Early gastric cancer associated with synchronous liver metastasis and portal tumorous embolism: report of a case

Stage IV Epstein-Barr Virus-Associated Early Gastric Cancer and Comparative Analysis of Genetic Alterations in Primary and Metastatic Tumors

Early gastric cancer (EGC) with synchronous distant metastasis is extremely rare. Here, we report a case of stage IV Epstein-Barr virus (EBV) -associated EGC. A 51-year-old man presented with vague abdominal pain of 3 weeks' duration. Imaging studies revealed enlargement of the left supraclavicular, perigastric, and para-aortic lymph nodes, a huge gastric polypoid mass, and multiple liver masses. Histopathological examination of a biopsy specimen of the supraclavicular lymph node showed poorly differentiated carcinoma expressing EBV in tumor cell nuclei. The gastric mass exhibited tubular adenocarcinoma, which also expressed EBV in tumor cell nuclei. After 3 weeks of palliative chemotherapy with fluoropyrimidine and platinum, the patient died of liver failure. Next-generation sequencing analysis revealed mutation of the CDKN1B gene in the metastatic carcinoma and mutations of the CTNNB1 and PIK3R1 genes in the gastric carcinoma. In addition to the rare presentation of EBV-associated EGC, this case showed marked morphological and molecular differences between primary and metastatic tumors, which suggests clonal evolution of EBV-associated GC.

Overt bone metastasis and bone marrow micrometastasis of early gastric cancer

Recently we encountered two cases of early gastric cancer (EGC) with bone metastasis after surgery. As they were not accompanied by overt liver, lung, or peritoneal metastasis, we examined the clinical significance of bone metastasis in EGC and its mechanisms by a review of the literature. We found only 10 cases of EGC complicated with overt bone metastasis in the English literature, so we also examined the Japanese reports of such cases. The main histologic type of cases of bone metastasis from EGC was the diffuse type, and there were long intervals between surgery and overt bone metastasis. One reason for such long intervals may have been the tumor dormancy. Two types of dormancy, dynamic and static, and two types of postoperative overt metastases, that of micrometastatic origin (normograde metastatic process) and that of bone marrow origin (retrograde metastatic process), were considered. We speculated that there may be specific routes by which the cancer cells infiltrate the bone marrow directly from EGC or lymph node metastasis. The procedures for diagnosing bone micrometastasis using monoclonal antibodies have recently been improved, but their accuracy rates are still not universally accepted. New, more reliable examinations are required to improve the survival rates of EGC.

Essential pre-treatment imaging examinations in patients with endoscopically-diagnosed early gastric cancer

Background

There have been no reports discussing which imaging procedures are truly necessary before treatment of endoscopically-diagnosed early gastric cancer (eEGC). The aim of this pilot study was to show which imaging examinations are essential to select indicated treatment or appropriate strategy in patients with eEGC.

Methods

In 140 consecutive patients (95 men, 45 women; age, 66.4 +/- 11.3 years [mean +/- standard deviation], range, 33-90) with eEGC which were diagnosed during two years, the pre-treatment results of ultrasonography (US) and contrast-enhanced computed tomography (CT) of the abdomen, barium enema (BE) and chest radiography (CR) were retrospectively reviewed. Useful findings that might affect indication or strategy were evaluated.

Results

US demonstrated useful findings in 13 of 140 patients (9.3%): biliary tract stones (n = 11) and other malignant tumors (n = 2). Only one useful finding was demonstrated on CT (pancreatic intraductal papillary mucinous tumor) but not on US (0.7%; 95% confidential interval [CI], 2.1%). BE demonstrated colorectal carcinomas in six patients and polyps in 10 patients, altering treatment strategy (11.4%; 95%CI, 6.1-16.7%). Of these, only two colorectal carcinomas were detected on CT. CR showed three relevant findings (2.1%): pulmonary carcinoma (n = 1) and cardiomegaly (n = 2). Seventy-nine patients (56%) were treated surgically and 56 patients were treated by endoscopic intervention. The remaining five patients received no treatment due to various reasons.

Conclusions

US, BE and CR may be essential as pre-treatment imaging examinations because they occasionally detect findings which affect treatment indication and strategy, although abdominal contrast-enhanced CT rarely provide additional information.

Early (mucosal) gastric cancer with synchronous osteosclerotic bone metastases: a case report

Early gastric cancer (EGC) is defined as an adenocarcinoma confined to the gastric mucosa or submucosa, regardless of the presence of lymph node metastases. Early gastric cancer carries an excellent prognosis, with a 5-year survival rate at least 85% in most series. However, there are rare cases where distant metastases exist. Bone metastases are rare in gastric cancer; osteoblastic bone metastases are even rarer. We report a patient with EGC (mucosal) and synchronous osteosclerotic bone metastasis. To our knowledge, this is the first reported case of submucosal EGC with synchronous bone metastases. The patient was operated and he received adjuvant chemotherapy and radiotherapy. He died 18 months after gastric surgery from generalized disease.