Malignant lymphoma occurring in the residual stomach following gastrectomy: plus discussion based on the literature in Japan

Malignant lymphoma of the remnant stomach was diagnosed in a 53-year-old man 8 years after gastrectomy for a perforated gastric ulcer. Endoscopic examination demonstrated protruding lesions spreading over the entire residual stomach, and biopsy revealed malignant lymphoma. Rectal cancer was diagnosed simultaneously. The residual stomach was completely excised, with splenectomy, in parallel with low anterior resection of the rectum. Histological studies revealed that the lesion in the residual stomach was a lymphoma of the diffuse, large-cell type, according to the Lymphoma–Leukemia Study Group (LSG) classification, with positivity for CD20 and CD45RA, leading to a diagnosis of B-cell lymphoma. Helicobacter pylori microorganisms were found on the luminal surface of the tumor. Despite postoperative chemotherapy, the patient died of disseminated lymphoma 34 months later. Although malignant lymphoma occurring in the residual stomach following gastrectomy is rare, particular attention should be given to the possible presence of a malignant tumor when examining the residual stomach following gastrectomy. Received: April 3, 2002 / Accepted: November 28, 2002 Offprint requests to: H. Oshita     

A case of malignant lymphoma of the remnant stomach

A 46-year-old woman was transferred to our facility with the complaint of epigastric discomfort of more than four months duration. She had undergone partial gastrectomy with Billroth I anastomosis 19 years prior to the admission. An upper GI series revealed multiple, variously sized elevated lesions scattered over the remnant stomach. Fiberscopic examination showed the gastric mucosa replaced by several elevated lesions and giant fold embellished by erosion, injection, and necrotic debris. Pathological examination revealed malignant lymphoma of the large cell type whose main growth was in the mucosa and submucosa. This case was significant in that malignant lymphoma occurred in the remnant stomach and that the tumor converted M-protein in the serum, which was confirmed as IgM-k in the cytoplasma immunohistochemically.     

Leiomyosarcoma of the remnant stomach--a case report

A case of leiomyosarcoma of the remnant stomach is reported. The patient was a 57-year-old woman whose chief complaint was easy fatigability. Twenty six years earlier, she had undergone gastrectomy with the diagnosis of duodenal ulcer. By X-ray examination of the stomach, a Borrmann type I gastric cancer was suspected on admission. Endoscopic study of the stomach was performed, and a diagnosis of leiomyosarcoma was made from the biopsy specimens. Total gastrectomy was performed. On the resected specimen, a Borrmann type I like tumor measuring 4.5 X 5.5 X 3.2 cm was identified in the anterior part of the body of the remnant stomach. Histologically, the lesion was confirmed as leiomyosarcoma of the stomach.     

Laparoscopy-assisted subtotal gastrectomy with very small remnant stomach: a novel surgical procedure for selected early gastric cancer in the upper stomach

Total gastrectomy or proximal gastrectomy is usually performed either as an open procedure or laparoscopically for the treatment of early gastric cancer (EGC) in the upper stomach. However, quality of life after either total or proximal gastrectomy is not so satisfactory. The authors report a novel surgical procedure, laparoscopy-assisted subtotal gastrectomy (LAsTG), by which a very small remnant stomach is preserved, for the surgery of selected EGCs in the upper stomach. Twenty-three patients with EGC in the upper stomach underwent LAsTG. After lymph node dissection and mobilization of the stomach, the stomach was transected about 2 cm proximal to the tumor and a very small remnant stomach was preserved. An anvil was inserted transorally into the remnant stomach by using the OrVil™ system. The reconstruction method was Roux-en-Y, and hemidouble-stapling gastrojejunostomy with a circular stapler was performed intracorporeally. There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 266.7 min and 54.6 ml, respectively. The overall incidence of early postoperative complications was 17.4%, and two patients underwent reoperation because of duodenal stump leakage and stenosis of the Y-anastomosis, respectively. During the follow-up period, two patients experienced gastrojejunostomy stenosis and both were treated successfully by endoscopic balloon dilation. LAsTG may be performed in selected patients with EGC in the upper stomach. With the described method, a very small remnant stomach can be preserved.     

A long-term survival case of metachronous liver metastasis from gastric cancer

A 62-year-old man was admitted for gastric cancer. He was performed a distal gastrectomy with Billroth I reconstruction in August 1999. Then he had remnant gastric cancer and metachronous liver cancer in November 2002. He was performed a total gastrectomy and partial hepatic resection. The histological findings of remnant stomach and liver cancer showed a same pattern of the primary gastric cancer. Another metachronous liver cancer appeared in March 2006. He was treated with chemotherapy using S-1 (day 1-21) and CDDP 20 mg/m2 (day 1, 8 and 15) q5w. The size of liver metastasis was kept the same for 16 months.     

A case of primary intracranial malignant lymphoma associated with gastric carcinoma

A case of synchronous multiple primary neoplasms, an intracranial malignant lymphoma and a gastric carcinoma, is presented. A 63-year-old man was admitted to our hospital with complaints of dizziness and a floating sensation on gait. A CT scan after admission, revealed a well-defined, nodular high density area in the left frontal lobe, which was markedly enhanced by the contrast medium. In order to rule out a metastatic brain tumor, examinations were performed as a consequence, and, the gastric carcinoma was found. A partial removal of the brain tumor and a gastrectomy were performed in two stages. Pathologically, the diagnosis of the brain tumor indicated a malignant lymphoma of large cell type, and that of the gastric carcinoma was an adenocarcinoma. The patient received postoperative irradiation and chemotherapy and was discharged in a good condition. He died of pneumonia 21 months after the operation. Necropsy revealed a marked atrophy of the brain without recurrence of the malignant lymphoma and no recurrence of a gastric cancer.     

Neoadjuvant therapy with imatinib mesilate for gastrointestinal stromal tumor of the stomach before subsequent successful surgical resection

A 65-year-old man is presented here with a huge mass of 13 cm in diameter in the left upper abdomen. Histopathologic assessment of endoscopic forceps biopsy revealed a c-kit positive gastrointestinal storomal tumor (GIST) of the stomach. Abdominal computed tomography (CT) showed a direct invasion to the pancreas. Imatinib mesilate was administered as neoadjuvant therapy according to the NCCN Guidelines. Imatinib mesilate therapy was stopped within 2 weeks because of adverse events such as Grade 2 of facial edema and dizziness. However, no hematological adverse event was shown. After three months of treatment (relative dose intensity was 87.5%), CT revealed a reduction in tumor diameter of 35.6% and showed no longer a direct invasion to the pancreas. The radical operation was considered feasible and partial gastrectomy was performed. The tumor was well encapsulated and radical surgery was possible without rupture. Adjuvant therapy was not performed. The patient has now been in good health without a recurrence for three months after the surgery.     

A case of recurrent intra-abdominal pediatric desmoid tumor undergoing surgical intervention for 6 times

A 15-year-old male patient with palpable abdominal tumor presented to our hospital. CT scan revealed a giant tumor, 15 cm in diameter, with infiltration to the pancreas body. In addition, the tumor invaded to the greater curvature of the stomach and the transverse colon. We performed distal gastrectomy, distal pancreatectomy, splenectomy and transverse colectomy. The final diagnosis of histopathology was desmoid tumor. The tumor recurred locally 9 months after the surgery. Recurrent legion was unresectable because of the invasion to the orifice of SMV and weekly combination chemotherapy of VLB and MTX was started. Although a partial response was achieved for a local recurrent legion after 20 courses, CT scan showed other new recurrent multiple lesions in the abdominal cavity. Due to the severe abdominal discomfort and intestinal obstruction, a reduction surgery was performed 5 times in total. Endocrine therapy and administration of NSAID were not effective. Tumor progression was uncontrollable, and the patient died 5 years and 8 months after the initial surgery.     

Hand-assisted laparoscopic surgery for a large gastrointestinal stromal tumor of the stomach

We report two cases of large gastrointestinal stromal tumor (GIST) of the stomach that were successfully treated by hand-assisted laparoscopic surgery (HALS). Two patients, a 56-year-old woman and a 60-year-old man, were admitted to our department for the treatment of a large submucosal tumor of the stomach. After gastrointestinal endoscopy, ultrasonography, computed tomography, and magnetic resonance imaging, we suspected that the masses, measuring 7.0 cm and 8.0 cm in diameter, respectively, were GISTs in the stomach. However, preoperatively, we could not rule out the possibility of malignant neoplasms, because they had been bleeding or gradually growing. Hand-assisted laparoscopic wedge resection was safely performed for the diagnosis and treatment of the submucosal tumor of the stomach. The immunohistochemical diagnosis in both patients was GIST of the stomach with intermediate-grade malignancy. HALS may be a good indication for large GISTs of the stomach that are difficult to diagnose preoperatively, whether they are malignant or benign, because it is safe and minimally invasive, promoting rapid recovery.     

胃大部切除术后食管癌的外科治疗(30例残胃食管吻合术)

自１９８９年６月至１９９６年６月对３０例胃大部切除术后食管癌采用经左胸切除，后充分游离残胃脾胰体尾并将其移入左胸内行残胃食管弓下、弓上或颈部吻合，取得良好效果。术后并发症５例（１６．６％）。其中吻合口瘘１例，非手术治愈，脓胸２例，心律失常频发室早、房早各１例，无手术死亡。作者认为本手术方法操作方便，手术时间短，除颈部吻合外通常一个切口一个吻合口即能完成手术，通过对残胃充分游离一般能上提２０～２５ｃｍ，使吻合无张力，同时食管切除长度达无瘤残留，同时还保留了残胃，有利于消化功能，是一种有实用意义的手术方式。     

A case of coexistent adenocarcinoma and primary malignant lymphoma of the stomach

A case of a simultaneous adenocarcinoma and a primary malignant lymphoma of the stomach is presented. A sixty-one-year-old male was referred to us with epigastralgia. Gastroscopy and a biopsy revealed a *** c-like lesion in the stomach and, on histological examination, was determined as being an adenocarcinoma. A proximal gastrectomy and an R2-resection of lymph nodes then was performed. A pathological examination of the resected stomach disclosed a malignant lymphoma neighboring the adenocarcinoma. The presence of a simultaneous carcinoma and a malignant lymphoma of the stomach is quite rare, with only twenty-eight documented patients reported in the Japanese literature. This entity is discussed.     

Multiple synchronous early gastric cancers: High-risk group and proper management

BackgroundMultiple early gastric cancers (MEGCs) may be easily missed on preoperative gastroscopy because the lesions are predominantly small and flat. This may increase the risks of gastric remnant lesions and recurrence. We aimed to define high-risk group of MEGC and suggest proper management of missed lesion after partial gastrectomy.MethodsA total of 117 patients with MEGCs and 2182 with solitary EGC who underwent gastrectomy between 2008 and 2010 were retrospectively analyzed to determine their clinicopathologic characteristics. We also assessed their family history, the presence of Helicobacter pylori infection, and of precancerous lesions; and the results of microsatellite instability and immunohistochemical staining of the primary (largest) lesion for p53, human epidermal growth factor receptor [HER1], and HER2 were also reviewed.ResultsMEGCs occurred more frequently in elderly males and in patients with adenoma, atrophic gastritis, or a family history of gastric cancer. These patients had more favorable pathologic findings, including less deep invasion, better differentiation, more intestinal type, and less frequent lymphovascular/perineural invasion than patients with solitary EGCs. The mean size of MEGCs was smaller (2.44 cm vs 3.36 cm) but there was no difference in the number of metastatic lymph nodes. Most accessory lesions were confined to the mucosal layer, with their average diameter was 1.82 cm.ConclusionsA careful preoperative gastroscopy should be performed in patients at high risk of MEGCs and more cautious postoperative endoscopic surveillance of the remnant stomach is required. For missed foci on remnant stomach, endoscopic resection can be a good option if it meets the criteria.     

An extraordinary case in whom gastrointestinal stromal tumor and low-grade malignant lymphoma are seen together in the stomach

Introduction Gastrointestinal system (GIS) is the most common site of involvement of all primary extranodal lymphomas. Gastric lymphoma constitutes 3–6% of all primary stomach malignancies. Stomach is also the commonest site of involvement of gastrointestinal stromal tumors (GIST). We would like to report these rare synchronous tumors in the same patient. Case A 68-year-old male was admitted to the internal medicine clinics with the complaints of abdominal distension. Physical examination was normal. On abdominal computed tomography a 12 × 14 × 22 cm sized giant tumoral mass was detected in left hypochondrium. A total gastrectomy was performed. Two distinct neoplasms were detected; one of which was located in the posterior wall of the stomach with the size of 24 × 16 × 13 cm, and the other one was localized in the fundus of the stomach and its size was 6 × 5 × 2 cm. Pathological evaluation revealed the diagnosis of GIST at the posterior wall and low-grade malignant lymphoma from the mass localized in the fundus of the stomach. Discussion Two primary tumors are not seen so often together in the stomach. Adenocarcinoma and associated tumors including gastric lymphoma (especially MALT lymphoma), carcinoid, leiomyosarcoma and rhabdomyosarcoma constitute most of the reported series. Rarely adenocarcinoma and associated GIST cases were reported. It is important to report concurrent gastric lymphoma and GIST case since it is extremely rare in the English literature.     

Metastatic gastric tumor from renal cell carcinoma

Metastatic tumors of the stomach are rare, with an incidence of 0.2%–0.7%, and they have been reported to result mainly from primary breast cancers, lung cancers, and melanoma. Further, among such metastatic tumors, the metastasis of renal cell carcinoma (RCC) to the stomach is an extremely rare disease, and it is usually reported in autopsy series. We report a rare case of metastatic gastric tumor derived from right renal carcinoma. Gastric endoscopy confirmed a large, polypoid, friable mass (type 1 tumor, about 7 cm in diameter) in the middle part of the stomach body. The mass was surgically excised and pathological examination showed that the gastric tumor was derived from a metastasis from the right kidney, because it was composed of malignant cells that were identical to those from the removed RCC. In addition, the tumor cells were immunoreactive for CD10, CD15, Ecadherin, early membrane antigen (EMA), and vimentin, but no reactivity was observed for cytokeratins 7 and 20 or c-KIT. Although gastric metastatic tumor derived from renal carcinoma is rare, the precise pre- and postoperative diagnosis may be important; thus, investigation for such metastatic tumors should be performed routinely in the follow up of patients who have been treated for RCC.     

A case of gastric gastrointestinal stromal tumor resected after chemotherapy with imatinib

We report a case of a residual stomach gastrointestinal stromal tumor (GIST) successfully treated with resection. We were able to curatively resect after treatment with imatinib. A 33-year-old man underwent distal gastrectomy for duodenal ulcer perforation at the age of 18. He began to experience back pain, and the diagnosis of mild gastritis was made over observation in near medicine, but he was admitted to our hospital because his symptoms continued for 5 months. Abdominal CT and MRI showed a protruding lesion of approximately 17 cm in the left upper-abdomen. Surgery was performed, but the tumor had directly invaded the surrounding organs. To find the definite diagnosis, a biopsy was performed. The histopathological diagnosis was c-kit-positive GIST. Administration of imatinib 400 mg/day was commenced. After 6 months of treatment, CT revealed a roughly 68% reduction in the tumor's diameter. The radical operation was considered feasible and total gastrectomy was performed. The postoperative course was uneventful. Neoadjuvant therapy with imatinib may become a useful means of conserving improve organ and complete resection rate increase with tumor reduction.     

Histiocytic and t-cell rich b-cell lymphoma (TCRBCL) of the stomach

Although stomach is a frequent site of extranodal lymphomas, histiocyte-rich TCRBCL has not yet been described there. Even histology of repeated gastrobiopsies of this uncommon, diffuse, large B-cell lymphoma may be inconclusive and partial gastrectomy cannot be avoided. It is only immunohistology (CD20, CD43, CD68) of the paraffin blocks from the resection specimen that can lead to the final diagnosis of intermediate grade malignant lymphoma.     

Primary gastric malignant lymphoma followed by gastric adenocarcinoma: report of 4 cases and review of the literature.

Four cases of primary gastric malignant lymphoma followed years later by adenocarcinoma of the stomach are described. Review of the literature revealed eleven other cases of these two lesions occurring in the same patient. In our four cases gastric adenocarcinoma developed many years after successful treatment of primary gastric lymphoma by partial gastrectomy. In three patients gastrectomy had been followed by radiation treatment to the upper abdomen. The relationship between the two tumors is discussed, including the possible role of treatment of the lymphoma in the development later of gastric adenocarcinoma. It is important to consider the possibility of the later development of a second primary gastric cancer in a patient who develops gastric symptoms, after successful treatment for primary gastric neoplasm.     

A case of AFP-producing gastric cancer patient with liver relapse occurred three months after endoscopic mucosal resection (EMR) and gastrectomy

A 60s male was admitted to our hospital for a diagnosis of gastric tumor sized 20 mm in diameter at the fornix of the stomach. Endoscopic mucosal resection (EMR) was performed, and the resected tumor was pap, m, ly0, v0, HMX, VM0, pathologically. One month after the EMR, the local recurrence was confirmed and a partial gastrectomy was performed. Pathological findings were tub1, sm2, ly1, v1, HM0, VM0. Total gastrectomy was added because of the possibility of the lymph node metastasis. Pathological findings revealed no residual cancers. The final pathological diagnosis was T1b(sm2) N0H0P0M0, Stage IA, based on the Japanese classification of gastric cancer. Three months thereafter, CT showed multiple liver metastases. Immunohistochemical study of the operated tumor revealed AFP-producing gastric cancer. Chemotherapy was performed, but he died of the gastric cancer. Endoscopic treatment is a minimally invasive therapeutic strategy, but it requires a considerable care in application.     

原发性乳腺恶性淋巴瘤12例分析

［目的］探讨原发性乳腺恶性淋巴瘤的诊断要点,以及肿瘤切除的相关问题和术后的辅助治疗。［方法］对１９７０年至１９９３年２月诊治的１２例原发性乳腺恶性淋巴瘤患者进行随访分析。［结果］经过６年４个月的中位随访期,５年总生存率为５０％。［结论］原发性乳腺恶性淋巴瘤临床诊断较难。肿块多生长迅速,但对皮肤、肌肉、腋淋巴结浸润少,无需选择根治手术。对肿瘤＜５ｃｍ者可行肿块切除术,＞５ｃｍ者行乳腺切除手术,腋窝淋巴结有肿大者可加做腋窝淋巴结清扫。术后早期化疗可有效延长患者的生存年限。