A case of late lymph node metastasis after three endoscopic mucosal resections of intramucosal gastric cancers
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CASE REPORT
WORLD JOURNAL OF SURGICAL ONCOLOGY
Open Access
A case of late lymph node metastasis after three endoscopic mucosal resections of intramucosal gastric cancers Eisuke Booka1, Tsunehiro Takahashi1*, Kazunori Tokizawa3, Yusuke Uchi3, Akihiko Okamura1, Kazumasa Fukuda1, Rieko Nakamura1, Norihito Wada1, Hirofumi Kawakubo1, Yoshiro Saikawa1, Tai Omori1, Hiroya Takeuchi1, Aya Sasaki2, Shuji Mikami2, Koichiro Kumai3, Kaori Kameyama2 and Yuko Kitagawa1
Abstract We describe a patient with solitary lymph node (LN) metastasis after three endoscopic mucosal resections (EMRs) in which a gastrointestinal stromal tumor was difficult to differentiate from the carcinoid and lymphoma tumors. A 77-year-old man underwent three EMRs at 62, 72, and 75 years of age, and all resections were determined to be curative. However, 2 years after the last EMR, screening abdominal ultrasonography detected a 20-mm solitary tumor at the lesser curvature of the upper stomach. Laparoscopic tumor resection confirmed the pathological diagnosis. Intraoperative pathological diagnosis showed that the adenocarcinoma was compatible with recurrence of gastric cancer; thus, total gastrectomy with D1 lymphadenectomy was performed. Metastasis was not recognized by pathological examination but was detected by preoperative radiological examinations of the LN. We report a rare recurrence case after several EMRs of intramucosal gastric cancers. Keywords: Endoscopic mucosal resection (EMR), Intramucosal gastric cancer, Lymph node metastasis, Piecemeal resection
Background In Japan, the Gastric Cancer Treatment Guidelines (GCTGs) (ver. 3) define absolute indications for endoscopic resection (ER), which include ≤20-mm intramucosal differentiated cancers without an ulcer [1]. Curative resection is restricted to en bloc resection in the latest guideline [1]. However, before the GCTGs were established, piecemeal resection was considered to be curative when the specimen was completely reconstructed and showed negative lymphovascular invasions and horizontal/vertical margins [2]. We experienced a rare late recurrence case of lymph node (LN) metastasis after endoscopic mucosal resections (EMRs) including a piecemeal resection that were curative on the basis of the GCTGs criteria at that time [1-3].
* Correspondence: [email protected] 1 Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan Full list of author information is available at the end of the article
Case presentation A 62-year-old man was admitted in 1998 because early gastric cancer (EGC) was detected by annual screening endoscopy. There was no specific finding in the physical examination or laboratory data. He had no medical history of malignant tumors. The lesion was a 10-mm type 0-IIc moderately differentiated adenocarcinoma without an ulcer located at the lesser curvature of the antrum (Figure 1a). We diagnosed that this lesion had a negligible risk of LN metastasis, and ER was indicated [4]. We explained to the patient that EMR was
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