Primary malignant tumors of the stomach in children

Pediatric gastric adenocarcinoma: A National Cancer Data Base review

PURPOSE

We sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients.

METHODS

Using the 2004 to 2014 National Cancer Database (NCDB), patients ≤21 years (pediatric) were retrospectively compared to >21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences.

RESULTS

Of the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73-1.15).

CONCLUSION

While gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Gastric adenocarcinoma in a 13-year-old boy: a diagnosis not often seen in this age group

Gastric adenocarcinoma is not uncommon in the adult population, but in the pediatric population it is an extremely rare entity. A 13-year-old boy was referred to a pediatric oncology unit for evaluation of a tumor in the upper abdomen. Further investigation revealed an advanced stage gastric carcinoma with metastases suggestive for a hereditary cause. Awareness for uncommon diagnoses is a key issue in regard of accurate treatment and overall prognosis.

Primary gastric tumors of infancy and childhood: 54-year experience at a single institution

BACKGROUND/PURPOSE

Primary gastric tumors are rare in infancy and childhood. Because of the infrequent occurrence of these tumors, the clinician may be unfamiliar with optimal management strategies. We review our experience over the past 54 years and the current literature.

METHODS

During the period extending from 1952 to 2006, 21 infants and children with primary gastric tumors were treated at Children's Hospital Los Angeles. The series includes 8 cases previously reported and 13 additional cases seen since the initial report. Follow-up information is included.

RESULTS

There were 12 males and 9 females, aged 12 days to 18 years, who were diagnosed with gastric tumors. The patients presented primarily with weight loss, vomiting, or an abdominal mass. Morphological analysis revealed gastric stromal tumors (n = 6), teratomas (n = 4), lymphomas (n = 4), adenocarcinomas (n = 2), inflammatory myofibroblastic tumors (n = 2), embryonal rhabdomyosarcoma (n = 1), and hamartomas (n = 3). There were 16 patients still alive (mean follow-up, 22.3 months), whereas 6 died from active disease despite multimodal treatment. The deaths occurred in patients with stromal tumors, adenocarcinomas, lymphomas, and rhabdomyosarcoma.

CONCLUSIONS

Gastric tumors in children are rare. A high index of suspicion is needed to diagnose these tumors. Most malignant tumors present at an advanced stage and carry a substantial rate of mortality. They should be completely resected whenever feasible. In the case of some malignancies, chemotherapy may play a major role. Metastatic evaluation should be performed in all patients with malignant gastric tumors.

Gastrointestinal tumors in children and adolescents

Tumors of the pediatric gastrointestinal tract are extremely rare. Their infrequent presentation at treatment centers has not allowed for the development of standardized treatment protocols and prospective review. The most prevalent gastrointestinal neoplasms and malignancies are described, including gastrointestinal lymphoma, colorectal carcinoma, carcinoid tumors, gastrointestinal stromal tumors, leiomyomas, juvenile polyps, inflammatory pseudotumors, gastric tumors, and Peutz-Jeghers polyposis syndrome. Current recommendations for the medical and surgical management of these tumors are reviewed and summarized for this vast group of gastrointestinal neoplasms in children.

Gastrointestinal stromal tumors of the stomach in children and young adults: a clinicopathologic, immunohistochemical, and molecular genetic study of 44 cases with long-term follow-up and review of the literature

Gastrointestinal stromal tumors (GISTs), specific KIT- or PDFGRA-signaling driven mesenchymal tumors, are rare in children and young adults, and their clinicopathologic and molecular genetic profile is incompletely understood. In this study, we analyzed 44 gastric GISTs occurring by the age of 21 years. There were 32 females and 12 males, youngest of whom were a 5-year-old boy and an 8-year-old girl. All but 1 of 25 patients under the age of 16 were girls. The patients most commonly received medical attention because of chronic, insidious gastrointestinal bleeding with anemia, less commonly with acute GI bleeding. Only 1 patient had Carney triad with pulmonary chondroma. None of the patients had family members with GIST. The tumors measured from 1.5 to 24 cm (median, 5.6 cm). A total of 21 tumors with specified location were in the antrum and 8 were in the gastric body. Histologically, 26 tumors were composed of epithelioid cells, 12 of spindle cells, and 6 of combination thereof. Mitotic activity varied form 0 to 65/50 HPF (median, 5/50). All but one of the 24 tumors tested were KIT-positive, and 20 were CD34-positive. Eleven patients developed liver or abdominal metastases, and 6 of them died of tumor surviving 5.5 to 35.5 years (median, 16 years) after the first surgery; three of these tumors had a low mitotic activity and size <10 cm. Twenty-one patients were alive with no evidence for disease 7 to 41 years (median, 17 years) after the first surgery. None of the 13 tumors examined (7 of them 8- to 16-year-old females) had KIT exon 9, 11, 13, or 17 or PDGFRA exon 12 or 18 mutation as typically seen in adult GISTs. Gastric GISTs in children have mainly epithelioid morphology, often occur in antrum, and have a somewhat unpredictable but slow course of disease. Their pathogenesis may differ from that of adult GISTs because no KIT or PDGFRA mutations were found; connection with Carney triad seems infrequent despite demographic and histologic similarities.

A microscopic adenocarcinoma of the stomach with pulmonary tumor thrombotic microangiopathy in a 17-year-old male

Pulmonary tumor thrombotic microangiopathy (PTTM), characterized by widespread fibrocellular intimal proliferation of the small pulmonary arteries and arterioles in patients with metastatic carcinomas, has been reported in only few cases. In childhood, gastrointestinal tumors represent less than 5% of pediatric neoplasms, and carcinomas within this subgroup have been very rarely described, in particular those arising in the stomach. We report on a case of a microscopic gastric signet-ring cell carcinoma identified by serial step sections through the entire stomach at autopsy. The patient was a 17-year-old high school student with severe dyspnea and marked pulmonary hypertension due to PTTM. Although the combination of PTTM with gastric cancer is very rare in childhood, it should be considered in the differential diagnosis of primary pulmonary hypertension and progressive respiratory failure, as indicated by a review of previously reported cases.

Recurrent neuroblastoma with gastric invasion

The authors present an unusual manifestation of neuroblastoma in a young child: upper gastrointestinal bleeding due to erosion of the tumor into the stomach. Included are reviews of gastrointestinal manifestations of neuroblastoma and gastric tumors in children.

Gastric adenocarcinoma mimicking achalasia in a 15-year-old patient: a case report and review of the literature

Although adenocarcinoma of the cardia is extremely rare in adolescent patients, the endoscopist should be alert to this disease in patients of any age with dysphagia, even if symptoms, and results of a barium study, upper endoscopy, and esophageal manometry are suggestive of primary achalasia, especially if family history is negative for achalasia. In addition, secondary achalasia should be suspected in patients who do not respond to therapy with botulinum toxin within 2 months. Because none of the mentioned tests can distinguish between primary achalasia and secondary forms due to carcinoma of the cardia, biopsy specimens should be obtained. It appears that, although there is a minimal risk for complications, a diagnostic procedure such as biopsy would be appropriate when the information obtained could be essential. In some cases EUS can be an additional diagnostic tool, because lesions of the submucosa and the surrounding area can be identified by EUS.

Adenocarcinoma at the esophageal gastric junction arising in an 11-year-old girl

Gastric adenocarcinoma is one of the most common gastrointestinal (GI) malignancies, especially among Japanese adults, but represents only 0.05% of all malignant pediatric GI tumors. We report a case of gastric adenocarcinoma arising at the esophageal gastric junction of an 11-year-old girl. The tumor was polypoid, measuring 3.0 x 3.0 x 1.2 cm and was light gray and partially red in color with a stalk. Light microscopic examination of the lesion demonstrated adenocarcinoma of variable degrees of both architectural and nuclear atypia with invasion into the submucosa. Immunohistochemical findings of cytokeratin subtypes revealed positive immunoreactivity for cytokeratin subtypes 8, 19 and 20 and negative for 5/6/18, 7, 13 and 14, which is consistent with those of gastric adenocarcinoma. The patient was alive and well 12 months postoperatively.

Gastric lymphoma causing gastric outlet obstruction

An unusual presentation of abdominal lymphoma causing gastric outlet obstruction is reported. Gastric lymphoma should be considered in the differential diagnosis of gastric outlet obstruction during childhood. The possibility of gastric malignancy should not be excluded only on the basis of the patient's age. Complete resection of the tumor, with postoperative radiation and/or chemotherapy is the best method of treatment for high-grade lymphomas.

Differential alpha-smooth muscle actin expression in a gastric epithelioid leiomyosarcoma in a 14 year old girl

Leiomyosarcoma in childhood is very rare. This report describes the immunohistochemical study of a gastric epithelioid leiomyosarcoma in a 14 year old girl. Microscopically, the tumor showed two distinct histological patterns within the same tumor: small epithelioid cells forming a lobular pattern and spindle-shaped cells forming interlacing fascicles, but no distinct border divided the two types of cells. Immunohistochemically, vimentin was positive in all tumor cells; alpha-smooth muscle actin, however, was negative in small epithelioid cells and positive in spindle-shaped cells. The data revealed that the tumor had components showing two stages of morphological and biochemical differentiation. This case indicates that leiomyosarcomas might lose smooth muscle actin during malignant transformation; or, alternatively, they might arise from a primitive type of smooth muscle cell and some of them could spontaneously differentiate into mature smooth muscle cells, expressing this actin.

Gastric leiomyoblastoma associated with extraadrenal paraganglioma and pulmonary chondroma: a new case of Carney's triad

Carney's triad is extremely rare. The authors report on a 12-year-old patient who had gastric epithelioid leiomyosarcoma, multiple pulmonary chondroma, and mediastinal paraganglioma. Thirty-five other cases are reviewed and analyzed.

Gastric carcinoma in children

Primary gastric carcinoma accounts for only 0.05% of pediatric gastrointestinal malignancies. The pattern, presentation, and location of childhood gastric carcinoma are similar to those of adult gastric carcinoma. Diagnosis is based on a high index of suspicion in children who present with symptoms mimicking acid peptic disease. Delay in diagnosis is common and avoided by early upper gastrointestinal radiography and endoscopy with biopsy. Surgical therapy alone may prolong survival but thus far it has proven only palliative. The role of chemotherapy and radiation in gastric carcinoma is still not well defined, although some new studies in adults may support the use of etoposide, doxorubicin, and cisplatin as primary therapy or combined with surgery and radiation. Long-term survival in children is rare. We present the case of a 3-year survivor, free of disease, treated with resection and chemotherapy.

Clinical and pathologic features of primary gastric rhabdomyosarcoma

The authors report a case of a collision tumor composed of a primary gastric rhabdomyosarcoma intermingled with an adjacent infiltrating gastric adenocarcinoma. Only eight cases of gastric rhabdomyosarcoma have been reported previously and little information is recorded about the behavior of this tumor. Gastric rhabdomyosarcoma has several distinctive clinical features. It is a highly aggressive tumor (median survival, 2.5 months) occurring in both children and adults and frequently presents as metastatic disease to lung or cervical lymph node. The initial diagnosis is often difficult to establish, especially on biopsy material. In several instances, the correct diagnosis was established only at autopsy. The authors' patient was correctly diagnosed during life and received considerable benefit from cyclophosphamide, doxorubicin, and vincristine (CAV) therapy and survived for 26 months after diagnosis. Two of the previously reported eight cases of primary gastric rhabdomyosarcoma and this case have adjacent admixed glandular gastric adenocarcinomas. Since three of the nine known cases of primary gastric rhabdomyosarcoma have an adjacent admixed gastric adenocarcinoma, there appears to be a greater than chance association between these two tumors.

Gastrointestinal malignancies in infancy, childhood, and adolescence

Gastrointestinal and hepatobiliary malignancies in the pediatric age group are rare tumors and are usually treated with frustratingly poor results because of late diagnosis. Current efforts to improve treatment are directed at earlier diagnosis of these tumors in combination with aggressive surgery and adjuvant therapy.

Linitis plastica in a child

Anaplastic infiltrative adenocarcinoma of the linitis plastica morphologic type is rare in children. The case of a 15-year-old child with this unusual form of gastric carcinoma is presented. One year postoperatively following radiation and chemotherapy, the child is free of disease.