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Gastric-type extremely well-differentiated adenocarcinoma arising in the blind pouch of a bypassed stomach, presenting as colonic pseudo-obstruction.

McFarland S, Manivel CJ, Ramaswamy A, Mesa H - Ann Gastroenterol (2015 Oct-Dec)

Bottom Line: EWDA of the stomach is rare, difficult to diagnose, and shows an aggressive clinical course discordant with its near-benign histology.Surveillance of the blind pouch is not currently recommended.Malignant infiltration of the colonic wall should be included in the differential diagnosis of CPO of unclear etiology.

View Article: PubMed Central - PubMed

Affiliation: University of Minnesota School of Medicine (Sarah McFarland, J. Carlos Manivel, Archana Ramaswamy), Veterans Administration Health Care Service, One Veterans, Drive Minneapolis, USA.

ABSTRACT
Gastric carcinoma after gastric bypass is rare. Extremely well-differentiated adenocarcinoma (EWDA) of the stomach is a rare variant that has been mostly reported in Japan. We present a case of a 68-year-old man with EWDA arising in the bypassed stomach that presented as a colonic pseudo-obstruction (CPO). Several imaging, endoscopic and pathologic studies performed in the course of 2 months were non-diagnostic. An iatrogenic duodenal perforation during a diagnostic procedure led to an emergent exploratory laparotomy in which the dilated colonic segment was resected. Pathologic examination showed metastatic EWDA in the colonic wall. Post-operative complications led to the patient's demise. At autopsy the primary tumor was identified in the blind pouch of the bypassed stomach. A literature review on gastric EWDA and carcinomas arising in bypassed stomachs is discussed. EWDA of the stomach is rare, difficult to diagnose, and shows an aggressive clinical course discordant with its near-benign histology. Gastric cancer arising in a bypassed stomach is uncommon; when it occurs it is usually diagnosed at advanced stage. Surveillance of the blind pouch is not currently recommended. Malignant infiltration of the colonic wall should be included in the differential diagnosis of CPO of unclear etiology.

No MeSH data available.


Related in: MedlinePlus

Stomach, autopsy specimen. (A) Bypassed stomach. The image shows a markedly thickened gastric wall at the pylorus. (B) Pyloric mucosa (hematoxylin & eosin (H&E), 20X): The left upper aspect of the image shows normal antropyloric mucosa (solid arrow), the right lower aspect shows intramucosal extremely well-differentiated adenocarcinoma (EWDA) (empty arrow), there is a slight variation in the contents of mucin, nuclear size and gland shape between the normal and neoplastic glands. Mild autolytic changes are present. (C) Pyloric submucosa and muscularis propria (H&E, 5X): The wall is infiltrated by neoplastic glands that assume the orientation of the stroma they invade, leading to either parallel or perpendicular orientation of the tumor glands. (D) EWDA (H&E, 40X): The image shows identical histological features to the tumor found in the wall of the colon S, gastric lumen; P, pylorus; D, duodenal lumen
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Figure 2: Stomach, autopsy specimen. (A) Bypassed stomach. The image shows a markedly thickened gastric wall at the pylorus. (B) Pyloric mucosa (hematoxylin & eosin (H&E), 20X): The left upper aspect of the image shows normal antropyloric mucosa (solid arrow), the right lower aspect shows intramucosal extremely well-differentiated adenocarcinoma (EWDA) (empty arrow), there is a slight variation in the contents of mucin, nuclear size and gland shape between the normal and neoplastic glands. Mild autolytic changes are present. (C) Pyloric submucosa and muscularis propria (H&E, 5X): The wall is infiltrated by neoplastic glands that assume the orientation of the stroma they invade, leading to either parallel or perpendicular orientation of the tumor glands. (D) EWDA (H&E, 40X): The image shows identical histological features to the tumor found in the wall of the colon S, gastric lumen; P, pylorus; D, duodenal lumen

Mentions: A 68-year-old male consulted for generalized abdominal pain and constipation. Past medical history included a RYGB for morbid obesity 7 years before presentation, and ischemic heart disease. Conservative therapy did not alleviate his symptoms. Computed tomography (CT) scan showed marked ascending colon dilatation (Fig. 1A) without an identifiable lesion indicative of CPO. The differential diagnosis for CPO included functional causes such as cardiac disease, metabolic or electrolyte imbalances, renal insufficiency, medications, and anatomic causes like inflammatory processes and malignancy. Over the course of 2 months several diagnostic procedures were done. Three colonoscopies with multiple biopsies of the right colon showed submucosal mucin extravasation without mucosal abnormalities. On workup for elevated liver enzymes, a magnetic resonance cholangiopancreatography demonstrated intrahepatic biliary dilation with a dilated common hepatic duct and could not rule out a lesion in the bile duct as the cause. A laparoscopically assisted endoscopic ultrasound (EUS) through the remnant stomach showed dilated intrahepatic ducts; a fine needle aspiration of the liver, performed to assess for a possible hilar lesion observed during the EUS, did not show abnormalities. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful due to distorted anatomy. After the ERCP attempt the patient developed shock and was found to have a perforation of the duodenum during emergent exploratory laparotomy. The perforation was closed and the dilated right colon excised. Shortly thereafter, additional procedures were necessary for intestinal infarction secondary to the perforation induced shock, emergent surgery, and poor cardiac function. He continued deteriorating, opted for comfort measures only and expired a week later. Pathologic examination of the colon showed prominent segmental dilatation but no discrete lesions (Fig. 1B). Microscopically pyloric-type glands with minimal cytologic atypia were present in the muscularis propria and subserosa (Fig. 1C). The tumor did not elicit a desmoplastic response. Architecturally, the tumor glands were well formed with no or minimal branching; the longest axis of the glands always followed the orientation of the collagen they were invading (Fig. 1D). The mucosa was free of tumor. By immunohistochemistry the tumor was positive for cytokeratin (CK) 7, SMAD4, S100P and negative for CK20 and CDX2, consistent with foregut origin. Ki-67 proliferative activity was 25%. At autopsy the primary tumor was located in the antrum of the RYGB, where it caused diffuse thickening of the wall (Fig. 2).


Gastric-type extremely well-differentiated adenocarcinoma arising in the blind pouch of a bypassed stomach, presenting as colonic pseudo-obstruction.

McFarland S, Manivel CJ, Ramaswamy A, Mesa H - Ann Gastroenterol (2015 Oct-Dec)

Stomach, autopsy specimen. (A) Bypassed stomach. The image shows a markedly thickened gastric wall at the pylorus. (B) Pyloric mucosa (hematoxylin & eosin (H&E), 20X): The left upper aspect of the image shows normal antropyloric mucosa (solid arrow), the right lower aspect shows intramucosal extremely well-differentiated adenocarcinoma (EWDA) (empty arrow), there is a slight variation in the contents of mucin, nuclear size and gland shape between the normal and neoplastic glands. Mild autolytic changes are present. (C) Pyloric submucosa and muscularis propria (H&E, 5X): The wall is infiltrated by neoplastic glands that assume the orientation of the stroma they invade, leading to either parallel or perpendicular orientation of the tumor glands. (D) EWDA (H&E, 40X): The image shows identical histological features to the tumor found in the wall of the colon S, gastric lumen; P, pylorus; D, duodenal lumen
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC4585402&req=5

Figure 2: Stomach, autopsy specimen. (A) Bypassed stomach. The image shows a markedly thickened gastric wall at the pylorus. (B) Pyloric mucosa (hematoxylin & eosin (H&E), 20X): The left upper aspect of the image shows normal antropyloric mucosa (solid arrow), the right lower aspect shows intramucosal extremely well-differentiated adenocarcinoma (EWDA) (empty arrow), there is a slight variation in the contents of mucin, nuclear size and gland shape between the normal and neoplastic glands. Mild autolytic changes are present. (C) Pyloric submucosa and muscularis propria (H&E, 5X): The wall is infiltrated by neoplastic glands that assume the orientation of the stroma they invade, leading to either parallel or perpendicular orientation of the tumor glands. (D) EWDA (H&E, 40X): The image shows identical histological features to the tumor found in the wall of the colon S, gastric lumen; P, pylorus; D, duodenal lumen
Mentions: A 68-year-old male consulted for generalized abdominal pain and constipation. Past medical history included a RYGB for morbid obesity 7 years before presentation, and ischemic heart disease. Conservative therapy did not alleviate his symptoms. Computed tomography (CT) scan showed marked ascending colon dilatation (Fig. 1A) without an identifiable lesion indicative of CPO. The differential diagnosis for CPO included functional causes such as cardiac disease, metabolic or electrolyte imbalances, renal insufficiency, medications, and anatomic causes like inflammatory processes and malignancy. Over the course of 2 months several diagnostic procedures were done. Three colonoscopies with multiple biopsies of the right colon showed submucosal mucin extravasation without mucosal abnormalities. On workup for elevated liver enzymes, a magnetic resonance cholangiopancreatography demonstrated intrahepatic biliary dilation with a dilated common hepatic duct and could not rule out a lesion in the bile duct as the cause. A laparoscopically assisted endoscopic ultrasound (EUS) through the remnant stomach showed dilated intrahepatic ducts; a fine needle aspiration of the liver, performed to assess for a possible hilar lesion observed during the EUS, did not show abnormalities. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful due to distorted anatomy. After the ERCP attempt the patient developed shock and was found to have a perforation of the duodenum during emergent exploratory laparotomy. The perforation was closed and the dilated right colon excised. Shortly thereafter, additional procedures were necessary for intestinal infarction secondary to the perforation induced shock, emergent surgery, and poor cardiac function. He continued deteriorating, opted for comfort measures only and expired a week later. Pathologic examination of the colon showed prominent segmental dilatation but no discrete lesions (Fig. 1B). Microscopically pyloric-type glands with minimal cytologic atypia were present in the muscularis propria and subserosa (Fig. 1C). The tumor did not elicit a desmoplastic response. Architecturally, the tumor glands were well formed with no or minimal branching; the longest axis of the glands always followed the orientation of the collagen they were invading (Fig. 1D). The mucosa was free of tumor. By immunohistochemistry the tumor was positive for cytokeratin (CK) 7, SMAD4, S100P and negative for CK20 and CDX2, consistent with foregut origin. Ki-67 proliferative activity was 25%. At autopsy the primary tumor was located in the antrum of the RYGB, where it caused diffuse thickening of the wall (Fig. 2).

Bottom Line: EWDA of the stomach is rare, difficult to diagnose, and shows an aggressive clinical course discordant with its near-benign histology.Surveillance of the blind pouch is not currently recommended.Malignant infiltration of the colonic wall should be included in the differential diagnosis of CPO of unclear etiology.

View Article: PubMed Central - PubMed

Affiliation: University of Minnesota School of Medicine (Sarah McFarland, J. Carlos Manivel, Archana Ramaswamy), Veterans Administration Health Care Service, One Veterans, Drive Minneapolis, USA.

ABSTRACT
Gastric carcinoma after gastric bypass is rare. Extremely well-differentiated adenocarcinoma (EWDA) of the stomach is a rare variant that has been mostly reported in Japan. We present a case of a 68-year-old man with EWDA arising in the bypassed stomach that presented as a colonic pseudo-obstruction (CPO). Several imaging, endoscopic and pathologic studies performed in the course of 2 months were non-diagnostic. An iatrogenic duodenal perforation during a diagnostic procedure led to an emergent exploratory laparotomy in which the dilated colonic segment was resected. Pathologic examination showed metastatic EWDA in the colonic wall. Post-operative complications led to the patient's demise. At autopsy the primary tumor was identified in the blind pouch of the bypassed stomach. A literature review on gastric EWDA and carcinomas arising in bypassed stomachs is discussed. EWDA of the stomach is rare, difficult to diagnose, and shows an aggressive clinical course discordant with its near-benign histology. Gastric cancer arising in a bypassed stomach is uncommon; when it occurs it is usually diagnosed at advanced stage. Surveillance of the blind pouch is not currently recommended. Malignant infiltration of the colonic wall should be included in the differential diagnosis of CPO of unclear etiology.

No MeSH data available.


Related in: MedlinePlus