To clarify whether or not the lymphatic routes that have long been generally accepted are indeed correct, we retrospectively examined the clinical records of patients with solitary lymph node metastasis from gastric carcinoma. From 735 patients gastrectomized with lymph node dissection (more than D1), 51 (7%) were histologically proven to have only one lymph node involved. In 44 of these 51 patients, the involved nodes were all in the perigastric region (N1). There were also 7 patients with a jumping metastasis to the N2-N3 nodes. Three of them were found along the left gastric artery (#7 according to Japanese classification) and the other 4 were found along either the common hepatic artery (#8) or the proper hepatic artery (#12). The depth of invasion was submucosal in 2, proper-muscular in 2, subserosal in 1, and serosa-exposed in 2, and the conclusive stage was II in 2, IIIa in 3, and IIIb in 2. However, 1 of these patients died of liver cirrhosis and 2 died of pneumonia, while the other 4 were still alive at the time of this report more than 5 years after surgery. These results suggest that not every sentinel node is located in the perigastric region near the primary tumor and that, if the preoperative examination indicates submucosal invasion, then a systematic regional lymph node dissection should therefore be carried out.
To clarify whether or not the lymphatic routes that have long been generally accepted are indeed correct, we retrospectively examined the clinical records of patients with solitary lymph node metastasis from gastric carcinoma. From 735 patients gastrectomized with lymph node dissection (more than D1), 51 (7%) were histologically proven to have only one lymph node involved. In 44 of these 51 patients, the involved nodes were all in the perigastric region (N1). There were also 7 patients with a jumping metastasis to the N2-N3 nodes. Three of them were found along the left gastric artery (#7 according to Japanese classification) and the other 4 were found along either the common hepatic artery (#8) or the proper hepatic artery (#12). The depth of invasion was submucosal in 2, proper-muscular in 2, subserosal in 1, and serosa-exposed in 2, and the conclusive stage was II in 2, IIIa in 3, and IIIb in 2. However, 1 of these patients died of liver cirrhosis and 2 died of pneumonia, while the other 4 were still alive at the time of this report more than 5 years after surgery. These results suggest that not every sentinel node is located in the perigastric region near the primary tumor and that, if the preoperative examination indicates submucosal invasion, then a systematic regional lymph node dissection should therefore be carried out.
Case reportThe patient, a 75-year-old man, consulted us because of epigastric discomfort in February 1993. Upper GI series and gastroscopy revealed a Borrmann 3 gastric tumor in the proximal stomach. Laboratory data showed slight anemia, 10.5 g/dl of hemoglobin, and elevation of tumor markers (174 ng/ml of CA 19-9 and 298 ng/ml of Sialyl Tn). Computed tomography (CT) indicated a giant gastric tumor that invaded the pancreatic tail; the left adrenal gland seemed normal (Fig. 1). He was subjected to a total gastrectomy and a distal pancreatosplenectomy. Although the left adrenal gland was within normal limits in size, it was intraoperatively palpated as a hard mass. Therefore it was also removed during an abdominal paraaortic lymph node dissection.The postoperative course was uneventful. Histopathological examinations revealed that the gastric tumor, which measured 8.7 汐 8.5 cm, was predominantly a poorly differentiated adenocarcinoma with scirrhous invasion with a partial component of tubular adenocarcinoma that invaded the pancreas and involved nine lymph nodes [perigastric: #1, #2, #3, #4s, and #4d; along splenic artery: #11(n2)]. The histopathological findings of the left adrenal tumor revealed that there were adenocarcinoma cells nested within the normal adrenal gland and that this was compatible with those of gastric cancer (Fig. 2). At present, 6 years after the operation, the patient is still alive with no evidence of recurrence of cancer.
DiscussionAdrenal metastases occur most commonly in patients with kidney, lung, and colon carcinomas. Recently, there have been three articles on adrenalectomy for metastatic carcinomas. Lo et al.[1] performed adrenalectomy in 52 patients with metastatic adrenal carciAbstract: Clinically curable adrenal metastases are rare. We treated a patient with gastric cancer and a synchronous adrenal metastasis who underwent curative resection. Upper GI examinations of a 75-year-old man revealed a Borrmann 3 gastric tumor in the proximal stomach. CT indicated a giant gastric tumor that invaded the pancreatic tail, and the left adrenal gland seemed normal. He was subjected to a total gastrectomy and a distal pancreatosplenectomy. Because a mass was palpated intraoperatively in the left adrenal gland, it was also removed. The gastric tumor was histopathologically a poorly differentiated adenocarcinoma with scirrhous invasion that invaded the pancreas, and the histopathological findings of the left adrenal tumor were compatible with those of gastric cancer. At present, 6 years after the operation, there has been no clear sign of cancer recurrence. It may be rational to excise the left adrenal gland en bloc in patients with serosa-positive Borrmann 3-4 gastric cancer.
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