Local recurrence of gastric cancer after total gastrectomy: an unusual presentation
© Martella et al; licensee BioMed Central Ltd. 2012
Published: 15 November 2012
A 71 years old Italian man had type 3 gastric cancer of the greater curvature. Total gastrectomy with splenectomy and D2 lymph node dissection were performed. After discharge chemotherapy ELF regimen was administred for 6 months. After 16 months from the operation a local recurrence was discovered by CT scan. Surgical en-bloc resection was performed removing pancreatic tail, splenic colic flexure and a portion of left diaphragm. Histological examination confirmed local recurrence of gastric adenocarcinoma infiltrating pancreas, colon and diaphragm with lymph node metastasis.
In Western countries gastric cancer still represents a disabling disease: unfortunately late diagnosis is common and loco-regional recurrence rate after surgery alone is high especially in patients with advanced stage disease at the time of diagnosis (gastric wall penetration and lymph node metastasis). Local recurrence may occur also in those patient which had R0 resection: management of these cases is extremely difficult for the involvement of regional structures resulting in poor surgical chances. Therefore multidisciplinary therapeutic approach is necessary to achieve better results. The aim of this report is to refer about an unusual presentation of local relapse in an old patient submitted to a total gastrectomy in which surgical approach permitted a good control of the disease.
Loco-regional recurrence and distant metastases are common events after surgery for gastric adenocarcinoma. Abdominal extraluminal recurrence of gastric cancer is a disarmimg condition because of poor therapeutic chances. Generally it is a matter of peritoneal carcinosis or multiple liver metastasis; in these cases surgery has little opportunities to be useful. Literature reports rare cases of single localization in abdominal cavity that may be resected. Menzel  reported a case of infrarenal aortic aneurysm whose detection permitted to discover gastric carcinoma. A similar condition is reported by Shimoyama  who diagnosed gastric cancer after nephroureterectomy for hydronephrosis due to ureteral metastasis. Imachi  referred about metastatic adenocarcinoma to the uterine cervix. Rare extrabdominal localizations are reported: intramuscular gluteal tumour , scalp and forehead , testis , axillary lymph node . Yoo and Colleagues  reported a multivariate analysis of risk factors involved in the recurrence of gastric cancer; in order they are lymph node metastasis, serosal invasion, infiltrative or diffuse type, larger tumour size (4 cm or greater), undifferentiated tumour and proximally located tumour. Serosal invasion and lymph node metastasis were common risk factors for all recurrence patterns. Buzzoni  underlined the role of radical surgery respect more conservative surgery to reduce the rate of loco-regional recurrence: particularly the pT stage was related to loco-regional recurrence whereas pN stage had importance on distant metastases. Motoori  developed a diagnostic system based on systematic analysis of gene expression profiling to predict the recurrence at clinically meaningful level: the prediction accuracy was high especially in patients with small tumours in I and II stage. Marrelli  obtained a scoring system with a regression model based on follow-up data to define subgroups of patients at risk for recurrence after radical surgery for gastric cancer. On the other hand, Bennet  affirmed that follow-up did not identify no symptomatic recurrence earlier than symptomatic one.
Our case is unusual in its presentation: an isolated bulk involving neighbouring organs suitable for surgical resection. The result after the en-bloc resection is very amazing. Considering the primary surgical specimen we may suppose the modalities of the local relapse: the spleen and local lymph-nodes were radically removed, but in spite of that, local contamination during the first operation remains the most reasonable interpretation. All risk factors suggested by Yoo and Colleagues  were present in the initial specimen: serosal invasion and nodal metastases, large tumour size (7 x 5 cm on the specimen) infiltrative and undifferentiated type and proximally located tumour. We can speculate that chemotherapy has favoured the delay of the clinical presentation of the recurrence. Recently developed new agents such as irinotecan, taxanes and capecitabine, provide more promising results also in metastatic gastric cancer such as new molecular targeting agents . Encouraging perspectives may result from IORT by virtue of its technical properties which permits to exceed conventional doses . We believe that an appropriate association between varies therapeutic option [16, 17] (surgery, chemo and radiotherapy – EBRT and/or IORT-) may bring about a change for a better management of recurrent gastric cancer.
This article has been published as part of BMC Surgery Volume 12 Supplement 1, 2012: Selected articles from the XXV National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/12/S1.
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