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In recent years the prognosis for oesophageal squamous cell carcinoma patients has improved. Together with this improvement, the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after oesophagectomy must be taken into account. We report a case of a patient who had this clinical presentation, which was revealed not in the normal follow-up, but in a consecutive operation carried out because of an anastomotic problem.
Oesophagectomy remains an efficacious treatment for patients with oesophageal carcinoma.1 The utilisation of the gastric tube as an oesophageal substitute became a well established method of reconstruction after the resection.2,3 Generally the prognosis for patients who suffer from oesophageal carcinoma has been regarded as poor,4,5 but recent advances, especially in diagnostics but also in treatment of the described disease, have led to an improvement in the outcome. This results in an increased attention focused on the incidence of a second malignancy in the reconstructed gastric tube.6,7
In this report we describe second primary carcinoma of the gastric tube after thoracic oesophagectomy complicated by an anastomotic leakage which led to a stenosis. This impeded the normal endoscopic follow-up of the patient and led to a second reconstructive operation.
A 74-year-old woman with no history of alcohol or tobacco abuse, presented to our department with an oesophageal squamous cell carcinoma located 25 cm from the incisors without associated gastric lesions.
The computed tomography (CT) scan showed a tumor <1 cm in diameter without any lymph node metastases (ctT1N0M0, stage I according to UICC).
On 23 May 2007, the patient underwent a subtotal oesophagectomy and lymphadenectomy through a right thoracotomy, cervicotomy and laparotomy, and afterwards a reconstruction through a gastric tube via the retrosternal route as well as nutritive microjejunostomy.
Histologically, the oesophageal tumor was a well differentiated squamous cell carcinoma invading the submucosa with no lymph node metastases (pT1 N0 M0, stage I according to the International Union Against Cancer (UICC)).
The postoperative course was complicated by a cardiovascular incident; the patient suffered twice from a cardiac arrest but was successfully resuscitated. Afterwards we observed an anastomotic leakage which in time led to a critical anastomotic stenosis. The patient was discharged from our department with an enteral nutrition conducted through microjejunostomy. Unsuccessful attempts of anastomotic dilation were carried out in an outpatient clinic.
Sixteen months after the initial treatment the patient was admitted to our department once again with the intention of restoring the normal continuity of the digestive tract. Before the surgery the patient had a CT examination of her chest which revealed no abnormality. In order to reconstruct the proper anastomosis we performed a laparotomy and a sternotomy, through which a mobilisation and refreshing of the ends of the proximal part of the gastric tube and oesophagus were carried out. During the mobilisation a small polyp was discovered in the gastric wall. The tumour was resected, but since the intraoperative examination could not be carried out, the specimen was send to the histopathological department to be examined in the normal mode. The anastomosis between the oesophagus and gastric tube was successfully reconstructed.
The postoperative recovery was uneventful and the patient was discharged without any complications after 9 days. Unfortunately for the patient the gastric tumor in the histopathologic examination proved to be a tubular adenocarcinoma and there were cancer cells present in the margins of resection (R1 resection).
After 1 month, as there were no contraindications for a curative resection, a gastrectomy through a second sternotomy was performed with a right colon interposition graft inserted between the upper esophagus and jejunum, via a retrosternal route with oesophago–colonic and colo–jejunal anastomoses. The postoperative course was uneventful, with a successful introduction of oral nutrition 5 days after the surgery. The patient was discharged 15 days after the operation. The final histopathologic examination of the resected specimen confirmed that the tumour of the gastric tube was a moderately differentiated adenocarcinoma, and revealed a residual tumor invading the muscularis propria without any lymph node metastases (pT2 N0 M0, stage IB according to UICC).
The patient returned to her daily routine. Five months after the surgery no recurrent disease, and no further anastomostic strictures, were detected. At present the follow-up time since the oesophagectomy results is 19 months.
Along with the improvement of the diagnostic and therapeutic procedures, which result in an increase in the number of long term survivors, the risk of developing secondary malignancies has become an important prognostic factor for patients with oesophageal cancer. The incidence of multiple cancers associated with oesophageal squamous cell carcinoma has been reported to be between 8.3–12.6%,8–12 and the head and neck regions13,14 as well as the gastric tube are mostly affected. The incidence of metachronous carcinoma of the gastric tube used for oesophageal substitution has been most thoroughly described by Japanese researchers.15–18 According to the literature its frequency has increased and at present is in the range of 0.2–1.0%.15,17,19–21
The aetiology of secondary carcinoma of the gastric tube is not well known. Some studies have indicated that long term reflux of pancreaticoduodenal secretions and bile,22,23 as well as irradiation of the mediastinum during adjuvant therapy, may lead to the carcinogenesis observed at long term follow-up. Also genetic disturbances cannot be excluded. Some reports have also described Helicobacter pylori infection as a cause of gastric cancer formation in the case described above.24
Regardless of the reasons mentioned, as a vagotomy had been performed during the initial operation, the presence of any lesion within the gastric mucosa should be treated as potentially neoplastic and is rarely a result of peptic ulcer disease of the stomach.25 For this reason all patients who have undergone oesophagectomy should be followed up by annual endoscopic examinations supported by indigo carmine dye spraying, that can detect even the smallest of lesions.26 Unfortunately in our case the proper follow-up was not possible, because of the critical contraction of the anastomosis. The only way to verify the stomach was to use chest CT examination, which did not reveal any pathological findings.
However, independently of the diagnostic method, the presence of metachronous adenocarcinoma in the gastric tube presents a dilemma to surgeons in devising their therapeutic strategy when curative treatment is possible.27 The possibility of carrying out an endoscopic examination which enables early detection can result in the need for less invasive surgery, such as an endoscopic mucosal resection (EMR) or partial resection of the gastric tube. Total gastrectomy or distal gastrectomy for gastric tube cancer is highly invasive and is considered to be associated with high surgical morbidity and mortality.28 Considering the fact that our patient had a history of two cardiac arrests after the first operation and underwent two extensive operations during a short period of time, the decision to undertake yet another surgical treatment was difficult. Nonetheless, taking into account that the metachronic gastric cancer could increase the risk of death we decided to undertake the subsequent intervention. The operation proved successful, with resection of the residual gastric carcinoma. Reviewing the available literature we observed that most metachronous gastric cancers after oesophagectomy in patients with oesophageal squamous cell carcinoma are male with a history of active smoking and alcohol abuse.29 This underlines the uniqueness of the case report presented here.
In conclusion, we would like to emphasise that early diagnosis of the gastric tube cancer is fundamental. In our patient it permitted less invasive treatment and better a prognosis. Hence careful consideration should be given to further research on the benefits and effectiveness of intensive postoperative supervision leading to detection or concealment of metachronous gastric carcinoma derived from gastric tubes after oesophagectomy. Under normal conditions it should be possible to make such a diagnosis using endoscopic examination. In this case only a careful examination of the stomach carried out during the second operation enabled tumour detection and initiation of adequate treatment in the following weeks.
The authors would like to give thanks to Muna Baslaim, MD for the critical review of the article and to Marta Sowa, MD for her help with the English revision of the text.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.