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A case of late lymph node metastasis after three endoscopic mucosal resections of intramucosal gastric cancers.

Booka E, Takahashi T, Tokizawa K, Uchi Y, Okamura A, Fukuda K, Nakamura R, Wada N, Kawakubo H, Saikawa Y, Omori T, Takeuchi H, Sasaki A, Mikami S, Kumai K, Kameyama K, Kitagawa Y - World J Surg Oncol (2014)

Bottom Line: Laparoscopic tumor resection confirmed the pathological diagnosis.Intraoperative pathological diagnosis showed that the adenocarcinoma was compatible with recurrence of gastric cancer; thus, total gastrectomy with D1 lymphadenectomy was performed.Metastasis was not recognized by pathological examination but was detected by preoperative radiological examinations of the LN.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. tsunehiro-t@a8.keio.jp.

ABSTRACT
We describe a patient with solitary lymph node (LN) metastasis after three endoscopic mucosal resections (EMRs) in which a gastrointestinal stromal tumor was difficult to differentiate from the carcinoid and lymphoma tumors. A 77-year-old man underwent three EMRs at 62, 72, and 75 years of age, and all resections were determined to be curative. However, 2 years after the last EMR, screening abdominal ultrasonography detected a 20-mm solitary tumor at the lesser curvature of the upper stomach. Laparoscopic tumor resection confirmed the pathological diagnosis. Intraoperative pathological diagnosis showed that the adenocarcinoma was compatible with recurrence of gastric cancer; thus, total gastrectomy with D1 lymphadenectomy was performed. Metastasis was not recognized by pathological examination but was detected by preoperative radiological examinations of the LN. We report a rare recurrence case after several EMRs of intramucosal gastric cancers.

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Endoscopic findings of three endoscopic mucosal resection (EMR) scars and an elevated lesion. Endoscopy showed the first EMR scar on the lesser curvature of the antrum (a), the second EMR scar on the anterior wall near the pylorus (b), last EMR scar on the greater curvature of the antrum (c), and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach (d).
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Fig3: Endoscopic findings of three endoscopic mucosal resection (EMR) scars and an elevated lesion. Endoscopy showed the first EMR scar on the lesser curvature of the antrum (a), the second EMR scar on the anterior wall near the pylorus (b), last EMR scar on the greater curvature of the antrum (c), and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach (d).

Mentions: A 62-year-old man was admitted in 1998 because early gastric cancer (EGC) was detected by annual screening endoscopy. There was no specific finding in the physical examination or laboratory data. He had no medical history of malignant tumors. The lesion was a 10-mm type 0-IIc moderately differentiated adenocarcinoma without an ulcer located at the lesser curvature of the antrum (Figure 1a). We diagnosed that this lesion had a negligible risk of LN metastasis, and ER was indicated[4]. We explained to the patient that EMR was an investigational treatment at that time, and he chose to receive EMR instead of surgery. EMR using piecemeal resection was performed, which was curative macroscopically. The specimens were completely reconstructed, and pathological examination confirmed a 10-mm type 0-IIc moderately differentiated adenocarcinoma, without an ulcer (Figure 1b). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins, which indicated that the resection was curative according to the Japanese 13th edition of the Classification of Gastric Carcinoma[2]. We performed endoscopy at 1, 3, and 6 months after EMR to check for local recurrence, and every biopsy of the EMR scars revealed no malignancy. Thereafter, we performed follow-up endoscopy and abdominal ultrasonography (AUS) to check locoregional or distant metastasis every year, and no recurrence was detected. After 10 years, another lesion was detected by endoscopy in 2008 when the patient was 72 years old. The lesion was a 12-mm type 0-IIa moderately differentiated adenocarcinoma without an ulcer located at the anterior wall near the pylorus (Figure 1c). En bloc EMR was performed; pathological examination revealed a 12-mm type 0-IIa lesion without an ulcer that was predominantly a moderately differentiated adenocarcinoma with papillary adenocarcinoma components (Figure 1d). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins, which indicated that the resection was curative according to the GCTG (ver. 2)[3]. Thereafter, we performed follow-up endoscopy and AUS every year; recurrence was not observed, but a nonrecurrent lesion was detected in 2011 when the patient was 75 years old. The lesion was a 7-mm type 0-IIa + IIc moderately differentiated adenocarcinoma without an ulcer, located at the greater curvature of the antrum (Figure 1e). En bloc EMR was performed; pathological examination revealed a 1-mm moderately differentiated adenocarcinoma without an ulcer (Figure 1f). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins. However, the tumor seemed to invade into the muscularis mucosa, which indicated that the resection was curative (GCTGs, ver. 3)[1]. Although subsequent endoscopy did not detect recurrence, a 20-mm tumor was detected along the lesser curvature of the stomach by screening AUS in 2013 when the patient was 77 years old (Figure 2a). We performed computed tomography (CT) and positron emission tomography (PET)-CT. CT showed a 20-mm tumor along the lesser curvature of the stomach and no other metastatic lesion (Figure 2b). PET-CT showed 18 F-fluorodeoxyglucose hot uptake in the same lesion (Figure 2c). We performed endoscopy to check for new lesions or local recurrence. The endoscopy showed three lesions on EMR scars and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach that had not been detected at the last endoscopy (Figure 3a-d). We performed biopsies of each EMR scar and the elevated lesion, but no malignancy was identified. Gastrointestinal stromal tumor (GIST), carcinoid tumor, and lymphoma were considered in the differential diagnosis along with LN metastasis. Although endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) was considered to determine a pathological diagnosis, EUS-FNA was not performed because of the risk of dissemination. We performed a laparoscopic total excisional biopsy to resect the tumor, and the intraoperative frozen section indicated LN metastasis of the adenocarcinoma (Figure 4a). Because this LN was recognized as #3a LN with stomach invasion, the operation was converted to an open standard total gastrectomy with D1 LN dissection. Postoperative pathological examination indicated that the resected LN was a metastasis of the moderately differentiated adenocarcinoma with stomach wall invasion (Figure 4b-d). Additionally, no remnant or recurrent malignancy was detected at any stomach EMR site, and no other metastasis was found among the 52 other LNs retrieved.Figure 1


A case of late lymph node metastasis after three endoscopic mucosal resections of intramucosal gastric cancers.

Booka E, Takahashi T, Tokizawa K, Uchi Y, Okamura A, Fukuda K, Nakamura R, Wada N, Kawakubo H, Saikawa Y, Omori T, Takeuchi H, Sasaki A, Mikami S, Kumai K, Kameyama K, Kitagawa Y - World J Surg Oncol (2014)

Endoscopic findings of three endoscopic mucosal resection (EMR) scars and an elevated lesion. Endoscopy showed the first EMR scar on the lesser curvature of the antrum (a), the second EMR scar on the anterior wall near the pylorus (b), last EMR scar on the greater curvature of the antrum (c), and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach (d).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4233046&req=5

Fig3: Endoscopic findings of three endoscopic mucosal resection (EMR) scars and an elevated lesion. Endoscopy showed the first EMR scar on the lesser curvature of the antrum (a), the second EMR scar on the anterior wall near the pylorus (b), last EMR scar on the greater curvature of the antrum (c), and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach (d).
Mentions: A 62-year-old man was admitted in 1998 because early gastric cancer (EGC) was detected by annual screening endoscopy. There was no specific finding in the physical examination or laboratory data. He had no medical history of malignant tumors. The lesion was a 10-mm type 0-IIc moderately differentiated adenocarcinoma without an ulcer located at the lesser curvature of the antrum (Figure 1a). We diagnosed that this lesion had a negligible risk of LN metastasis, and ER was indicated[4]. We explained to the patient that EMR was an investigational treatment at that time, and he chose to receive EMR instead of surgery. EMR using piecemeal resection was performed, which was curative macroscopically. The specimens were completely reconstructed, and pathological examination confirmed a 10-mm type 0-IIc moderately differentiated adenocarcinoma, without an ulcer (Figure 1b). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins, which indicated that the resection was curative according to the Japanese 13th edition of the Classification of Gastric Carcinoma[2]. We performed endoscopy at 1, 3, and 6 months after EMR to check for local recurrence, and every biopsy of the EMR scars revealed no malignancy. Thereafter, we performed follow-up endoscopy and abdominal ultrasonography (AUS) to check locoregional or distant metastasis every year, and no recurrence was detected. After 10 years, another lesion was detected by endoscopy in 2008 when the patient was 72 years old. The lesion was a 12-mm type 0-IIa moderately differentiated adenocarcinoma without an ulcer located at the anterior wall near the pylorus (Figure 1c). En bloc EMR was performed; pathological examination revealed a 12-mm type 0-IIa lesion without an ulcer that was predominantly a moderately differentiated adenocarcinoma with papillary adenocarcinoma components (Figure 1d). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins, which indicated that the resection was curative according to the GCTG (ver. 2)[3]. Thereafter, we performed follow-up endoscopy and AUS every year; recurrence was not observed, but a nonrecurrent lesion was detected in 2011 when the patient was 75 years old. The lesion was a 7-mm type 0-IIa + IIc moderately differentiated adenocarcinoma without an ulcer, located at the greater curvature of the antrum (Figure 1e). En bloc EMR was performed; pathological examination revealed a 1-mm moderately differentiated adenocarcinoma without an ulcer (Figure 1f). The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins. However, the tumor seemed to invade into the muscularis mucosa, which indicated that the resection was curative (GCTGs, ver. 3)[1]. Although subsequent endoscopy did not detect recurrence, a 20-mm tumor was detected along the lesser curvature of the stomach by screening AUS in 2013 when the patient was 77 years old (Figure 2a). We performed computed tomography (CT) and positron emission tomography (PET)-CT. CT showed a 20-mm tumor along the lesser curvature of the stomach and no other metastatic lesion (Figure 2b). PET-CT showed 18 F-fluorodeoxyglucose hot uptake in the same lesion (Figure 2c). We performed endoscopy to check for new lesions or local recurrence. The endoscopy showed three lesions on EMR scars and an elevated lesion displaced from the outside at the lesser curvature of the upper stomach that had not been detected at the last endoscopy (Figure 3a-d). We performed biopsies of each EMR scar and the elevated lesion, but no malignancy was identified. Gastrointestinal stromal tumor (GIST), carcinoid tumor, and lymphoma were considered in the differential diagnosis along with LN metastasis. Although endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) was considered to determine a pathological diagnosis, EUS-FNA was not performed because of the risk of dissemination. We performed a laparoscopic total excisional biopsy to resect the tumor, and the intraoperative frozen section indicated LN metastasis of the adenocarcinoma (Figure 4a). Because this LN was recognized as #3a LN with stomach invasion, the operation was converted to an open standard total gastrectomy with D1 LN dissection. Postoperative pathological examination indicated that the resected LN was a metastasis of the moderately differentiated adenocarcinoma with stomach wall invasion (Figure 4b-d). Additionally, no remnant or recurrent malignancy was detected at any stomach EMR site, and no other metastasis was found among the 52 other LNs retrieved.Figure 1

Bottom Line: Laparoscopic tumor resection confirmed the pathological diagnosis.Intraoperative pathological diagnosis showed that the adenocarcinoma was compatible with recurrence of gastric cancer; thus, total gastrectomy with D1 lymphadenectomy was performed.Metastasis was not recognized by pathological examination but was detected by preoperative radiological examinations of the LN.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. tsunehiro-t@a8.keio.jp.

ABSTRACT
We describe a patient with solitary lymph node (LN) metastasis after three endoscopic mucosal resections (EMRs) in which a gastrointestinal stromal tumor was difficult to differentiate from the carcinoid and lymphoma tumors. A 77-year-old man underwent three EMRs at 62, 72, and 75 years of age, and all resections were determined to be curative. However, 2 years after the last EMR, screening abdominal ultrasonography detected a 20-mm solitary tumor at the lesser curvature of the upper stomach. Laparoscopic tumor resection confirmed the pathological diagnosis. Intraoperative pathological diagnosis showed that the adenocarcinoma was compatible with recurrence of gastric cancer; thus, total gastrectomy with D1 lymphadenectomy was performed. Metastasis was not recognized by pathological examination but was detected by preoperative radiological examinations of the LN. We report a rare recurrence case after several EMRs of intramucosal gastric cancers.

Show MeSH
Related in: MedlinePlus