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

Esophageal Carcinoma in Children: Report of 2 Cases and a Review of the Literature

Esophageal carcinoma in children and adolescents is extremely rare. Here, we report 2 cases of pediatric esophageal carcinoma presenting with progressive dysphagia. There was not any underlying specific risk factor in our cases. The histopathological subtypes were adenocarcinoma in one and squamous cell carcinoma in another case. Response to combined modality treatment was good in the case of adenocarcinoma, while the patient with squamous cell carcinoma was unresponsive to treatment and died of the progressive disease. We reviewed the pediatric cases of esophageal carcinoma reported in the literature. Progressive dysphagia was observed in 89% of these cases. One third of pediatric cases had underlying risk factors. Squamous cell carcinoma is a more common type of childhood esophageal carcinoma. In contrast to adults, pediatric esophageal squamous cell carcinoma may distribute throughout the esophagus. Esophageal adenocarcinoma was seen in the distal esophagus in pediatric cases. Metastatic disease was found in 48% of pediatric patients at presentation, and the prognosis is poor. Collaborative efforts are needed for success in the treatment of esophageal carcinoma.

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 presenting with gastric outlet obstruction in a child

Gastric carcinoma is extremely rare in children representing only 0.05% of all gastrointestinal malignancies. Here, we report the first pediatric case of gastric cancer presenting with gastric outlet obstruction. Upper endoscopy revealed a markedly thickened antral mucosa occluding the pylorus and a clean base ulcer 1.5 cm × 2 cm at the lesser curvature of the stomach. The narrowed antrum and pylorus underwent balloon dilation, and biopsy from the antrum showed evidence of Helicobacter pylori gastritis. The biopsy taken from the edge of the gastric ulcer demonstrated signet-ring-cell type infiltrate consistent with gastric adenocarcinoma. At laparotomy, there were metastases to the liver, head of pancreas, and mesenteric lymph nodes. Therefore, the gastric carcinoma was deemed unresectable. The patient died few months after initiation of chemotherapy due to advanced malignancy. In conclusion, this case report underscores the possibility of gastric adenocarcinoma occurring in children and presenting with gastric outlet obstruction.

Diagnosis, misdiagnosis, and associated diseases of achalasia in children and adolescents: a twelve-year single center experience

PURPOSE

Although achalasia is a rare disorder in children, its symptom may mimic common childhood diseases. This study aimed to assess the diagnosis and management of achalasia in children and adolescents in a Brazilian single center during a 12-year period.

METHODS

Patients with achalasia were identified from a database built during the period of January 2000-January 2012 from a Pediatric Gastroenterology reference center. Information regarding demographic data, clinical symptoms, diagnosis, treatment, and long-term follow-up were described.

RESULTS

Thirteen patients were studied; median age was 7 (1-14) years. Most frequent symptoms were vomiting (84.6 %) and dysphagia (69.2 %). Weight loss occurred in 46.0 % of patients and chronic cough in 46.1 %. Associated disorders were Down's syndrome, Allgrove syndrome, and congenital central hypoventilation syndrome. Achalasia was misdiagnosed with anorexia nervosa. Six patients were previously treated as having gastroesophageal reflux disease and asthma. Five patients had pneumatic balloon dilation as initial therapy whereas five had esophageal myotomy. Finally, 11 patients had surgical therapy with a favorable follow-up.

CONCLUSION

Achalasia symptoms may mimic common diseases in children, and therefore, may delay the diagnosis. This study emphasizes the importance of the clinical symptoms for the diagnosis of achalasia, mainly in those cases with associated disorders.

Achalasia secondary to neoplasia: a disease with a changing differential diagnosis

Achalasia secondary to neoplasia is an uncommon entity, but recognition is paramount given the concern of missing a cancer diagnosis. Most case series of secondary achalasia occurred in prior decades raising the question of whether the underlying neoplastic causes have changed. All cases of achalasia secondary to neoplasia were reviewed at the Mayo Clinic from 2000 to the present. Cases were assessed for underlying cause of achalasia, whether achalasia was the primary presentation and demographic and clinical factors. Seventeen patients with achalasia secondary to neoplasia were identified. This was 1.5% of all patients with achalasia seen. The most common causes were adenocarcinoma of the esophagus, followed by breast and non-small cell lung cancer. No cases of gastric cancer were identified. Most patients had weight loss and rapid onset of symptoms but could not clearly be distinguished from primary achalasia. Nine patients presented with achalasia, whereas eight patients had known neoplasia. Five of these patients had a positive paraneoplastic panel suggestive of a paraneoplastic syndrome. Prognosis was generally poor except for patients with esophageal leiomyomatosis. This case series demonstrates a changing differential diagnosis for achalasia secondary to neoplasia with a higher number of patients presenting with a known primary and with a paraneoplastic syndrome. Awareness of secondary achalasia and its differentiation from primary causes is still essential.

Does gastric atrophy exist in children?

Several clinical reports confirmed that gastric atrophy is a pathology not only limited to adult patients. In pediatrics, it is most often described in association with a H pylori infection but this bacteria does not seem to be the only etiological factor of this preneoplastic state in children. The frequency of gastric atrophy and intestinal metaplasia in children are unknown because they are not systematically sought during upper gastrointestinal endoscopy. The lack of specific histological classification of children’s gastropathies makes their diagnosis difficult for pathologists. Based on our knowledge to date, we think that it is necessary to describe, in detail, the natural course of this lesion during childhood. A close and prolonged clinical and endoscopic follow-up is important for children with gastric atrophy.

Gastro-oesophageal reflux disease and motility disorders

Gastro-oesophageal reflux (GOR) is a common phenomenon occurring at any age with a benign prognosis in the majority of cases, but requiring prompt evaluation and treatment when presenting with alarm symptoms or when persisting. Complications of GOR disease (GORD) may be severe. This chapter will discuss the epidemiology, natural course, pathophysiology, clinical presentation, diagnostic and therapeutic approach towards GORD and motility disorders according to different ages. Similarities and differences between infants, children and adults will be highlighted. The superior efficacy and safety of proton pump inhibitors have recently changed the diagnostic and therapeutic recommendations in adults, and possible indications in children are discussed. Only in patients unresponsive to optimal medical treatment are further investigations to exclude other aetiologies for GORD needed (e.g. eosinophilic oesophagitis in infants, scleroderma in adults). Special patient groups such as those with congenital malformations (e.g. oesophageal atresia) are not considered, whereas neurological, respiratory and allergy-affected patients as well as Helicobacter pylori infection are briefly discussed.

Esophageal motor disorders

Refinements continue in the measurement, display, and interpretation of pressure events that serve as signatures of esophageal motor disorders, and esophageal manometry retains its position as the diagnostic gold standard. The focus of attention remains with achalasia, not because of pathophysiologic developments or changing prevalence, but in response to the growing interest in minimally invasive surgery and its success. Some controversy remains regarding the role of preoperative motility assessments in patients undergoing antireflux surgery, as peristaltic features do not solely predict outcome. The disconnect between motor dysfunction and symptoms continues to promote careful consideration of sensory dysfunction as a component of esophageal motor disorders.