Fulminant metastatic spread in a patient with an early gastric cancer

A patient with an early gastric cancer was treated initially by endoscopic submucosal dissection (ESD) at our hospital. The resected specimen showed a depth of submucosal infiltration of more than 500 µm. Therefore, in accordance with the extended criteria with regard to EMR, the patient underwent gastrectomy. The TNM stage was pT1 (sm3), pN0 (0 / 58), cM0, L0, V0, G2 after surgery (UICC stage Ia). At 3 months later ultrasound revealed a new mass in the liver, and biopsy showed a rapidly growing metastasis of the gastric adenocarcinoma. Finally, immunohistochemical analysis of all the lymph nodes of the resected stomach revealed a micrometastasis (3mm) directly under the ESD site. The patient died 6 months later. This clinical case highlights the risk of affected lymph nodes in early gastric cancer and the consequent risk of metastasis which increases with greater depth of infiltration to the submucosa.

References

• 1 Oyama T, Tanaka M, Tomori A. et al . Prognosis of endoscopic submucosal dissection for early gastric cancer, results of 3 years or more after treatment.  Stomach Intest. 2006;  46 87-90
• 2 Soetikno R, Kaltenbach T, Yeh R. et al . Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract.  J Clin Oncol. 2005;  20 4490-4498
• 3 Li C, Kim S, Lai S F. et al . Risk factors for lymph node metastasis in undifferentiated early gastric cancer.  Ann Surg Oncol. 2008;  15 764-769
• 4 Oda I, Gotoda T, Sasako M. et al . Treatment strategy after non-curative endoscopic resection of early gastric cancer.  Br J Surg. 2008;  Oct 21 [Epub ahead of print]
• 5 Oda I, Saito D, Tada M. et al . A multicenter retrospective study of endoscopic resection for early gastric cancer.  Gastric Cancer. 2006;  9 262-270
• 6 Wu B, Wu D, Wang M. et al . Recurrence in patients following curative resection of early gastric carcinoma.  J Surg Oncol. 2008;  98 411-414
• 7 Haruta H, Hosoya Y, Sakuma K. et al . Clinicopathological study of lymph-node metastasis in 1389 patients with early gastric cancer: Assesment of indications for endoscopic resection.  J Dig Dis. 2008;  9 213-218
• 8 Nagano H, Ohyama S, Fukunaga T. et al . Two rare cases of node-positive differentiated gastric cancer despite their infiltration to sm1, their small size, and lack of lymphatic invasion into the submucosal layer.  Gastric Cancer. 2008;  11 53-57; discussion 57 – 58 [Epub 2008 Mar 29]
• 9 Ishikawa S, Togashi A, Inoue M. et al . Indications for EMR/ESD in cases of early gastric cancer: relationship between histological type, depth of wall invasion, and lymph node metastasis.  Gastric Cancer. 2007;  10 35-38