Ann Thorac Surg 2004;77:1189-1192
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma
Nobuhiko Okamoto, MDa,
Soji Ozawa, MDa*,
Yuko Kitagawa, MDa,
Yoshimasa Shimizu, MDa,
Masaki Kitajima, MDa
a Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
Accepted for publication September 5, 2003.
* Address reprint requests to Dr Ozawa, Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
e-mail: ozawa{at}sc.itc.keio.ac.jp
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Abstract
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BACKGROUND: Cases of metachronous gastric carcinoma arising from a gastric tube used for reconstruction have been increasing in long-term survivors of esophageal cancer in recent years. We investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it.
METHODS: Between 1980 and 1997, 508 patients underwent radical esophagectomy for esophageal carcinoma at Keio University Hospital. Reconstruction was performed with a gastric tube in 414 (81.5%) of them, and 8 of them developed a metachronous carcinoma in the gastric tube. The clinical and pathologic characteristics of the gastric tube carcinomas were evaluated in this study.
RESULTS: Gastric cancer was detected during follow-up endoscopic examinations or in an upper gastrointestinal series in seven patients. All of the cancers were diagnosed as adenocarcinoma histopathologically. Endoscopic mucosal resection was performed in two patients, partial resection of the residual stomach was performed in three patients. One patient was treated by endoscopic mucosal resection as palliative therapy, since he had severe pulmonary emphysema. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of other organ by the cancer. The 5 patients who underwent curative resection are alive with no subsequent recurrence.
CONCLUSIONS: Since early diagnosis permits less invasive treatment and curative treatment is difficult in advanced cases, strict postoperative examinations are important after radical esophagectomy to ensure early detection of metachronous gastric carcinoma arising from gastric tubes used for reconstruction.
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Introduction
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Advances in diagnostic and surgical techniques have enabled remarkable improvement in the outcome of patients with esophageal carcinoma [1–3]. The 3-year and 5-year survival rates for curative and palliative resection between 1981 and 1995 at Keio University Hospital were 52.5% and 40% respectively [2]. In recent years metachronous carcinoma has been increasing, especially, metachronous gastric carcinoma arising from gastric tubes used for reconstruction in long-term survivors of esophageal cancer [4–9].
Because in our experience some differences have been found between the diagnostic and therapeutic strategies that are effective for gastric tube carcinoma and primary gastric carcinoma, we investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it.
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Patients and methods
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Between 1980 and 1997, 872 patients with esophageal carcinoma were referred to Keio University Hospital and 508 of them were treated by radical esophagectomy. A gastric tube was used for reconstruction in 414 (81.5%) of these cases, and metachronous carcinoma has occurred in the gastric tube in 8 of them. Metachronous multiple primary carcinoma was defined according to the criteria described by Warren and Gates [10]: (1) the tumors had to be clearly malignant on histologic examination; (2) they had to be separated by normal mucosa; and (3) the possibility of second tumor representing a metastasis had to be excluded. Seven of these patients were male and 1 patient was female, and their ages ranged from 52 to 72 years (mean, 64). All patients had squamous cell carcinoma at the time of the esophagectomy, and the procedure consist of total or subtotal thoracic esophagectomy through a right thoracotomy with regional lymph node dissection. The route of the gastric tube used for the reconstruction was retrosternal in 5 cases, intrathoracic in 2 cases, and posterior-mediastinal in 1 case (Table 1).
Two of the 8 patients had received adjuvant radiation therapy when mediastinal lymph node recurrence was detected.
The following clinical and pathologic characteristics of the gastric tube carcinoma were evaluated: interval between the radical esophagectomy and the diagnosis of gastric cancer, the method of the diagnosis, the clinical and pathologic stage, treatment modality, and outcome.
The clinical and pathologic staging of esophageal carcinoma and gastric carcinoma was according to the TNM classification [11].
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Results
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The interval between the two malignancies ranged from 39 to 221 months (mean, 109). All patients were asymptomatic when their gastric carcinomas were detected. In 1 patient the cancer was suspected based on a high serum carcinoembryonic antigen level. The patient had been followed up by annual upper gastrointestinal (upper GI) series after the initial operation. The remaining seven cancers were detected during follow-up endoscopic examinations or upper GI series. The morphologic findings (including upper GI series, endoscopic examination, and computed tomography) and histopathological examinations of the biopsy specimens revealed that three of the cancers were well-differentiated adenocarcinomas (G1) that had invaded the lamina propria, one was a moderately differentiated adenocarcinomas (G2) that had invaded the lamina propria, one was a G2 that had invaded the submucosa, one was a poorly differentiated adenocarcinomas (G3) that had invaded the submucosa, and two were G3 tumors that had penetrated the serosa (Table 2).
None of the patients had any evidence of distant metastasis.
The indications for endoscopic mucosal resection (EMR) are the same as for gastric cancer [12–14]: well-differentiated adenocarcinoma (G1); depth of invasion limited to the lamina propria; less than 1.0 cm in diameter; and no ulceration. Two of the G1/mucosa patients fulfilled the criteria and EMR with local injection of highly concentrated saline and epinephrine (HSE) by the double-channel endoscopy was performed. In both cases piecemeal resections were done but histologic examination revealed no cancer cells at the surgical margin. The indications for partial resection of the gastric tube are depth of invasion limited to the lamina propria or submucosa, no lymph nodes metastasis, and tumor located in the abdominal cavity or anterior chest wall. One G1/mucosa patient, the G2/mucosa patient, and the G3/submucosa patient were treated by partial resection through the laparotomy. The surgical margin of the resected specimen was checked by intraoperative frozen sections and confirmed to be cancer free in all cases. The resections in these 5 patients were histopathologically confirmed to be curative.
Patients who were did not meet the criteria for EMR or partial resection of the gastric tube had indications for total or distal resection of the gastric tube. The patient with the G2/lesion in the submucosal layer whose tumor was located in the posterior mediastinum was considered a candidate for total resection of the gastric tube but radical surgery was abandoned because of severe pulmonary emphysema and EMR was used as palliative therapy instead. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of the mediastinum in 1 case and lymph node invasion to the pancreas in the other. Five patients who underwent curative resection are alive and have not experienced subsequent recurrence. The patient treated by palliative EMR experienced a local recurrence. Of the 2 patients with an unresectable lesions, 1 died 6 months and the other 1 year after the operation.
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Comment
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As the prognosis of esophageal carcinoma has improved in recent years, the incidence of multiple carcinomas associated with esophageal carcinoma has been increasing, especially in gastric tube used for reconstruction [4–9]. The incidence of multiple cancers associated with esophageal carcinoma has been reported to be 8.3% to 12.6% [15–19].
From 1980 to 1997 the incidence of multiple cancers associated with esophageal carcinoma at Keio University Hospital was 11.5%. There were 85 cases of double cancer, 14 cases of triple cancer, and 2 cases of quadruple cancer and the most frequently affected organ was the stomach. Synchronous gastric carcinoma accounted for 30% of the multiple cancers, and metachronous head and neck cancers accounted for 21%. Gastric carcinoma in a gastric tube used for reconstruction accounted for 7% of the multiple cases (Table 3).
The etiology of the secondary carcinoma in the gastric tube is not well known. Some reports have indicated that long-term reflux of bile and pancreaticoduodenal secretions is involved in the genesis of gastric carcinoma in the rat [20, 21] and irradiation of the mediastinum as adjuvant therapy may cause carcinogesis during long-term follow-up. Dubrow [22] reported that the TD5/5 (minimal tolerance dose resulting in 5% injury in 5 years) for the stomach is 45 Gy. One patient in our series who underwent radiation therapy of the upper mediastinum developed gastric tube carcinoma in the radiation field 15 years later. The field map of radiation involved 50 Gy in 25 fractions to the upper portion of gastric tube adjacent to a metastatic lymph node. Some reports have described Helicobacter pylori infection as a cause of gastric cancer [23] but no H pylori infection was detected in the resected or biopsy specimens in our series. The lower incidence of H pylori infection in the gastric tube may be attributed to bile reflux to the gastric tube as a result of a drainage procedure such as pyloroplasty or reduction of the acidity in the gastric mucosa as a result of denervation of the stomach [23].
The intervals between the malignancies varied ranging from 33 to 221 months (mean, 109), and the secondary cancer was detected more than 5 years and 10 years after esophagectomy in 5 and 3 of our cases respectively, indicating the need for long-range follow-up after esophagectomy. At Keio University Hospital radical esophagectomy patients are routinely followed up by annual endoscopic examinations. All of the gastric cancers detected during periodic endoscopic examinations in our experience have been limited to the early stage, and curative and less invasive treatment was possible in all of them except 1 patient who had the concomitant disease. Some reports have described the importance of periodic endoscopic examinations after radical esophagectomy to detect early gastric cancer, especially mucosal cancer, for which EMR or partial resection of the gastric tube is indicated [8, 9]. On the other hand advanced disease was detected in 2 patients in our series followed up by means of upper GI series. The lower mobility and deformity of the gastric tube appear to increase the difficulty of detecting early cancers by upper GI series.
The feasibility and curability of treatment gastric cancer in gastric tubes mainly depends on the depth of the tumor in reconstructed gastric cancer. Early detection permits less invasive surgery such as EMR or partial resection of the gastric tube, and EMR is curative treatment for mucosal cancer. Total gastrectomy or distal gastrectomy for gastric tube cancer is highly invasive and is problematic in patients who have undergone radical esophagectomy. Some reports have described attempts at total or distal gastrectomy for advanced carcinoma. Sugiura and colleagues [9] described their experience with gastrectomy plus regional lymph node dissection in 7 patients with gastric tube carcinoma and reported high surgical morbidity (5 cases of anastomotic leakage) and treatment failure (4 cases of recurrence of gastric or esophageal carcinoma). If the esophagus is reconstructed through the posterior-mediastinal route a right thracotomy is needed to complete the total gastrectomy, and if the reconstruction is made through retrosternal route a median sternotomy is required. These surgical approaches involve problems in completing radical operations because of severe adhesion of the gastric tube or invasion of adjacent organs by the tumor in some cases. When distal gastrectomy is performed the right gastroepiploic artery must be preserved to maintain the blood supply of the residual gastric tube and the dissection of the regional lymph nodes may be insufficient.
In conclusion, early diagnosis permits less invasive treatment of metachronous gastric carcinoma arising from gastric tubes used for reconstruction. Curative treatment is difficult in advanced cases and strict postoperative examinations are important after radical esophagectomy to ensure early detection.
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Abstract
Introduction
