Metachronous liver and bone metastasis from small early gastric carcinoma without lymph node involvement: A case report

Abstract

Abstract.A 65-year-old man was referred to our Hospital for examination of gastric cancer initially diagnosed by medical check-up. Esophagogastroduodenoscopy demonstrated a superficial depressed-type gastric cancer in the antrum, and abdominal computed tomography showed no evidence of distant metastases. A tumor measuring 11 mm in diameter was removed by endoscopic submucosal dissection (ESD). Since histological examinations of ESD specimens showed a well-differentiated adenocarcinoma invading the submucosal layer with lymphatic invasion, the patient subsequently underwent laparoscopy-assisted distal gastrectomy with regional lymph node dissection, resulting in no residual carcinoma and no lymph node metastasis. The patient developed solitary liver metastasis one year later and was treated with trastuzumab plus capecitabine/cisplatin since results of the immunohistochemical analysis of the resected specimens demonstrated overexpression of the human epidermal growth factor receptor 2 (HER2). The patient was alive 12 months after surgical resection of the liver metastasis and subsequently developed bone metastasis. Controversy remains over the role of HER2 status as a prognostic factor in gastric cancer. However, it has been generally reported that HER2 overexpression correlates with aggressive biological behavior and poor prognosis. HER2 overexpression is a potentially useful predictive factor for tumor recurrence and poor prognosis even in early gastric cancer cases. IntroductionEarly gastric cancer (EGC) is defined as the presence of a lesion confined to the mucosa or submucosa, regardless of the presence of regional lymph node metastasis, and has a good prognosis with appropriate treatment (1). Although the outcome of patients with EGC following curative surgery is excellent, cancer recurrence is a rare event and could occur even after curative gastrectomy with an incidence of 1.4-2.7% (2-5).Endoscopic resection with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is widely accepted as the standard treatment for EGC without lymph node metastasis and enables a clinician to resect a target lesion en bloc (6,7). Most EGC confined to the mucosa can be curatively treated by endoscopic resection, since lymph node metastasis is rare in such cases. Endoscopic resection is currently considered appropriate for the treatment of intestinaltype gastric cancer cases without central ulceration that are <2 cm in diameter, according to guidelines for EMR/ESD established by the Japanese Gastric Cancer Association (7). However, gastrectomy with lymph node dissection should be performed in patients with submucosal invasion with or without margin involvement following endoscopic resection (8,9).In this study, a case of metachronous liver and bone metastasis after laparoscopy-assisted distal gastrectomy is described, following initial treatment by ESD for small EGC without lymph node metastasis, showing human epidermal growth factor receptor 2 (HER2) overexpression. All diagnostic procedures and therapy...

Evaluation of a trastuzumab-containing treatment regimen for patients with unresectable advanced or recurrent gastric cancer

“…While overexpression of HER2 is a factor that is associated with poor prognosis in patients with breast cancer, its association with prognosis in patients with gastric cancer is widely debated (25). For this reason, improvements in the accuracy of HER2 testing and further research on this topic are required (26,27). Nonetheless, the survival advantage provided by trastuzumab plus chemotherapy in patients with HER2-positive gastric cancer has been confirmed, with data showing that this regimen is efficacious and safe.…”

Pattern of extragastric recurrence and the role of abdominal computed tomography in surveillance after endoscopic resection of early gastric cancer: Korean experiences

“…A number of studies have reported a favorable prognosis after curative resection of EGC by endoscopic resection [5][6][7][8]. Although the 5-year overall survival and 5-year disease-specific survival rates of patients with EGC after curative therapy are more than 97% and 99% respectively [7][8][9], there have been several reports of EGC recurrence after curative treatment, which can lead to unfavorable outcomes [8,10,11]. After curative endoscopic resection, the recurrence rate ranges from 4.5% to 16%.…”

Aberrant metastatic behavior and particular features of early gastric cancer

“…In EGCs, the rate of solitary liver metastasis is about 0.4–0.7% . It is correlated with the presence of the angio‐lymphatic invasion and is higher than 5% in lymph node‐metastatic EGC .…”

“…Early gastric cancer is considered a carcinoma confined to either the gastric mucosa (pT1a) or submucosa (pT1b), which is independent of the presence of lymph node metastases or other clinicopathological characteristics . Tumors smaller than 5 mm in diameter are considered minute carcinomas, but 3–9% of them are pT1b stage and can be metastatic .…”

“…Only 79 cases of EGC‐related bone metastases were published between 1983 and 2015 (Table ). The cervical and thoracic vertebra were mostly affected (66–96%), followed by the ribs (40–75%), pelvis (15–44%), skull (16–30%), femur (30%), and sternum (16%) .…”