Endoscopic submucosal dissection of squamous cell carcinoma in the upper stomach 5 years after chemoradiotherapy for adenocarcinoma

Primary squamous cell carcinoma is rarely observed, with a reported incidence of 0.04–0.07 % of all gastric cancers. An 81-year-old male underwent chemoradiotherapy for type 1 gastric cancer of the posterior wall of the cardiac region in 2005. The tumor disappeared after 1 year of therapy, following which an area of white epithelium, approximately 30 mm in diameter and continuous with the esophageal mucosa, became visible. Biopsy of the white epithelium indicated normal squamous epithelium. An elevated lesion was subsequently detected in the area of white epithelium on upper gastrointestinal endoscopy during a follow-up examination 5 years after therapy. As a biopsy of the same site indicated squamous cell carcinoma, we performed endoscopic submucosal dissection. Histopathological examination indicated high-grade fibrosis due to radiotherapy and showed a moderately differentiated squamous cell carcinoma invading the scarred portion. We describe a case where the developmental process of a squamous cell carcinoma was observed using endoscopy, including narrow band imaging with magnification. This carcinoma likely originated from squamous metaplasia that developed after chemoradiotherapy was administered for a gastric cancer.     

A case of superficial esophageal carcinoma with papilloma resected by en bloc endoscopic submucosal dissection

A 71-year-old man underwent upper gastrointestinal endoscopy, and a slightly protruded lesion was detected 26 cm from the incisors. Biopsy specimen revealed chronic esophagitis. One year later, re-examination with upper gastrointestinal endoscopy showed persistence of the protruded lesion and also new findings of a slightly depressed and erythematous lesion at the opposite side. He was admitted to our hospital, and histological examination of the biopsy specimens from upper gastrointestinal endoscopy revealed concomitant squamous cell papilloma and squamous cell carcinoma. [¹⁸F]-fluorodeoxyglucose (FDG) accumulated in the squamous cell papilloma and/or in the mucosal squamous cell cancer. Endoscopic submucosal dissection was performed. Human papillomavirus (HPV) 16/18 was not detected in either lesion. Concomitant esophageal papilloma and esophageal squamous cell carcinoma is extremely rare. Additional study is required to characterize the etiology, diagnosis (including FDG accumulation), and clinical course of this phenomenon. The relationship between HPV infection and esophageal squamous cell carcinoma is reviewed.     

SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH BULKY GASTRIC HIATUS LYMPH NODE METASTASIS: A CASE REPORT

In patients with superficial esophageal cancer, especially in those with tumor invasion above the muscularis mucosae, lymph node metastasis is very rare. We report a case of superficial esophageal cancer who presented with lymph node metastasis. In another hospital a 49‐year‐old man was found to have a bulky tumor adjacent to the cardiac area of the stomach and a total gastrectomy was carried out. Postoperatively, the tumor was identified as a lymph node containing metastatic squamous cell carcinoma. The main lesion could not be identified on fluorodeoxyglucose positron emission tomography. On esophagogastric endoscopy, using the iodine spray technique, we found an unstained lesion about 32 cm from the incisor teeth. The tumor was removed using endoscopic mucosal resection. The entire resected specimen was examined histopathologically; the depth of the tumor was above the muscularis mucosae. Thirty‐four months after endoscopic mucosal resection, there is no sign of tumor recurrence or metastasis.     

Granulocyte colony-stimulating factor-producing esophageal squamous cell carcinoma following chemoradiotherapy and bone marrow transplantation for acute lymphoblastic leukemia

A 30-year-old man, who had been treated with craniospinal irradiation, total-body irradiation, and bone marrow transplantation for acute lymphoblastic leukemia at 20 years of age, complained of dysphagia. The patient had spike fever with leukocytosis (19,020/μl). Serum granulocyte colony-stimulating factor (G-CSF) level was also increased (53.7 pg/ml). Immunohistochemistry revealed positive staining for anti-G-CSF antibody in carcinoma cells obtained by endoscopic biopsy. The patient was diagnosed with G-CSF-producing locally advanced esophageal squamous cell carcinoma. The clinical diagnosis was T4; tumor invaded aorta, with regional lymph node metastases (N1). The patient underwent transthoracic esophagectomy with three-field lymph node dissection and gastric tube reconstruction following a radiation dose of 41.4 Gy with 5-fluorouracil continuous infusion as neoadjuvant therapy. There were no viable cancer cells in the resected esophageal specimen and lymph nodes. The patient had no evidence for typical risk factors for developing esophageal cancer. After the operation, neutrophils and G-CSF decreased to normal levels. The patient had recurrence of regional and distant multiple lymph node metastases at 3 months after operation.     

Electrocautery therapy combined with oral steroid administration for refractory corrosive esophageal stenosis prevents restenosis

A 61-year-old female with refractory corrosive esophageal stenosis repeatedly underwent endoscopic balloon dilation at another hospital; however, no improvements were observed in the esophageal stenosis. Consequently, she had been on a liquid diet for the previous three years. She was admitted to our department for further treatment. A radial incision was made, by use of the SB knife Jr, for a pinhole-like stenosis in a short segment 39 cm from the incisor, and dilation was safely performed by use of a CRE balloon dilator. Subsequently, prednisolone was orally administered to prevent re-stenosis. This was followed by a favorable clinical course.     

Implantation of esophageal cancer onto post-dissection ulcer after gastric endoscopic submucosal dissection

A case in which implantation of esophageal squamous cell carcinoma onto a post-dissection gastric ulcer was strongly suspected is presented. A 72-yearold man with alcoholic liver cirrhosis underwent esophagogastroduodenoscopy(EGD). Esophageal cancer(EC)(Mt, 20 mm, 0-Is) and gastric cancer(GC)(antrum, 15 mm, 0-Ⅱc) were identified. Biopsy specimens revealed moderately differentiated squamous cell carcinoma(SCC) and differentiated adenocarcinoma, respectively. The GC was resected by endoscopic submucosal dissection(ESD) [14 mm × 9 mm, type 0-Ⅱc, tub1, p T1a(M), ly0, v0, HM(-), VM(-)]. Two months after ESD, radiation therapy was started for the EC, and an almost complete response was obtained. Nine months after the ESD, a follow-up EGD showed a submucosal tumor-like lesion with ulceration, located immediately under the post-ESD scar, and biopsy specimens showed moderately differentiated SCC. There were no similar lesions suggesting hematogenous or lymphatic metastasis in the stomach.     

A case of sigmoid colon adenocarcinoma diagnosed as facial cutaneous metastasis for survival after operation for 37 months

Cutaneous metastasis of an internal malignancy is uncommon and is estimated to occur in 0.7–9% of patients with internal cancer including autopsy cases. We would like to report a case of long survival of sigmoid colon adenocarcinoma diagnosed as an instance of facial cutaneous metastasis. A 68-year-old male was admitted to our hospital for a tumor mass on the left side of his cheek. In his past history, acute myocardial infarction had occurred 2 years earlier. He also had chronic renal failure and chronic obstructive pulmonary disease. Histologic findings from the biopsy sample of this facial lesion were moderately differentiated adenocarcinoma. Colonoscopy revealed a tumor 20 mm × 30 mm in diameter in the sigmoid colon. Histologic findings of the biopsy sample of this tumor also indicated moderately differentiated adenocarcinoma. The patient was diagnosed with sigmoid colon cancer with cutaneous metastasis to the face. We performed a sigmoidectomy with lymph node dissection and resection of the facial cutaneous metastasis. After being discharged, low dose chemotherapy was performed in consideration of the patient's renal function. Although long-term management of his general condition was provided, the patient died 37 months after surgery because of chronic heart failure.     

A case of intramural gastric tube metastasis from esophageal squamous cell carcinoma

A 53-year-old Japanese man with advanced squamous cell carcinoma of the thoracic esophagus underwent a subtotal esophagectomy with gastric tube reconstruction through the posterior mediastinum. The staging was T3N0M0. Gastrointestinal endoscopy 6?months after surgery revealed a submucosal lesion in the gastric tube used for reconstruction. A biopsy yielded a diagnosis of squamous cell carcinoma, consistent with metastasis from the esophageal carcinoma. Despite chemotherapy and radiotherapy, the patient died of bleeding 11?months after initial surgery. We report the clinical, endoscopic, and computed tomographic findings in this patient with intramural gastric-tube metastasis.     

Fluorescence induced with 5-aminolevulinic acid for the endoscopic detection and follow-up of esophageal lesions.

BACKGROUND: The aim of this study was to investigate the use of orally administered 5-aminolevulinic acid (ALA) for in vivo photodynamic diagnosis and follow-up of premalignant and malignant esophageal lesions. METHODS: Twenty-two patients with known or treated malignant and precancerous esophageal lesions were sensitized with orally administered ALA (15 mg/kg). Six patients had Barrett's esophagus, with or without severe dysplasia, 5 squamous cell cancer or early-stage (uT1N0M0) adenocarcinoma, 1 advanced-stage (uT3N1) adenocarcinoma, and 1 patient a lesion with an appearance that suggested esophageal cancer. Nine patients underwent photodynamic diagnosis for follow-up after treatment of esophageal cancer with curative intent; 6 had no macroscopically visible lesion and 3 a barely visible lesion under standard (white-light) endoscopy. Photodynamic diagnosis was conducted 6 to 7 hours after oral administration of ALA by using a special light source capable of delivering either white or violet-blue light. Red fluorescence was detected with a charged coupled device camera attached to a fiberoptic endoscope. Corresponding endoscopic, fluorescence, and microscopic findings were compared. RESULTS: By using histology as the reference standard (n = 86 biopsies), 85% of the biopsy sites with premalignant or malignant histopathology exhibited red fluorescence, whereas only 25% were detected with white-light endoscopy. CONCLUSION: ALA-induced fluorescence might be useful for the early endoscopic detection of malignant esophageal lesions and follow-up after treatment of such lesions with curative intent.     

Primary squamous cell carcinoma of the liver concomitant with primary colon cancer: report of a case

A 55-year-old Japanese female was admitted to our hospital to treat colon cancer. Computed tomography revealed a 2.6 × 2.0 cm liver mass considered to be liver metastasis. She synchronously underwent right colectomy with D3 lymph node dissection and subsegmentectomy 8 under the diagnosis of advanced colon cancer with liver metastasis. The pathology examination revealed the liver nodule was pure squamous cell carcinoma (SCC), whereas histology of colon cancer was a well differentiated tubular adenocarcinoma containing no squamous component. The patient underwent intensive checkup by imaging for a primary site of SCC. However, no lesion considered as possible primary site of SCC was found. Therefore, the liver nodule was finally diagnosed as a primary hepatic SCC. Primary SCC of the liver is a rare and high-grade malignant tumor. Recurrent multiple liver nodule was found at 13 months after surgery and the patient died of cancer 17 months after surgery.     

Isolated breast metastasis from gastric cancer in a male patient

A 72-year-old man underwent total gastrectomy for gastric cancer (por2, T3, N2, Stage IIIA). Eleven courses of postoperative chemotherapy with TS-1 (tegafur/gimeracil/oteracil) were administered. Five months after surgery, the serum carcinoembryonic antigen value was slightly elevated. However, computed tomography did not reveal any metastatic lesions in other organs. Two years after surgery, the patient felt a mass in the left mammary. A 2-cm tumor was palpable in the central portion of the breast. Ultrasonography revealed a hypoechoic tumor, which was Class 3 on aspiration biopsy cytological examination. No mass was detected on positron emission tomography–computed tomography. The mammary gland tumor increased in size to 3 cm, and a core needle biopsy procedure was performed. Histological examination findings revealed breast metastasis of gastric cancer. No other recurrence was found, and radical mastectomy was performed 2 years and 5 months after gastrectomy. Immunohistological analysis of the resected material confirmed breast metastasis of the gastric cancer. Two courses of TS-1 + cisplatin were administered, but this treatment was subsequently terminated because the patient experienced Grade 3 diarrhea and neutropenia. Three years and 1 month after the gastrectomy, the tumor recurred in the pelvic area. Chemotherapy and radiation therapy were performed, but the patient’s overall condition became progressively worse, and he died 3 years and 9 months after gastrectomy.     

A case of verrucous squamous cell carcinoma of the esophagus

We report a rare case of verrucous squamous cell carcinoma (VSC) of the esophagus. A 73-year-old woman presented to our hospital with dysphagia. On gastrointestinal endoscopy, a white mass with a cauliflower-like appearance (3.5 cm in diameter) was detected in the upper esophagus at 23 cm from the incisors. Histological examination of a biopsy specimen revealed squamous epithelial hyperplasia and no malignancy. During 17 months of follow-up by repeated endoscopy, the lesion showed no marked changes in appearance. However, reexamination of the specimen obtained by partial endoscopic mucosal resection (EMR) using a jumbo biopsy forceps revealed very well differentiated squamous cell carcinoma corresponding to VSC. The clinical and histopathological characteristics of esophageal VSC are discussed on the basis of the published literature.     

Endoscopic removal of a large hyperplastic (inflammatory) polyp in esophagogastric anastomosis after esophagectomy

Hyperplastic (inflammatory) polyp (HP) is uncommon in the esophagus and esophagogastric junction. We report a case of HP arising in the esophagogastric anastomosis 2 years after esophagectomy for esophageal squamous cell carcinoma in a 64-year-old woman. The lesion was resected endoscopically. The histopathological diagnosis was HP. There has been no evidence of carcinoma or HP for more than 6 years after initial surgery. This is the first reported case of HP arising in an esophagogastric anastomosis after esophageal surgery that was successfully treated by endoscopic resection.     

A tiny esophageal cancer diagnosed accurately by magnifying endoscopy and endocytoscopy: report of a case

An 82-year-old woman presented for a periodic endoscopic examination after radiotherapy and endoscopic mucosal resection (EMR) of a cancer in the esophagus. Conventional endoscopy demonstrated a tiny, flat, reddish lesion about 1 mm in diameter proximal to the scar of the previous esophageal EMR. Observation after iodine staining showed an apparent unstained area in the lesion. Magnifying observation using a Q240Z (Olympus, Tokyo, Japan) revealed a clearly demarcated aggregation of dilated intrapapillary capillary loops in this part of the lesion. Endocytoscopic observation (XEC120U prototype; Olympus) showed increased cellular density and irregularity of the epithelial nuclei. Endoscopic mucosal resection of the lesion was performed. Pathological studies of the resected specimen revealed a squamous cell carcinoma, maximal diameter 920 μm, confined to the epithelium. We believe that the Endocytoscope has the potential to reduce biopsy histology in cases of esophageal squamous cell carcinoma.     

A patient with esophageal cancer with bone metastasis who achieved pain relief with repetitive administration of strontium-89 chloride

A 75-year-old woman was diagnosed with esophageal cancer with difficulty in swallowing. She had a past history of rheumatoid arthritis, scleroderma, interstitial pneumonia, angina pectoris (with coronary artery bypass surgery) and arrhythmia (with pacemaker implantation). She refused surgery, and chemotherapy and radiotherapy were not performed because of the high risk accompanied with multiple comorbidities. She received proton therapy at another hospital and the primary lesion shrank. Bone metastasis in the thoracic vertebrae was diagnosed 10 months after diagnosis of esophageal cancer. Non-steroidal anti-inflammatory drugs and zoledronic acid were administered for back pain. Oxycodone was also administered but discontinued due to nausea. After strontium-89 (⁸⁹Sr) chloride administration, her back pain was relieved. ⁸⁹Sr was administered five times every 3 months, and the pain did not worsen until her death due to pneumonia 2 years after diagnosis of esophageal cancer. ⁸⁹Sr was effective for pain from bone metastasis of esophageal cancer, and its repeated administration was safe.     

Esophageal verrucous carcinoma arising from hyperkeratotic plaques associated with human papilloma virus type 51

Esophageal verrucous carcinoma is a rare variant of esophageal squamous cell carcinoma. We report a case of esophageal verrucous carcinoma associated with human papilloma virus (HPV) type 51. The patient had long‐standing dysphagia and odynophagia, and white esophageal plaques showing hyperkeratosis on biopsy. At repeat endoscopy, the esophagus was covered with verrucous white plaques and areas of nodular mucosa with white fronds, with a distal 10‐cm smooth mass protruding into the lumen. Biopsies demonstrated an atypical squamoproliferative lesion but no frank malignancy. HPV type 51 DNA was detected in endoscopic biopsy specimens by polymerase chain reaction. Because the size of the lesion favored an underlying verrucous carcinoma, our patient underwent minimally invasive esophagectomy with gastric pull‐up and cervical anastomosis. The pathologic diagnosis was a well‐differentiated esophageal verrucous carcinoma. One year after esophagectomy, the patient feels well and is free of disease. Although HPV DNA was not detected in the cancer tissue obtained at surgery, our case suggests an association between HPV type 51 and esophageal verrucous carcinoma. The clinical evolution in this case highlights the importance of endoscopic surveillance in patients with exuberant esophageal hyperkeratosis, and of definitive surgical resection when malignancy is suspected even if frank malignancy is not demonstrated on superficial biopsies.     

Primary adenocarcinoma arising in an interposed colon

We herein report a rare case of adenocarcinoma arising in an interposed colon. A 71-year-old male underwent total thoracic esophagectomy for thoracic esophageal cancer followed by antesternal reconstruction using the right colon. Seven months later, ¹⁸F-fluorodeoxy-glucose positron emission tomography revealed increased uptake in the interposed colon. Endoscopy detected a mass 25 mm in diameter in the cecum of the interposed colon approximately 10 cm from the distal anastomosis. An endoscopic biopsy showed well-differentiated adenocarcinoma. Partial resection of the interposed colon was performed, and the patient’s postoperative course was uneventful. The patient is currently alive with no signs of recurrence three years after the final surgery. We herein report a case of primary adenocarcinoma arising from an interposed colon after esophagectomy and review the literature.     

Endotracheal metastasis from basaloid squamous carcinoma of the esophagus

Endobronchial metastases from extrapulmonary neoplasms are rare events, and there is no report in the literature of metastasis originating from esophageal cancer. Basaloid squamous carcinoma of the esophagus is a rare histologic type that is known to be a biologically aggressive phenotype. We describe a rare case of metachronous endotracheal metastasis originating from esophageal basaloid squamous carcinoma. A 72-year-old Japanese man underwent esophagectomy for stage I esophageal cancer. Pathological diagnosis of the resected specimen was basaloid squamous carcinoma. One year later, a follow-up computed tomography scan displayed a tumor shadow in the tracheal wall. Bronchoscopy revealed a protruding tumor in the tracheal wall, and the pathologic diagnosis of the biopsy specimen was also basaloid squamous carcinoma. According to the diagnosis of metachronous endobronchial metastasis from esophageal basaloid squamous carcinoma, we treated the patient with chemotherapy comprising docetaxel, cisplatin, and 5-fluorouracil followed by chemoradiotherapy, and complete response was achieved. The patient has not suffered a recurrence of the disease for 23 months since the diagnosis of the endobronchial tumor. Careful follow-up is needed to ensure that rare types of metastasis are not missed in cases with biologically aggressive tumors.     

Skeletal muscle metastasis from esophageal cancer: a report of two cases and a review of the literature

Skeletal muscle metastases from carcinoma are very rare. This report describes two cases of skeletal muscle metastasis from esophageal cancer as the first distant metastasis. Case 1, a 58-year-old man with stage IVa upper thoracic esophageal squamous cell carcinoma (SqCC), underwent chemoradiotherapy (CRT) and a subtotal esophagectomy with a three-field lymph node dissection. After the operation, he complained of a painful mass in his forearm, which was diagnosed to be metastatic SqCC by a biopsy. Local radiation therapy and systemic chemotherapy were performed, but he died 7 months after the first CRT. Case 2, a 61-year-old woman with stage IVa middle thoracic SqCC, underwent CRT. ¹⁸F-Fluorodeoxyglucose positron emission tomography (FDG-PET) after the CRT showed a hot spot in the right gluteus maximus muscle, and it was diagnosed to be metastatic SqCC by a biopsy. Although additional treatment was performed, she died 6 months after the first visit. A short review of the literature concerning skeletal muscle metastasis from esophageal cancer was conducted.     

Can common hepatic artery lymph node dissection be safely omitted in surgery for clinical T1N0 thoracic esophageal squamous cell carcinoma?

Common hepatic artery lymph node dissection is regarded as a standard procedure in esophageal cancer surgery because of aggressive lymphatic dissemination of esophageal cancer. However, lymph node dissection can prolong operation time and may be associated with complications such as chylous ascites. Here, we aimed to evaluate the effectiveness of common hepatic artery lymph node dissection in clinical T1N0 thoracic esophageal squamous cell carcinoma. Between 1996 and 2009, 1390 patients underwent surgery for esophageal cancer in our institution, and 209 were found to have clinical T1N0 disease. Exclusion criteria were nonsquamous carcinoma, double primary cancer, definite distant metastasis, administration of neoadjuvant treatment, and incomplete abdominal lymph node dissection. We retrospectively analyzed medical records, operative and pathologic data, and follow‐up information. Forty‐two patients were excluded from the study. Among the 167 enrolled patients, preoperative endoscopic ultrasound evaluation was performed in 160 patients. Fifty‐two patients had distal esophageal or esophagogastric junction tumor. Surgery included 2 cases of tri‐incisional esophagectomy, 17 cases of transhiatal esophagectomy, and 148 cases of two‐field esophagectomy (Ivor Lewis operation). Common hepatic artery lymph node dissection was performed in all cases, and none of the patients had metastasis. Mean follow‐up period was 35.4 ± 28.7 months. In‐hospital mortality was one, and 5‐year survival rate was 80.6%. Among the 15 patients with recurrence, there were two distant metastases and five distant and local recurrences but no intra‐abdominal recurrence with common hepatic artery lymph node. Common hepatic artery lymph node dissection may be safely omitted in surgery for clinical T1N0 esophageal squamous cell carcinoma when preoperative evaluations including chest computed tomography, positron emission tomography and computed tomography, and esophagogastroduodenoscopy or endoscopic ultrasound are performed.