Treatment for isolated Ioco-regional recurrence of gastric adenocarcinoma： Does surgery play a role？

AIM: To evaluate the role of surgical treatment for isolated loco-regional recurrences of operated gastric adenocarcinoma. METHODS: Among the 837 patients operated for gastric adenocarcinoma between December 1979 and April 2004, 713 (85%) underwent resection with curative intent. A retrospective review of a prospectively collected gastric cancer database was carried out. Overall recurrence rate was 44% (315 cases), with 75% occurring within the first 2 years from the operation. Isolated L-R recurrences were observed in 38 (12%) patients. Symptomatic lesions were observed in 27 (71%). RESULTS: Six (16%) patients were macroscopically resected with curative intent. The recurrence was located in the gastric stump after a STG in three patients, in the esophagojejunal anastomosis after a TG in two patients and in the gastric bed after a TG in one patient. Surgical procedures consisted of three secondary TG, two esophagojejunal resection and one excision of an extraluminal recurrence. Postoperative complications occurred in two patients (33%), including one anastomotic leakage and one hemorrhage. The latter patient died of sepsis 35 d after the surgery (mortality rate 17%). All patients died of recurrent gastric cancer: 2 within 1 year from surgery (8 and 11 mo, respectively), 2 after 16 and 17 mo respectively and 1 after 28 mo from the second operation. CONCLUSION: Surgery plays a very limited role in the treatment for isolated loco-regional recurrence of gastric adenocarcinoma.     

Metastatic gastric tumor secondary to pancreatic adenocarcinoma

Metastatic disease, from the pancreas, involving the stomach is an unusual clinical event. Local recurrence, liver metastases, and peritoneal spread are the most common recurrent patterns after curative resection of pancreatic cancer. We report a patient who suffered from gastric metastasis secondary to pancreatic adenocarcinoma 1 year after pancreatectomy. A 49-year-old woman underwent distal pancreatectomy with intraoperative radiation therapy for cancer of the body of the pancreas in October 2002. The histological diagnosis was well-differentiated adenocarcinoma of the pancreas, stage IIB; T1N1M0. Multiple liver metastases were detected on computed tomography (CT) in March 2003. Combination chemotherapy of 5-fluorouracil hepatic arterial continuous infusion and systemic gemcitabine administration led to the disappearance of the liver metastases on CT in September 2003. One month later, she complained of epigastric pain and underwent gastric endoscopy, which revealed a submucosal tumor in the fornix posterior wall. Histological diagnosis of the biopsy specimen was well-differentiated adenocarcinoma, and immunohistochemical studies, using anti-cytokeratin 7 and -20 monoclonal antibodies, were compatible with gastric metastasis from pancreatic carcinoma. A F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) scan revealed a high-uptake lesion, which coincided with the gastric tumor. No other abnormal uptake could be found. Histopatholoical examination of the resected specimen revealed submucosal growth of the metastatic cancer (well-differentiated adenocarcinoma).     

Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA

BACKGROUND: Studies have suggested an increased risk of peritoneal seeding in patients with pancreatic cancer diagnosed by percutaneous FNA. EUS-FNA is an alternate method of diagnosis. The aim of this study was to compare the frequency of peritoneal carcinomatosis as a treatment failure pattern in patients with pancreatic cancer diagnosed by EUS-FNA vs. percutaneous FNA. METHODS: Retrospective review of patients with non-metastatic pancreatic cancer identified 46 patients in whom the diagnosis was made by EUS-FNA and 43 with the diagnosis established by percutaneous FNA. All had neoadjuvant chemoradiation. Patients underwent restaging CT after completion of therapy, followed by attempted surgical resection if there was no evidence of disease progression. RESULTS: There were no significant differences in tumor characteristics between the two study groups. In the EUS-FNA group, one patient had developed peritoneal carcinomatosis compared with 7 in the percutaneous FNA group (2.2% vs. 16.3%; p<0.025). No patient with a potentially resectable tumor in the EUS-FNA group had developed peritoneal carcinomatosis. CONCLUSIONS: Peritoneal carcinomatosis may occur more frequently in patients who undergo percutaneous FNA compared with those who have EUS-FNA for the diagnosis of pancreatic cancer. A concern for peritoneal seeding of pancreatic cancer via percutaneous FNA is warranted. EUS-guided FNA is recommended as the method of choice for diagnosis in patients with potentially resectable pancreatic cancer.     

Peritoneal dissemination of pancreatic cancer caused by endoscopic ultrasound-guided fine needle aspiration: A case report and literature review

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity.Although needle-tract seeding caused by EUS-FNA has been recently reported,dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis.However,the frequency of dissemination and needle-tract seeding appears to have been underestimated.We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA.CASE SUMMARY An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening.Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma;hence laparoscopic distal pancreatectomy with lymphadenectomy was performed.No intraoperative peritoneal dissemination and liver metastasis were visually detected,and pelvic lavage cytology was negative for carcinoma cells.The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin;however,pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site,and the cells were suspected to be disseminated via EUSFNA.Hence,the patient received adjuvant therapy with S-1(tegafur,gimeracil,and oteracil potassium);however,computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis.The patient received palliative therapy and died 8 mo after the operation.CONCLUSION The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination,especially for cancers in the pancreatic body or tail.     

Suture line recurrence in the jejunal pouch after curative proximal gastrectomy for gastric cancer: report of two cases

We report two patients with suture line recurrence in the jejunal pouch after curative proximal gastrectomy for gastric cancer. The first patient was a 60-year-old asymptomatic woman with gastric cancer (T2N0M0) after curative proximal gastrectomy with jejunal pouch interposition. She had to undergo a second resection for suture line recurrence in the jejunal pouch 12 months later. On examination of the resected specimen, histological examination revealed a moderately differentiated adenocarcinoma, which was similar to that of the primary tumor. The second patient was a 74-year-old man who was also diagnosed as having locoregional recurrences in the jejunal pouch after a curative proximal gastrectomy with an S-shaped pouch for gastric cancer (T2N0M0). Histological examination of the resected specimen revealed moderately differentiated adenocarcinoma, which had a similar histopathology to that of the primary tumor. During the first procedure, the jejunal pouch was formed using several disposable devices and the end-to-side esophagojejunostomy was performed with another circular stapler to avoid contamination through surgical instruments. Exfoliated cancer cells that may have detached from the primary tumor during the surgical procedures could have contributed to local recurrence along the longitudinal suture line of the pouch.     

Factors affecting recurrence in node-negative advanced gastric cancer

Background and Aim:  Prognostic factors of lymph node-negative gastric adenocarcinoma after curative resection have been discussed. Recurrent pattern of advanced lymph node-negative gastric cancer after curative resection has rarely been described.
Methods:  Recurrent sites and correlated clinicopathological factors of 372 patients with lymph node-negative advanced gastric adenocarcinoma that underwent R0 resection from 1988 to 2005 were analyzed.
Results:  Recurrence was noted in 51 (13.7%) patients. Recurrent rates according to site of recurrence were 26 peritoneal seeding (51.0%), 26 locoregional (51.0%), 17 hematogenous (33.3%), and 4 lymph node metastasis (7.8%). Clinicopathological factors to predict peritoneal seeding were serosal exposure, lymphovascular invasion, Lauren's diffuse type differentiation and scirrhous stromal reaction. Serosal exposure, tumor size, microscopic infiltrating growth type predicts locoregional recurrence. Tumor had only lymphovascular invasion predict hematogenous spreading.
Conclusion:  Node-negative advanced gastric cancer has more peritoneal seeding and locoregional recurrence. Aggressive cell behavior predicted the route of tumor cell spreading.     

The analysis of resectability and survival in pancreatic cancer patients with vascular invasion

One of the major limitations of curative resection in patients with pancreatic cancer is local tumor extension to the mesenteric vessels. Thus, the purposes of our study were to assess the clinical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival of patients with pancreatic cancer with suspicious vascular invasion and to assess the influence of curative resection on the survival of these patients. We enrolled 40 patients with pancreatic cancer who were suspected of having an involvement of the adjacent large vessels and who subsequently underwent operation with curative intent in the study. Resectability and survival were correlated with CT findings such as segment length, degree of encasement, and type and number of vessels involved. The survival rate was compared between the curative and palliative resection groups, and survival rate was compared between the resected and unresected groups. Of the 40 patients with adenocarcinoma of the pancreas, 14 had curative resections and 26 had palliative resections. The probability of curative resection was higher in patients with segment lengths less than 2 cm, as compared with segment lengths more than 2 cm. However, there was no difference in survival between the two groups. There were no differences in resectability and survival according to the degree of encasement and type and number of vessels involved. There was no difference in survival between the curative and palliative resection groups. There was no difference in survival between the resected and unresected groups. A survival benefit was not achieved by curative resection in patients with pancreatic cancer with vascular invasion. Therefore, it would be better to avoid aggressive surgery in patients with pancreatic cancer with vascular invasion.     

Subcutaneous metastasis at a surgical drain site after the resection of pancreatic cancer

The aggressive nature of pancreatic cancer makes surgical control of disease an arduous challenge. Tumor seeding during resection is a feared complication during operations performed for this disease. Recurrence within the peritoneal cavity commonly occurs after resection for curative intent. Cutaneous metastasis, however, is a rare event. The majority of skin metastasis reported in the literature occurred after palliative procedures, in which the tumor burden remains. In this report, we describe an unusual case of cutaneous recurrence at the site of a surgical drain after resection for curative intent and discuss the impact of surgery on tumor-growth characteristics.     

Pure gastric yolk sac tumor that was diagnosed after curative resection: case report and review of literature

We recently experienced an 87-yr-old man with gastric yolk sac tumor. Preoperative diagnosis was poorly differentiated adenocarcinoma in the cardia of stomach without apparent metastasis. A total gastrectomy was performed. The precise histological examination after surgery revealed the tumor was composed of pure gastric yolk sac tumor without adenocarcinomatous components. The surgical margin and the resected lymph nodes were histologically negative for the tumor and a curative resection was performed. Five months after the operation, enlargement of the intraabdominal lymph nodes occurred with elevation of serum alpha fetoprotein (AFP), and the patient died 2 mo later. Gastric yolk sac tumors are very rare, and only six cases of gastric yolk sac tumors have been previously reported in the literature. Five out of six cases are accompanied by components of adenocarcinoma, and our present case is the second report of pure gastric yolk sac tumor to the best of our knowledge.     

Analysis of circulating cell-free DNA after endoscopic ultrasound-guided fine needle aspiration in pancreatic ductal adenocarcinoma

Background/ObjectivesRecently, increase in cell-free DNA (cfDNA) concentration or newly detected KRAS mutation after endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy were reported to be related to the occurrence of new distant metastasis. In this study, we investigated whether cfDNA concentration increased with the release of tumor components into the blood after EUS-FNA and whether its increase was related to prognosis.MethodsSixty-eight patients underwent EUS-FNA and were pathologically confirmed as having pancreatic ductal adenocarcinoma (PDAC). We measured plasma cfDNA concentration and the copy number of KRAS mutation in 68 patients and circulating tumor cells in 8 before and after EUS-FNA.ResultsThe average cfDNA concentration after EUS-FNA (672.5 ± 919.6 ng/mL) was significantly higher than that before EUS-FNA (527.7 ± 827.3 ng/mL) (P < 0.001). KRAS mutation in plasma was detected in 8 patients (11.8%), however a significant increase in cfDNA concentration after EUS-FNA was not related to the change in KRAS-mutant copy number. Minimal increase in circulating tumor cells was observed in 3 of 8 patients. New distant metastasis was observed within 286 days to initial metastasis detection in 6 of 12 patients with ≥2-fold increase in cfDNA concentration and 26 of 56 patients with <2-fold increase within 185 days. In 32 patients who underwent surgery, ≥2-fold increase in cfDNA did not affect early recurrence.ConclusionsThe increase in cfDNA concentration after EUS-FNA was not caused by tumor cell components released into blood vessels. Hence, the risk of seeding via the blood stream after EUS-FNA may need not be considered.     

Influence of the safety and diagnostic accuracy of preoperative endoscopic ultrasound-guided fine-needle aspiration for resectable pancreatic cancer on clinical performance

AIM:To evaluate the safety and diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA)in a cohort of pancreatic cancer patients.METHODS:Of 213 patients with pancreatic cancer evaluated between April 2007 and August 2011,82were thought to have resectable pancreatic cancer on the basis of cross-sectional imaging findings.Of these,54 underwent EUS-FNA before surgery(FNA+group)and 28 underwent surgery without preoperative EUSFNA(FNA-group).RESULTS:All 54 lesions were visible on EUS,and all54 attempts at FNA were technically successful.The diagnostic accuracy according to cytology and histology findings was 98.1%(53/54)and 77.8%(42/54),respectively,and the total accuracy was 98.1%(53/54).One patient developed mild pancreatitis after EUS-FNA but was successfully treated by conservative therapy.No severe complications occurred after EUS-FNA.In the FNA+and FNA-groups,the median relapse-free survival(RFS)was 742 and 265 d,respectively(P=0.0099),and the median overall survival(OS)was1042 and 557 d,respectively(P=0.0071).RFS and OS were therefore not inferior in the FNA+group.These data indicate that the use of EUS-FNA did not influence RFS or OS,nor did it increase the risk of peritoneal recurrence.CONCLUSION:In patients with resectable pancreatic cancer,preoperative EUS-FNA is a safe and accurate diagnostic method.     

Successful resection of a liver metastasis from AFP-producing pancreatic cancer resulting in long-term survival: a case report and review of literature

The prognosis of patients with alpha-fetoprotein (AFP)-producing pancreatic cancer is generally very poor. We, however, present a case of a 33-year-old man who survived AFP-producing pancreatic cancer and its metachronous liver metastasis. The patient had undergone a curative total pancreatectomy for AFP-producing pancreas head cancer invading to the tail, which was postoperatively confirmed by immunohistochemical staining of the resected specimen. At 1 year and 4 months after the operation, the serum AFP level was elevated to 26 ng/mL, and a 2.6 cm-sized mass was found in the lateral segment of the liver. He underwent lateral segmentectomy, and the tumor was histopathologically diagnosed as having metastasized from the AFP-producing pancreatic cancer removed earlier. The patient is doing well 8 years and 5 months after resecting the liver metastasis, with no signs of recurrence. This case suggests that surgery may also be a treatment of choice for patients with liver metastasis from AFP-producing pancreatic cancer, particularly for those with a metachronous and solitary tumor. It should be remembered that some pancreatic cancers produce AFP and that monitoring of postoperative serum AFP levels in such cases will be useful for early detection of recurrence and selection of appropriate surgical intervention.     

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

BACKGROUNDPancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.CASE SUMMARYWe reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.CONCLUSIONAccurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.     

Gastrojejunostomy followed by induction chemotherapy for incurable gastric cancer with outlet obstruction

A 72-year-old male gastric cancer patient with outlet obstruction underwent laparoscopic exploration. The examination disclosed intraperitoneal free cancer cells with no overt peritoneal, lymphatic, or hepatic metastasis. The patient underwent laparoscopy-assisted gastroje-junostomy (LAGJ) and started chemotherapy with S-1 plus cisplatin on postoperative day 13. Three course of the chemotherapy shrank the tumor markedly. Then, the patient underwent gastrectomy with a curative intent. Laparotomy revealed no ...     

Effectiveness of preoperative chemotherapy for far advanced gastric cancer

We herein report a case in which preoperative chemotherapy with cisplatin and 5-fluorouracil was found to effectively treat far advanced gastric cancer invading the pancreas forming a huge mass with regional and distant lymph node metastases. As a result of this treatment regimen, a potentially curative resection was performed which led to a substantially increased survival. The patient was treated with 10 mg of cisplatin and 1000 mg of 5-fluouracil each day preoperatively. After the continuous administration of these drugs for 28 days, the findings of extensive pancreas invasion and lymph node metastases dramatically disappeared. The tumor could be curatively resected by a total gastrectomy with lymph nodes dissection, combined with a distal pancreatectomy and splenectomy. A histological study of a resected specimen showed some cancer cell infiltration remaining within the muscularis propria with fibrous change. There was no evidence of either pancreas invasion or lymph node metastasis. As a result, postoperative adjuvant chemotherapy was performed, 14 months later lymph nodes recurrence was detected and the patient died 20 months after surgery. Our findings suggest that preoperative chemotherapy may thus be effective for the treatment of gastric cancer by both reducing the tumor burden and prolonging survival.     

Clinical and pathologic prognostic factors for curative resection for pancreatic cancer

Background. Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease. Objective. The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma. Methods. Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients. Results. Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors. Conclusion. Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.     

Solitary AFP- and PIVKA-II-producing hepatoid gastric cancer with giant lymph node metastasis

A 61-year-old man was admitted to our hospital because of abdominal pain and an abdominal mass. The patient had anemia and elevated serum alpha-fetoprotein (AFP) (9630ng/mL) and PIVKA-II (91mAU/mL) levels. Roentgenographic examination revealed an extra-gastric tumor in the upper abdomen, and gastroscopy revealed Bormann type 2 gastric cancer in the lower portion of the stomach. The preoperative diagnosis was synchronous gastric cancer and hepatocellular carcinoma (HCC), and surgery was performed. The extra-gastric tumor appeared to be an extra-hepatically growing HCC because the tumor was fed by vessels ramifying from the umbilical portion of the liver. Distal gastrectomy with resection of the extra-gastric tumor was performed, and histological examination of the resected specimen revealed that the gastric cancer was an AFP-producing hepatoid gastric adenocarcinoma and that the extra-gastric tumor was a lymph node metastasis. AFP-producing hepatoid gastric adenocarcinoma tends to metastasize to the regional lymph nodes and form a giant tumor. A giant tumor in the upper abdomen associated with gastric cancer may therefore be a clinical manifestation of AFP-producing hepatoid gastric adenocarcinoma.     

Adenosquamous carcinoma of the stomach associated with separate early gastric cancer (type IIc)

Adenosquamous carcinoma originating in the stomach is a relatively rare entity. It comprises less than 0.5% of all gastric cancers. Recently, we encountered a patient with gastric adenosquamous carcinoma associated with separate early gastric cancer (type IIc). The patient was a 72-year-old man who was diagnosed as having gastric cancer in a multiphasic health screening examination conducted in May 1992. The patient subsequently underwent pylorogastrectomy. Examination of the resected specimen revealed two lesions, advanced cancer (Borrmann 2) and early cancer (type IIc). The lesions were histopathologically diagnosed as adenosquamous carcinoma and adenocarcinoma, respectively. The majority of gastric adenosquamous carcinomas are stage III or IV advanced cancers, and are treated according to the therapeutic protocol for adenocarcinomas. Their prognosis is generally poor. Continuous follow up is required for patients with these adenosquamous cancers, even after curative resection has been performed, because of the advanced nature of these lesions.     

Case of early gastric cancer with nodular gastritis

A case of depressed early gastric cancer with nodular gastritis is described. A 47‐year‐old Japanese man was referred to our hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopy examination showed a 4.5 × 3.0 cm depressed lesion with a deep central ulceration in the anterior wall of the lower corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Immunoglobulin G antibody and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis was diagnosed and a subtotal gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor infiltrating a poorly differentiated adenocarcinoma with a depressed lesion in the corpus (type 0 IIc + III) and nodular gastritis in the antrum. The patient is doing well 1 year after surgery.     

Pancreatic metastasis of malignant melanoma diagnosed by EUS-guided fine needle aspiration (EUS-FNA)]

Pancreatic metastasis of malignant melanoma is rarely diagnosed while the patient is alive. We report a case of metastatic melanoma of the pancreas in a 35-year-old woman presenting with a solid mass of the pancreas. Her past medical history included a radical hysterectomy 2 years previously for malignant melanoma of the vagina. Twelve months later, lung metastasis was also resected. EUS-guided fine needle aspiration (EUS-FNA) identified that the pancreatic tumor was histologically and immunohistochemically identical to the surgical specimen of her lung neoplasm. Imaging studies including US, CT, and MRI have limited value to distinguish the tumors from primary ductal adenocarcinoma. EUS-FNA can provide tissue diagnosis from pancreatic masses, specifically when other modalities have failed.