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Small Early Carcinoma of the Stomach with Extra-Perigastric Lymph Node Metastasis: A Case Report Masaru HARAGUCHI,Daisuke KORENAGA,Takeshi OKAMURA, Shunichi TSUJITAN1and Keizo SUGIMACHI ABSTRACT: An early gastric carcinoma, measuring 1.7 X 0.6 cm, had already metastasized to the extra-perigastric lymph node in a 71 year old symptom-free roan. Radiographic and endoscopic studies showed a small depressed lesion on the lesser curvature o f the antrum and histology o f the biopsied specimen revealed a well differentiated adenocarcinoma. Under the diagnosis o f IIc type intramucosal carcinoma, partial gastrectomy and wide lymph node dissection was performed. Pathologic study o f the resected specimen showed that the cancer cells had invaded the submucosa at an area via a lymphatic vessel and that only one lymph node along the c o m m o n hepatic artery was involved. KEY WORDS: metastasis
early gastric carcinoma, extra-perigastric lymph n o d e
INTRODUCTION R e c e n t developments in endoscopic and Xray equipment have increased the ability to detect early gastric carcinomas, which usually have an excellent prognosis. 1,2 Based on their good prognosis, endoscopic treatment has been given, 3-~ but the potential risk o f lymph node metastasis is reportedly 4 per cent in cases of intramucosal carcinoma and as high as 18.9 per cent in cases o f submucosal carcinoma. 6 Nevertheless, to our knowledge, the extent of lymph node metastasis according to size and gross form o f early carcinoma has not b e e n reported. We recently treated a man whose early gastric carcinoma had metastasized to an
The Second Department of Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan Reprint requests to: Masaru Haraguchi, MD, The Second Department of Surgery, Faculty of Medicine, Kyushu University, 3-1-! Maidashi, Higashi-ku, Fukuoka 812,Japan
extra-perigastric lymph node even though the original lesion was less than 2 cm.
CASEREPORT A 71 year old, symptom-free Japanese man had u n d e r g o n e radiographic studies of the stomach twice a year, since 1981. O n August 1st, 1984, a small depressed lesion on the lesser curvature of the antrum was evident (Fig. 1) and subsequent endoscopy revealed a r e d d e n e d and slightly depressed mucosa with an irregular margin (Figs. 2, 3). The diagnosis o f IIc type intramucosal carcinoma was thus made and histologic examination o f the biopsied specimen revealed a well differentiated adenocarcinoma. As his general condition was good witfi no risk factors for surgery, a partial gastrectomy with wide lymph node dissection was performed on August 14, 1984. Macroscopically, the resected specimen showed a depressed lesion o f 1.7 X 0.6 cm with no fold convergency (Fig. 4). Microscopically, the depressed mR-
J~ANES~Jotre~J. OF StmGERY,VOL. 20, No. 1 pp. 111-114, 1990
112
Haraguchi et al.
Fig. 1. RadiogTaphic findings of a compression study showing a small depressed lesion (arrow) on the lesser curvature of the antrum.
Fig. 2. Endoscopic findings of the lesion (arrow) showing a small and slight depression in the mucosa. cosa was invaded by cancer cells of well differentiated a d e n o c a r c i n o m a and invasion of the submucosa had occurred only in one area via a lymphatic vessel (Figs. 5, 6). Metastasis to one lymph node along the c o m m o n hepatic artery was present (Fig. 7), but the perigastric lymph nodes were normal. H e h a d an uneventful postoperative recovery a n d survived for m o r e than four years without recurrence.
Jpn. J. Surg. January 1990
Fig. 3. Endoscopic findings of the lesion (arrow) clarified by spraying indigocarmine. Note the irregular margin.
Fig. 4. Gross view of the specimen.
DISCUSSION In Japan, wide dissection of regional lymph nodes at the time of gastrectomy is now the standard p r o c e d u r e for treating patients with early gastric carcinoma. 7 The five-year survival rate of early gastric carcinoma now exceeds 95 p e r cent 1 and, based on this good prognosis, investigators have reported endoscopic treatment a-~ and local resection or limited lymph n o d e dissection 1
Volume 20 Number 1
Early gastric carcinoma
Fig. 5. Microscopic findings of the lesion. All the depressed mucosa was invaded by cancer cells. (HE X22)
Fig. 6. A higher magnification of Fig. 5 showing a well differentiated adenocarcinoma with submucosal invasion through a lymphatic vessel. (HE X108) for cases of early gastric carcinoma. They analyzed the frequency o f lymph node metastasis according to size, depth of cancer invasion, gross type and the association of an ulcer in the lesion, and p r e p a r e d the following criteria. Oguro et al? reported endoscopic laser therapy for geriatric and p o o r risk patients. Their criteria for absolute indication was 1) focal carcinoma, 2) the I I a type of early carcinoma of less than 3 cm, and 3) gastritislike early carcinoma of less than 2 cm. Kitaoka et al. 1 reported that dissection of the perigastric lymph nodes is adequate in cases of an intramucosal carcinoma and that local
113
Fig. 7. Microscopic findings of metastatic lymph node along {he common hepatic artery. (HE X29) resection or simple gastrectomy without lymp h a d e n e c t o m y is sufficient for an intramucosal polypoid carcinoma of less than 2 cm. Nevertheless, preoperatively diagnosing the depth o f cancer invasion a n d the presence o f lymph node metastasis is most difficult. T h e present patient was preoperatively diagnosed as a case of intramucosal carcinoma and met the above criteria, however, if we had adhered to this criteri a , metastatic lymph nodes would have b e e n left behind, resulting in a recurrence. Hirota et a12 reported that the frequency o f small early carcinomas of 2.0 cm or smaller, increased to 36 p e r cent a m o n g all early gastric carcinomas during the ten years from 1974. According to one report 6 the incidence of lymph node metastasis in cases of early carcinomas of 2.0 cm or smaller was 6.8 per cent, but they did not analyze the extent o f metastasis with a differentiation o f perigastric and extraperigastric lymph nodes. Some J a p a n e s e reports lm-12 showed the rate of extra-perigastric lymph node involvem e n t as being 2.6-3.9 per cent in early carcinomas. In fact, O h t a et a12 analyzed 374 early carcinomas, located in the lower part of the stomach and found 14 (3.7 per cent) cases of metastasis to the lymph nodes along the c o m m o n hepatic artelT. Thus, in assessing endoscopic therapy and limited surgery for patients with an early
Haraguchi et al.
114
gastric c a r c i n o m a , t h e possibility o f a n extraperigastric lymph node metastasis must be taken into consideration. ACKNOWLEDGMENT W e t h a n k M. O h a r a , K y u s h u University, for critical r e a d i n g o f t h e m a n u s c r i p t . ( R e c e i v e d for p u b l i c a t i o n o n Mar. 2, 1989) REFERENCES 1. Kitaoka H, Yoshikawa K, Hirota T, Itabashi M. Surgical treatment of early gastric cancer. Jpn J Clin Oncol 1984; 14: 283-293. 2. Peter HRG, O'Toole KM, Weinberg LM, Goldfarb JP. Early gastric cancer. Gastroenterology 1981; 81: 247-256. 3. Oguro Y, Hirashima T, Tajiri H, Yoshida S, Yamaguchi H, Yoshimori M, Itabashi M, Hirota T. Endoscopic treatment of early gastric cancer: Polypectomy and laser treatment. Jpn J Clin Oncot 1984; 14: 271-282. 4. PappJP, JosephJI. Adenocarcinoma occurring in a hyperplastic gastric polyp. Removal by electrosurgical polypectomy. Gastroint Endosc 1976; 33: 38-42. 5. Rrsch W, Frfihmorgen P. Endoscopic treatment of precancerouses and early gastric carcinoma. Endoscopy 1980; 12: 10%1t3.
aPn. J. Surg. uary 1990
6. Fukutomi H, Sakita T. Analysis of early gastric cancer cases collected from major hospitals and institutes in Japan. Jpn J Clin Oncol 1984; 14: 169-179. 7. Kodama Y, Sugimachi K, Soejima 14, Matsusaka T, Inokuchi !4. Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJ Surg 1981; 5: 241-248. 8. Hirota T, Itabashi M, Daibo M, Kitaoka H, Oguro Y, Yamada T, Ichikawa H. Chronological changes in the morphological features of early gastric cancer, especially recent changes in macroscopic findings. JpnJ Clin Oncol 1984; 14: 181-199. 9. Ohm H, Takagi K, Ohashi I, Tamura S, Kuno K, Kajitani T, Kato Y. Studies of the 1,000 cases of early gastric cancer --with special reference to macroscopic classification--. Nippon Shokaki Geka Gakkai Zasshi (Jpn J Gastroenterol Surg) 1981; 14: 1399-1408. (in Japanese) 10. Ohta H, Noguchi Y, Taka# K, Nishi M, Kajitani T, Kato Y. Early gastric carcinoma with special reference to macroscopic classification. Cancer 1987; 60: 1099-1106. 11. Suzuki H, Endo M, Suzuki S, Hasegawa T, Kitamura Y, Saito S, Arai T, Yamashita Y. A study of the lymph node metastasis on early gastric cancer. Nippon Shokaki Geka Gakkai Zasshi (Jpn J Gastroenterol Surg) 1984; 17: 1517-1526. (inJapanese) 12. Kito T, Yamamura Y, Hirai T, SakamotoJ, Yasui K, Morimoto T, Kato T, Yasue M, Miyaishi S, Nakazato H. Surgical treatment for early gastric cancer. Nippon Shokaki Geka Gakkai Zasshi (JpnJ Gastroenterol Snrg) 1989; 22: 24-3t. (in Japanese)
Small Early Carcinoma of the Stomach with Extra-Perigastric Lymph Node Metastasis: A Case Report Masaru HARAGUCHI,Daisuke KORENAGA,Takeshi OKAMURA, Shunichi TSUJITAN1and Keizo SUGIMACHI ABSTRACT: An early gastric carcinoma, measuring 1.7 X 0.6 cm, had already metastasized to the extra-perigastric lymph node in a 71 year old symptom-free roan. Radiographic and endoscopic studies showed a small depressed lesion on the lesser curvature o f the antrum and histology o f the biopsied specimen revealed a well differentiated adenocarcinoma. Under the diagnosis o f IIc type intramucosal carcinoma, partial gastrectomy and wide lymph node dissection was performed. Pathologic study o f the resected specimen showed that the cancer cells had invaded the submucosa at an area via a lymphatic vessel and that only one lymph node along the c o m m o n hepatic artery was involved. KEY WORDS: metastasis
early gastric carcinoma, extra-perigastric lymph n o d e
INTRODUCTION R e c e n t developments in endoscopic and Xray equipment have increased the ability to detect early gastric carcinomas, which usually have an excellent prognosis. 1,2 Based on their good prognosis, endoscopic treatment has been given, 3-~ but the potential risk o f lymph node metastasis is reportedly 4 per cent in cases of intramucosal carcinoma and as high as 18.9 per cent in cases o f submucosal carcinoma. 6 Nevertheless, to our knowledge, the extent of lymph node metastasis according to size and gross form o f early carcinoma has not b e e n reported. We recently treated a man whose early gastric carcinoma had metastasized to an
The Second Department of Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan Reprint requests to: Masaru Haraguchi, MD, The Second Department of Surgery, Faculty of Medicine, Kyushu University, 3-1-! Maidashi, Higashi-ku, Fukuoka 812,Japan
extra-perigastric lymph node even though the original lesion was less than 2 cm.
CASEREPORT A 71 year old, symptom-free Japanese man had u n d e r g o n e radiographic studies of the stomach twice a year, since 1981. O n August 1st, 1984, a small depressed lesion on the lesser curvature of the antrum was evident (Fig. 1) and subsequent endoscopy revealed a r e d d e n e d and slightly depressed mucosa with an irregular margin (Figs. 2, 3). The diagnosis o f IIc type intramucosal carcinoma was thus made and histologic examination o f the biopsied specimen revealed a well differentiated adenocarcinoma. As his general condition was good witfi no risk factors for surgery, a partial gastrectomy with wide lymph node dissection was performed on August 14, 1984. Macroscopically, the resected specimen showed a depressed lesion o f 1.7 X 0.6 cm with no fold convergency (Fig. 4). Microscopically, the depressed mR-
J~ANES~Jotre~J. OF StmGERY,VOL. 20, No. 1 pp. 111-114, 1990
112
Haraguchi et al.
Fig. 1. RadiogTaphic findings of a compression study showing a small depressed lesion (arrow) on the lesser curvature of the antrum.
Fig. 2. Endoscopic findings of the lesion (arrow) showing a small and slight depression in the mucosa. cosa was invaded by cancer cells of well differentiated a d e n o c a r c i n o m a and invasion of the submucosa had occurred only in one area via a lymphatic vessel (Figs. 5, 6). Metastasis to one lymph node along the c o m m o n hepatic artery was present (Fig. 7), but the perigastric lymph nodes were normal. H e h a d an uneventful postoperative recovery a n d survived for m o r e than four years without recurrence.
Jpn. J. Surg. January 1990
Fig. 3. Endoscopic findings of the lesion (arrow) clarified by spraying indigocarmine. Note the irregular margin.
Fig. 4. Gross view of the specimen.
DISCUSSION In Japan, wide dissection of regional lymph nodes at the time of gastrectomy is now the standard p r o c e d u r e for treating patients with early gastric carcinoma. 7 The five-year survival rate of early gastric carcinoma now exceeds 95 p e r cent 1 and, based on this good prognosis, investigators have reported endoscopic treatment a-~ and local resection or limited lymph n o d e dissection 1
Volume 20 Number 1
Early gastric carcinoma
Fig. 5. Microscopic findings of the lesion. All the depressed mucosa was invaded by cancer cells. (HE X22)
Fig. 6. A higher magnification of Fig. 5 showing a well differentiated adenocarcinoma with submucosal invasion through a lymphatic vessel. (HE X108) for cases of early gastric carcinoma. They analyzed the frequency o f lymph node metastasis according to size, depth of cancer invasion, gross type and the association of an ulcer in the lesion, and p r e p a r e d the following criteria. Oguro et al? reported endoscopic laser therapy for geriatric and p o o r risk patients. Their criteria for absolute indication was 1) focal carcinoma, 2) the I I a type of early carcinoma of less than 3 cm, and 3) gastritislike early carcinoma of less than 2 cm. Kitaoka et al. 1 reported that dissection of the perigastric lymph nodes is adequate in cases of an intramucosal carcinoma and that local
113
Fig. 7. Microscopic findings of metastatic lymph node along {he common hepatic artery. (HE X29) resection or simple gastrectomy without lymp h a d e n e c t o m y is sufficient for an intramucosal polypoid carcinoma of less than 2 cm. Nevertheless, preoperatively diagnosing the depth o f cancer invasion a n d the presence o f lymph node metastasis is most difficult. T h e present patient was preoperatively diagnosed as a case of intramucosal carcinoma and met the above criteria, however, if we had adhered to this criteri a , metastatic lymph nodes would have b e e n left behind, resulting in a recurrence. Hirota et a12 reported that the frequency o f small early carcinomas of 2.0 cm or smaller, increased to 36 p e r cent a m o n g all early gastric carcinomas during the ten years from 1974. According to one report 6 the incidence of lymph node metastasis in cases of early carcinomas of 2.0 cm or smaller was 6.8 per cent, but they did not analyze the extent o f metastasis with a differentiation o f perigastric and extraperigastric lymph nodes. Some J a p a n e s e reports lm-12 showed the rate of extra-perigastric lymph node involvem e n t as being 2.6-3.9 per cent in early carcinomas. In fact, O h t a et a12 analyzed 374 early carcinomas, located in the lower part of the stomach and found 14 (3.7 per cent) cases of metastasis to the lymph nodes along the c o m m o n hepatic artelT. Thus, in assessing endoscopic therapy and limited surgery for patients with an early
Haraguchi et al.
114
gastric c a r c i n o m a , t h e possibility o f a n extraperigastric lymph node metastasis must be taken into consideration. ACKNOWLEDGMENT W e t h a n k M. O h a r a , K y u s h u University, for critical r e a d i n g o f t h e m a n u s c r i p t . ( R e c e i v e d for p u b l i c a t i o n o n Mar. 2, 1989) REFERENCES 1. Kitaoka H, Yoshikawa K, Hirota T, Itabashi M. Surgical treatment of early gastric cancer. Jpn J Clin Oncol 1984; 14: 283-293. 2. Peter HRG, O'Toole KM, Weinberg LM, Goldfarb JP. Early gastric cancer. Gastroenterology 1981; 81: 247-256. 3. Oguro Y, Hirashima T, Tajiri H, Yoshida S, Yamaguchi H, Yoshimori M, Itabashi M, Hirota T. Endoscopic treatment of early gastric cancer: Polypectomy and laser treatment. Jpn J Clin Oncot 1984; 14: 271-282. 4. PappJP, JosephJI. Adenocarcinoma occurring in a hyperplastic gastric polyp. Removal by electrosurgical polypectomy. Gastroint Endosc 1976; 33: 38-42. 5. Rrsch W, Frfihmorgen P. Endoscopic treatment of precancerouses and early gastric carcinoma. Endoscopy 1980; 12: 10%1t3.
aPn. J. Surg. uary 1990
6. Fukutomi H, Sakita T. Analysis of early gastric cancer cases collected from major hospitals and institutes in Japan. Jpn J Clin Oncol 1984; 14: 169-179. 7. Kodama Y, Sugimachi K, Soejima 14, Matsusaka T, Inokuchi !4. Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJ Surg 1981; 5: 241-248. 8. Hirota T, Itabashi M, Daibo M, Kitaoka H, Oguro Y, Yamada T, Ichikawa H. Chronological changes in the morphological features of early gastric cancer, especially recent changes in macroscopic findings. JpnJ Clin Oncol 1984; 14: 181-199. 9. Ohm H, Takagi K, Ohashi I, Tamura S, Kuno K, Kajitani T, Kato Y. Studies of the 1,000 cases of early gastric cancer --with special reference to macroscopic classification--. Nippon Shokaki Geka Gakkai Zasshi (Jpn J Gastroenterol Surg) 1981; 14: 1399-1408. (in Japanese) 10. Ohta H, Noguchi Y, Taka# K, Nishi M, Kajitani T, Kato Y. Early gastric carcinoma with special reference to macroscopic classification. Cancer 1987; 60: 1099-1106. 11. Suzuki H, Endo M, Suzuki S, Hasegawa T, Kitamura Y, Saito S, Arai T, Yamashita Y. A study of the lymph node metastasis on early gastric cancer. Nippon Shokaki Geka Gakkai Zasshi (Jpn J Gastroenterol Surg) 1984; 17: 1517-1526. (inJapanese) 12. Kito T, Yamamura Y, Hirai T, SakamotoJ, Yasui K, Morimoto T, Kato T, Yasue M, Miyaishi S, Nakazato H. Surgical treatment for early gastric cancer. Nippon Shokaki Geka Gakkai Zasshi (JpnJ Gastroenterol Snrg) 1989; 22: 24-3t. (in Japanese)
