Gastric neo-adenocarcinoma arising in a gastric tube after Ivor Lewis oesophagectomy for oesophageal adenocarcinoma

Introduction

A case of gastric tube cancer seven years after Ivor-Lewis oesophagectomy for an oesophageal cancer is presented. In future, we may see more patients with gastric tube cancers because early detection and radical treatment of oesophageal cancer have led to prolonged survival of the patients. This presents questions regarding causation, and has implications for the potential early prevention and treatment of such cancers. We present our patient and a review of literature of similar cases and discuss management of these patients.

Case report

In December 2011, a 69-year-old man, who seven years previously had undergone a two-stage Ivor-Lewis oesophagectomy, was diagnosed to have a moderately differentiated 4 cm, malignant ulcer within the gastric tube remnant on an endoscopic biopsy. His medical history included multiple myeloma, for which he was treated with chemotherapy and stem cell transplant in 2001, following which further investigations to detect any recurrence were consistently negative.

His original presentation to us in 2004 was with a T1N0 oesophageal adenocarcinoma, described histologically as intestinal in phenotype with inflammatory features. Given the grade and stage of his tumour, and pre-operative physiology, he was deemed fit for radical resection in the form of Ivor-Lewis oesophagectomy. He was followed up on yearly basis in surgical clinics and also with two yearly endoscopies. In a routine follow-up endoscopy in June 2010 he was noted to have a small hyperplastic gastric polyp on an endoscopy and biopsy. He subsequently had a normal endoscopy in June 2011 to investigate weight loss and gastro-oesophageal reflux type symptoms. He presented six months later with anaemia and melena and was found to have a malignant ulcer in the mid body of his gastric tube on a repeat endoscopy which was confirmed to be a gastric adenocarcinoma on biopsy (Figure 1). A staging CT scan confirmed localised disease with no evidence of distant metastasis. OPEN IN VIEWER

He underwent fitness assessment with Cardiopulmonary Exercise Testing (CPEX) and his MET (metabolic equivalent) was 4.4 (normal >5.5 ml O₂ · kg⁻¹ · min⁻¹) with Anaerobic Threshold 10 ml/kg/min (38% predicted maximum) putting him in a relatively high risk group. After multidisciplinary discussion a decision was taken to perform a wedge resection of the gastric tube including the tumour as opposed to total gastrectomy and colonic interposition due to borderline fitness of the patient. The surgery involved right posterolateral thoracotomy through the previous scar. Dense pulmonary adhesions to the chest wall were encountered needing partial resection of posterior basal segment of right lung. The tumour was palpable, a wedge resection of the gastric tube including the tumour was carried out with an Endo GIA Stapler (Figure 2). He made initial good recovery after extubation but required a brief period (24 h) of ventilation a week after his surgery due to worsening hypoxia. His post-operative contrast swallow on day 8 did not show any evidence of anastomotic leak. He recovered and was discharged home three weeks after his surgery. The biopsy showed T3 N0 (0/7 lymph nodes) and R0 moderately differentiated adenocarcinoma of intestinal phenotype with papillary features which was considered to be a new primary tumour after comparing it with previous oesophageal tumour histopathology (Figure 3). He has been subsequently reviewed in outpatient clinics and remains well. OPEN IN VIEWER

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Figure 3.

Microscopic appearance of gastric tube cancer. Carcinoma invading through muscularis propria into adjacent adventitia.

Discussion

Gastric tube cancer is defined as the development of primary gastric carcinoma within the gastric tube after oesophagectomy for oesophageal tumour. The incidence of such a carcinoma has been reported between 0.2 and 3% mainly in Japanese series.^1–3 There is higher incidence in males and histopathologically in almost all cases it has been reported to be adenocarcinoma developing in the distal part of gastric tube.^2–4

The pathogenesis and cause are unclear. However, several possibilities have been investigated. Kise et al. ⁴ analysed the clinicopathological features of eight patients with gastric tube carcinoma from 1991 to 2000 with the aim of discovering a potential link to the presence of Helicobacter pylori. However, they could not find any evidence to support the role of H. pylori in the development of gastric tube cancer.

It has been postulated that the upper aerodigestive tract and colon tend to develop synchronous and metachronous cancers due to these tissues becoming genomically unstable after prolonged exposure to carcinogens leading to field change. ¹ Kamikawa et al., ⁵ on the other hand, reported no significantly increased risk of carcinogenesis in gastric tubes post-oesophagectomy. At present, with limited data, and the increased survival of oesophagectomy patients coincident with an increase in gastric tube carcinoma, a causal link with field change due to previous carcinogen/s exposure cannot be excluded.

Proposed surgical treatments are dependent on patient’s fitness for any major resection and may vary from Endoscopic Mucosal Resection (EMR) to partial resection with preservation of right gastroepiploic vessels or total gastrectomy and intestinal interposition via the retromediastinal route.^1–3 However, the surgery is complex and high risk because of adhesions due to previous surgery and finding an appropriate replacement organ in case of total gastrectomy. Total gastrectomy involves reconstruction with colonic or jejunal interposition and patients may not be fit enough to undergo such a major undertaking. The literature reflects this view, illustrating very few examples of total resection. For example, Okamoto et al. ² identified eight gastric tube adenocarcinomas in their case series. Two patients underwent EMR and three had partial resection with curative intent. Two patients were potential candidates for total gastric resection. However, resection in both patients was unsuccessful due to direct invasion of the other organs by the cancer. One patient underwent palliative EMR. Five out of eight patients who underwent curative management have been reported alive with no subsequent recurrence. Hashimoto et al., ⁶ presented two cases who underwent gastric tube resection and replacement following radical oesophagectomy. One operation was carried out on a 72-year-old male found to have a bleeding peptic ulcer within his gastric tube. This was resected and replaced with pedicled segment of left colon. The second case was a 65-year-old male who had initially been treated with an oesophagectomy for oesophageal cancer. One year post-operatively he was found to have a new early gastric cancer within the antrum, which was approached surgically with resection of the distal tube and replacement with a pedicled jejunal graft.

The anecdotal reports in the literature of gastric tube cancers are mainly from Japan. We may see an increasing number of these patients in the Western part of the world in future because patients with oesophageal malignancies living longer due to early detection, aggressive treatment of the disease with surgery and combined chemotherapy. ² There is no uniform policy or consensus opinion on the follow-up of patients with oesophageal cancer after surgical resection. Post-operative follow-up including clinical assessment imaging and endoscopy vary from centre to centre. We suggest that in such oesophagectomy cases regular endoscopy may be of value in detecting these metachronous cancers which may be curable by further intervention.