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.
Highlights
In Japan, the Gastric Cancer Treatment Guidelines (GCTGs) define absolute indications for endoscopic resection (ER), which include ≤20-mm intramucosal differentiated cancers without an ulcer [1]
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 [1,2,3]
The tumor was confined to the mucosa with negative lymphovascular invasions and horizontal/vertical margins, which indicated that the resection was curative according to the Japanese 13th edition of the Classification a b c d e f of Gastric Carcinoma [2]
Summary
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]. 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]. En bloc EMR was performed; pathological examination revealed a 12-mm type 0-IIa lesion without an ulcer that was predominantly a moderately differentiated adenocarcinoma with papillary adenocarcinoma components (Figure 1d). We performed a laparoscopic total excisional biopsy to resect the tumor, and the intraoperative frozen section indicated LN metastasis of the adenocarcinoma (Figure 4a) Because this LN was recognized as #3a LN with stomach invasion, the operation was converted to an open standard total gastrectomy with D1 LN dissection. Postoperative pathological examination indicated that the resected LN was a metastasis of the moderately differentiated adenocarcinoma with stomach wall invasion (Figure 4b-d). No remnant or recurrent malignancy was detected at any stomach EMR site, and no other metastasis was found among the 52 other LNs retrieved
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