ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Esophageal Tumor After Radical Surgery for Gastric Cancer Tsutomu Namikawa, Michiya Kobayashi, and Kazuhiro Hanazaki Department of Surgery, Kochi Medical School, Kochi, Japan
Question: A 63-year-old man underwent total gastrectomy and regional lymphadenectomy with Roux-en-Y reconstruction for gastric cancer in the anterior wall of upper third of the stomach. Pathologic examination revealed signet-ring cell carcinoma that had invaded the muscularis propria, measuring 7.0 6.5 cm, with metastasis to 1 lymph node and no lymphatic or venous invasion. The margins of the resected specimen including proximal, distal, and vertical sides were all free of cancer cells, and the proximal margin was 5.2 cm. Although Helicobacter pylori was detected in the resected stomach, H pylori eradication therapy was not undertaken in the patient owing to post total gastrectomy state. The patient received adjuvant chemotherapy with oral fluoropyrimidine, which is a prodrug of fluorouracil, and underwent periodic follow-up physical examinations. Thirty-nine months after surgery, esophagogastroduodenoscopy showed an elevated lesion with a central split area located in the esophagus (Figure A). Spraying with lugol solution stained the margin of the elevated lesion, whereas the central split area remained unstained (Figure B). Barium examination revealed an irregular deformity on the left side of the esophageal wall (Figure C, arrow), but no deformity at the site of the esophagojejunostomy (Figure C, arrowhead). Contrast-enhanced CT showed no lymph node swelling in the thoracic and abdominal cavities, and there was no evidence of further remarkable lesions in other organs. Based on the image findings, what is your diagnosis and how would you manage the condition? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.056
Gastroenterology 2015;148:e9–e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 5: Solitary Esophageal Metastasis Arising From Gastric Cancer
Biopsy samples from the esophageal tumor confirmed signet-ring cell carcinoma infiltrating the submucosal layer (Figure E shows a higher magnification image of the area indicated by the box in Figure D). The patient was subsequently treated using chemotherapy consisting of S-1 plus cisplatin under a clinical diagnosis of esophageal metastatic recurrence of gastric cancer. Because the patient developed esophageal obstruction owing to progressive growth of the tumor 6 months after chemotherapy, we continued second-line chemotherapy using nab-paclitaxel after dilatation using a covered, selfexpandable metallic stent. At the time of writing, the patient is alive and continuing on chemotherapy 10 months after the esophageal metastasis of the gastric cancer. Esophageal metastasis arising from gastric cancer is a rare condition, whereas esophageal invasion occasionally occurs in cases of advanced cardiac cancer. Because there are abundant lymphatic channels within the submucosal and subserosal layers between the esophagus and stomach, intramural spread of upper gastrointestinal tract tumors can occur through these channels regardless of the histologic type of the tumor.1,2 Most previous cases have been synchronous esophageal metastasis with marked lymphovenous infiltration in patients with other metastases.2,3 To the best of our knowledge, this is the first case of metachronous solitary esophageal metastasis after radical surgery for gastric cancer to be reported in the English literature. This case proves the possibility of singular metastatic appearance of signet ring cell carcinoma, even if the degree of lymphatic or venous invasion of the primary lesion is not severe.
References 1. 2. 3.
e10
Hashimoto T, Arai K, Yamashita Y, et al. Characteristics of intramural metastasis in gastric cancer. Gastric Cancer 2013; 16:537–542. Ki SH, Jeong S, Park IS, et al. Esophageal mucosal metastasis from adenocarcinoma of the distal stomach. World J Gastroenterol 2013;19:3699–3702. Szántó I, Vörös A, Nagy P, et al. Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction. Endoscopy 2002;34:418–420.
Question: A 63-year-old man underwent total gastrectomy and regional lymphadenectomy with Roux-en-Y reconstruction for gastric cancer in the anterior wall of upper third of the stomach. Pathologic examination revealed signet-ring cell carcinoma that had invaded the muscularis propria, measuring 7.0 6.5 cm, with metastasis to 1 lymph node and no lymphatic or venous invasion. The margins of the resected specimen including proximal, distal, and vertical sides were all free of cancer cells, and the proximal margin was 5.2 cm. Although Helicobacter pylori was detected in the resected stomach, H pylori eradication therapy was not undertaken in the patient owing to post total gastrectomy state. The patient received adjuvant chemotherapy with oral fluoropyrimidine, which is a prodrug of fluorouracil, and underwent periodic follow-up physical examinations. Thirty-nine months after surgery, esophagogastroduodenoscopy showed an elevated lesion with a central split area located in the esophagus (Figure A). Spraying with lugol solution stained the margin of the elevated lesion, whereas the central split area remained unstained (Figure B). Barium examination revealed an irregular deformity on the left side of the esophageal wall (Figure C, arrow), but no deformity at the site of the esophagojejunostomy (Figure C, arrowhead). Contrast-enhanced CT showed no lymph node swelling in the thoracic and abdominal cavities, and there was no evidence of further remarkable lesions in other organs. Based on the image findings, what is your diagnosis and how would you manage the condition? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.056
Gastroenterology 2015;148:e9–e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 5: Solitary Esophageal Metastasis Arising From Gastric Cancer
Biopsy samples from the esophageal tumor confirmed signet-ring cell carcinoma infiltrating the submucosal layer (Figure E shows a higher magnification image of the area indicated by the box in Figure D). The patient was subsequently treated using chemotherapy consisting of S-1 plus cisplatin under a clinical diagnosis of esophageal metastatic recurrence of gastric cancer. Because the patient developed esophageal obstruction owing to progressive growth of the tumor 6 months after chemotherapy, we continued second-line chemotherapy using nab-paclitaxel after dilatation using a covered, selfexpandable metallic stent. At the time of writing, the patient is alive and continuing on chemotherapy 10 months after the esophageal metastasis of the gastric cancer. Esophageal metastasis arising from gastric cancer is a rare condition, whereas esophageal invasion occasionally occurs in cases of advanced cardiac cancer. Because there are abundant lymphatic channels within the submucosal and subserosal layers between the esophagus and stomach, intramural spread of upper gastrointestinal tract tumors can occur through these channels regardless of the histologic type of the tumor.1,2 Most previous cases have been synchronous esophageal metastasis with marked lymphovenous infiltration in patients with other metastases.2,3 To the best of our knowledge, this is the first case of metachronous solitary esophageal metastasis after radical surgery for gastric cancer to be reported in the English literature. This case proves the possibility of singular metastatic appearance of signet ring cell carcinoma, even if the degree of lymphatic or venous invasion of the primary lesion is not severe.
References 1. 2. 3.
e10
Hashimoto T, Arai K, Yamashita Y, et al. Characteristics of intramural metastasis in gastric cancer. Gastric Cancer 2013; 16:537–542. Ki SH, Jeong S, Park IS, et al. Esophageal mucosal metastasis from adenocarcinoma of the distal stomach. World J Gastroenterol 2013;19:3699–3702. Szántó I, Vörös A, Nagy P, et al. Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction. Endoscopy 2002;34:418–420.
