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Hindawi Case Reports in Oncological Medicine Volume 2020, Article ID 3738798, 6 pages https://doi.org/10.1155/2020/3738798 Case Report Rare Abdominal Wall Metastasis following Curative Resection of Gastric Cancer: What Can Be Learned from the Use of Percutaneous Catheters? 1 1 2 3 Arthur A. Parsee , Kerry L. Thomas, Masoumeh Ghayouri, Rutika Mehta, 4 1 1 1 Kujtim Latifi, Jennifer Sweeney, Daniel Jeong, and Abraham Ahmed Department of Radiology, Moﬃtt Cancer Center, Tampa, Florida, USA Department of Pathology, Moﬃtt Cancer Center, Tampa, Florida, USA Department of Gastrointestinal Oncology, Moﬃtt Cancer Center, Tampa, Florida, USA Department of Radiation Oncology, Moﬃtt Cancer Center, Tampa, Florida, USA Correspondence should be addressed to Arthur A. Parsee; arthur.parsee@moﬃtt.org Received 23 January 2020; Revised 21 April 2020; Accepted 23 April 2020; Published 14 May 2020 Academic Editor: Jose I. Mayordomo Copyright © 2020 Arthur A. Parsee et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In cancer care, tissue seeding after curative resections is a known potential complication, despite precautions taken during surgical treatment. We present an uncommon case of an abdominal wall metastasis along the tract of a surgical drain following gastrectomy for gastric adenocarcinoma. To our knowledge, this is the ﬁrst case of such an occurrence in the setting of a negative staging peritoneal lavage. Aside from the rarity of such a recurrence, this instance highlights an opportunity to reevaluate best practices with regard to the extent of coverage of postoperative salvage radiotherapy. The oncologic patient provides many challenges and may require multiple catheters for drainage and at times infusion of nutrition or therapeutic agents. These foreign bodies should be scrutinized both clinically and radiographically, as they may create vulnerabilities in keeping malignant diseases contained and controlled. We provide a review of the literature with reasonable treatment options for the beneﬁt of future patients. 1. Introduction lights the presentation and timing with subsequent treatment of an abdominal wall metastasis following total gastrectomy. Cancer treatment is multidisciplinary and comprehensive with the ultimate goal of tumor eradication to maximize sur- vival and minimize morbidity. Complications must be han- 2. Case Presentation dled expediently to mitigate morbidity and improve prognosis. Metastatic seeding following resection is a rare A 62 year-old female with no signiﬁcant past medical history but signiﬁcant occurrence warranting further therapy. was found to have a normocytic anemia (Hgb 8.6) on routine Spread patterns of gastric cancer rely primarily on histology, bloodwork. The primary care provider’s workup included with generic adenocarcinoma mostly involving the liver upper endoscopy (Figure 1) which revealed a mass 40 cm (48%), followed by the peritoneum (32%) and lung (15%), from the incisors, arising from the gastric cardia, with exten- and least often to the bone (12%) . The signet ring subtype sion to the gastroesophageal junction. Endoscopic biopsy of adenocarcinoma has a predilection for the peritoneum, returned invasive moderately-diﬀerentiated gastric adenocar- with a lesser burden in the liver and lungs. The second consid- cinoma. Risk factors include smoking (19 pack-years; quit eration is tumor location, with cases divided into the cardia more than 10 years ago) and occasional alcohol consumption and noncardia categories, with the latter also demonstrating of 2-3 drinks per week. No complaints of dysphagia, weight a tendency for peritoneal carcinomatosis . This case high- loss, or change in bowel habits. Intermittent gastroesophageal 2 Case Reports in Oncological Medicine Figure 1: EGD photograph—an ulcerated mass 40 cm from incisors is shown, with stigmata of recent bleeding involving the gastric cardia, extending to the gastroesophageal junction. Figure 2: EUS—a hypoechoic mass involving two-thirds of the gastric circumference measured 4:8× 1:9 cm, with serosal invasion and two malignant-appearing lymph nodes (one shown in ﬁeld-of-view) in the paracardial region (level 16), T3N1MX by endosonographic criteria. (a) (b) Figure 3: Initial axial fused PET/CT image (a) showing robust hypermetabolism of the gastric cardia (max SUV 10.4) with subsequent axial fused PET/CT image (b.) following neoadjuvant therapy with reduced size and uptake (SUV 4.3), consistent with 60% reduction in FDG concentration. Case Reports in Oncological Medicine 3 Figure 4: Axial postcontrast CT performed in the postoperative period showed leaked contrast concentrated at the tip of the surgical drain (black arrow). Contrast level is also present within Jackson-Pratt drain reservoir (white arrow). Physical Physical (a) (b) Figure 5: Coronal (a) and sagittal (b) overlays with isodense lines of planned external beam radiotherapy (XRT) with coverage of the surgical bed. reﬂux disease (GERD) was treated with pantoprazole. No per- lessening disease burden prior to a curative resection for a sonal or family history of cancer was noted. Siewert III gastroesophageal junction cancer . Neoadju- Staging endoscopic ultrasound (Figure 2) demonstrated a vant chemotherapy was initiated, and it consisted of 6 cycles of 5-ﬂuorouracil, leucovorin, oxaliplatin, and docetaxel well-circumscribed hypoechoic mass measuring up to 4.8 cm with sonographic evidence of serosal invasion. Two (FLOT) with docetaxel being excluded from the last round. malignant-appearing lymph nodes were identiﬁed in the A restaging PET/CT (Figure 3) showed reduction in both paracardial region (level 16) 5 mm from the tumor, lending tumor bulk and FDG avidity by approximately 60%, with to staging of T3N1MX. Initial 18-ﬂuoro-deoxyglucose CEA level decreased to 2.3 (initially 5.6). ( Following standard preoperative cardiac clearance, the FDG) positron-emission tomography/computed tomog- raphy (PET/CT) showed concentrated uptake within only patient underwent a robotic-assisted total gastrectomy and the gastric mass, with a standardized uptake value (SUV) of D2 lymphadenectomy. En bloc resection included 4 cm of 10.4, but no evidence of distant metastasis. Initial carcinoem- the distal esophagus as well as total omentectomy. Just prior bryonic antigen (CEA) level was 5.6 ng/mL (normal is less to this, a small lymph node in the splenic hilum was sent for frozen section, which was negative for malignancy. Before than 5.2). Diagnostic laparoscopy showed no peritoneal disease, construction of the esophagojejunostomy, frozen sections of and lavage washings were negative for malignant cells. A the resection margins returned, which were also clear of multidisciplinary approach concluded the best path towards any tumor. A Jackson-Pratt (JP) drain was placed behind 4 Case Reports in Oncological Medicine (a) (b) Figure 6: Coronal noncontrast (a) and postcontrast (b) CT reconstructions demonstrating a new vascular nodule (black arrow) in close proximity to the drain tract with the residual barium demarcating tract (white arrow). the anastomosis. Endoscopic testing was negative for any leaks. A feeding jejunostomy was also placed. Postoperative recovery was initially as expected, with routine ﬂuoroscopic interrogation of the anastomosis show- ing no leak with either water-soluble or barium contrast and with normal esophageal motility. On day 4, an episode of fever, tachycardia, and hypertension occurred. Antipyretic and empiric antibiotics were started, and a CT was per- formed for further investigation (Figure 4). This revealed a small collection of extraluminal contrast near the tip of the surgical drain and a concentration of contrast within the drain’s reservoir, both suggesting a small previously occult anastomotic leak. Endoscopy conﬁrmed a small ulceration at the anastomosis, 35 cm from the incisors, which was eﬀectively covered by a 7:0×2:3 cm EndoMAXX stent (Merit Medical, South Jordan UT, USA) traversing 31 to 38 cm from the incisors. On day 9, a repeat CT showed a new subphrenic collection as well as more leaked contrast Right lat abd wall trans within Morison’s pouch. A CT-guided drain was placed to eﬀectively evacuate the subphrenic collection. The remainder Figure 7: Doppler ultrasound conﬁrming the subcutaneous nodule of the postoperative course was relatively uneventful, with with internal vascularity and distortion of associated subcutaneous the jejunostomy removed once the patient was tolerating a tissue planes, performed concurrent with image-guided biopsy. soft mechanical diet. Surgical pathology showed both lymphovascular and perineural invasion, with tumor within 1 mm of the omental margin. Only 2 of 27 nodes were positive, without treatment biopsy. Pathology from core biopsy (Figure 8) showed an eﬀect of the primary tumor present, yielding a ﬁnal stage of identical histological pattern as the original gastric adenocar- ypT4aN1. A regimen of salvage chemoradiation was initi- cinoma. Immunohistochemical analysis was performed in ated, which included capectabine, as well as 1.8 Gy fractions hopes of eliciting additional treatment options. This revealed divided over 25 sessions, for a total dose of 45 Gy focused 3+ expression of the HER2/neu receptor. HER2 testing was on the surgical bed (Figure 5). not performed on the original endoscopic biopsy or the gas- trectomy specimen. A regimen was undertaken consisting of Two months later, a near-tripling in CEA (6.4 from 2.3) was concurrent with a new CT ﬁnding of a 1.1 cm hypervas- four cycles of calcium folinate, 5-ﬂuorouracil, oxaliplatin, cular lesion embedded within the right abdominal wall sub- and leucovorin (FOLFOX) as well as Herceptin (trastuzu- cutaneous fat (Figure 6) in close proximity to the previous mab). After treatment, the nodule was no longer palpable JP surgical drain. This was palpable on the physical exam. and had resolved on imaging. The patient is now on mainte- An ultrasound was performed (Figure 7) to facilitate targeted nance Herceptin alone and is disease free. Case Reports in Oncological Medicine 5 (a) (b) Figure 8: Hematoxylin and eosin-stained histology slides of primary gastric adenocarcinoma at 4x magniﬁcation, moderately-diﬀerentiated with solid nests and glandular architecture (a). Identical pattern found after biopsy of the abdominal wall mass (b) at 1x magniﬁcation. 3. Discussion example, an intracranial glioma has been reported to disperse into the peritoneum via a ventricular shunt . Further- more, seeding is not speciﬁc to the peritoneum or abdomen. Gastric cancer speciﬁcally is known to spread primarily via Malignant eﬀusions spreading from the pleura to the chest the peritoneum; the two primary paths being stomata-like wall have been reported to be as high as 22% . oriﬁces along the omentum and transvessel migration facili- tated by hypoxic-induced factor-1α . Esophagectomy As it has been established that tract seeding can arise with a variety of tissue types and through variable media, it is rea- studies have suggested a mechanical disruption of lymphatic sonable to undertake protective measures to prevent tract channels as being another method for the spread . These seeding. While surgical literature has described the impor- studies suggest that the peritoneal ﬂuid at some point tance of resecting open biopsy tracts, this appears to be spe- becomes contaminated with viable tumor cells, which can be conﬁrmed with lavage of both the peritoneal cavity and ciﬁc to sarcomas and not necessarily applicable to needle biopsies . An argument has been made to justify prophy- surgical wounds. In cases of en bloc resection, a study found lactic radiation to chest tube sites in the setting of mesotheli- that wound washings were positive in 13% of instances, with oma, in the form of a single-dose 10 Gy fraction . While drained ﬂuid being positive in 9%, in a pool of 184 patients there are several treatment options that may be applied to . Studies of upper gastrointestinal cancers with anasto- GI malignancies, it is generally acknowledged that isolated motic leaks are sparse; however, analogous reviews of colo- tract metastases, once removed or resolved, generally do rectal cancers did not ﬁnd that leaks had a signiﬁcant not recur  as currently holds true in this case. impact on survival, tract or peritoneal seeding, or local recur- This report serves as both an example and warning that rence [6, 7]. gastrointestinal cancers with anastomotic leaks can seed Peritoneal lavage has been established as an adjunct in catheter tracts, even with a negative staging lavage of the peri- staging, albeit of debated utility [8, 9]. A patient series with toneum. Any catheter site must be scrutinized, as it will exclusive gastrointestinal malignancies found that staging extend beyond the irradiated ﬁeld. Tumor markers and lavage was only helpful in 1.3% of cases in providing useful prognostic information . The most consistent risk factor imaging are helpful in diagnosing abdominal wall metastases. Informed consent was obtained and a copy is available to consider is the size of the primary tumor at initial staging upon request. The case was anonymized, with the exemption . The precise moment of seeding may be diﬃcult to from IRB approval. determine, as various interventions create a multitude of seeding vulnerabilities. Percutaneous biopsies, whether core or ﬁne needle, provide one possibility of dissemination . Data Availability Enterostomy tubes for either drainage or feeding deliver yet another path for tumor propagation . The most corrobo- Not applicable. rated risk is transhepatic drainage for malignant biliary obstructions [14–16]. 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Case Reports in Oncological Medicine – Hindawi Publishing Corporation
Published: May 14, 2020
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