.5%) and small intestine (23.8%) were the most common perforation sites in cancer-related cases, rectosigmoid (60.7%) in cancer-unrelated cases, and colon (45.5%) in unknown-cause cases. Patients with perforation of unknown cause showed a higher prevalence of comorbidities, particularly arterial hypertension (63.6%). Median OS was 12.1 months, with 30-day mortality of 20.5%. Hypertension and metastatic burden were associated with worse prognosis, while colorectal, breast, and hematologic malignancies showed improved survival.
CONCLUSION
Gastrointestinal perforation is an uncommon but severe event in cancer patients, with a distinct subset of cases occurring without an identifiable cause and with a prognosis influenced by comorbidities and metastatic burden.
Core Tip: In this single-center retrospective study, a small but clinically relevant subset of gastrointestinal perforations occurred without an identifiable cause. Patients with perforation of unknown origin showed distinctive clinical and pathological features compared with cancer-related and cancer-unrelated cases, including a higher burden of comorbidities, particularly arterial hypertension, a different distribution of primary tumors (lung and kidney cancers), and preferential involvement of the colon and small intestine. Although outcomes appeared broadly comparable across groups, these findings suggest that patient-related factors may contribute to spontaneous perforation, highlighting an under-recognized clinical scenario in oncology practice.
