Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Rare Abdominal Wall Metastasis following Curative Resection of Gastric Cancer: What Can Be Learned from the Use of Percutaneous Catheters?

Rare Abdominal Wall Metastasis following Curative Resection of Gastric Cancer: What Can Be... 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%) [1]. 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 [1]. 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 [2]. 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 [19]. 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% [20]. orifices along the omentum and transvessel migration facili- tated by hypoxic-induced factor-1α [3]. 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 [4]. 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 [21]. 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 [22]. While drained fluid being positive in 9%, in a pool of 184 patients there are several treatment options that may be applied to [5]. 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 [23] 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 [10]. 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 [11]. 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 [12]. Data Availability Enterostomy tubes for either drainage or feeding deliver yet another path for tumor propagation [13]. The most corrobo- Not applicable. rated risk is transhepatic drainage for malignant biliary obstructions [14–16]. The prevalence of catheter tract seed- ing is somewhat disputed, with two reviews displaying rates Conflicts of Interest ranging from as low as 6% to as high as 22% [17, 18]. In addi- tion, soft tissue spread is not unique to GI malignancies; for The authors have nothing to disclose. 6 Case Reports in Oncological Medicine [16] L. Solin and M. Mohiuddin, “Subcutaneous seeding of pan- References creatic carcinom along a transhepatic biliary catheter tract,” [1] M. Riihimäki, A. Hemminki, K. Sundquist, J. Sundquist, and British Journal of Radiology, vol. 56, no. 671, pp. 883-884, K. Hemminki, “Metastatic spread in patients with gastric can- 2014. cer,” Oncotarget, vol. 7, no. 32, pp. 52307–52316, 2016. [17] S. Talukder, A. Behera, C. Tandup, and S. Mitra, “Isolated [2] R. BHAvon, H. J. Stein, and J. R. Siewert, “Surgical manage- implant metastasis in chest wall due to seeding of transpleu- ment of esophagogastric junction tumors,” World Journal of rally placed PTBD catheter tract in a case of hilar cholangio- Gastroenterology, vol. 12, no. 41, pp. 6608–6613, 2006. carcinoma,” BMJ Case Reports, vol. 10, no. 1136, p. 219864, [3] F. Sun, M. Feng, and W. Guan, “Mechanisms of peritoneal dis- semination in gastric cancer (review),” Oncology Letters, [18] L. Wang, N. Lin, F. Xin, Q. Ke, Y. Zeng, and J. Liu, “A system- vol. 93, no. 4, pp. 243–248, 2017. atic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percuta- [4] T. Nishimaki, T. Suzuki, and K. Hatakeyama, “Implantation neous transhepatic biliary drainage for resectable malignant metastasis of esophageal carcinoma to the surgical wound after biliary obstruction,” World Journal of Surgical Oncology, radical esophagectomy,” Surgery, vol. 119, no. 3, p. 359, 1996. vol. 17, no. 1, pp. 116–119, 2019. [5] J. C. Fisher, A. S. Ketcham, R. B. Hume, and R. A. Malmgren, [19] S. Stephens, G. Tollesson, T. Robertson, and R. Campbell, “Significance of cancer cells in operative wounds,” American “Diffuse midline glioma metastasis to the peritoneal cavity Journal of Surgery, vol. 114, no. 4, pp. 514–519, 1967. via ventriculo-peritoneal shunt: case report and review of liter- [6] F. Jörgren, R. Johansson, L. Damber, and G. Lindmark, “Anas- ature,” Journal of Clinical Neuroscience, vol. 67, pp. 288–293, tomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer- [20] K. Cattapan, W. Tanomkiat, S. L. Geater, and N. Kiranantawat, specific survival?,” Colorectal Disease, vol. 13, no. 3, pp. 272– “Procedure-related tumour seeding in lung cancer with malig- 283, 2011. nant pleural effusion: radiological features and outcomes,” [7] T. Sueda, M. Tei, Y. Yoshikawa et al., “Prognostic impact of Journal of Medical Imaging and Radiation Oncology, vol. 62, postoperative intra-abdominal infections after elective colo- no. 5, pp. 619–624, 2018. rectal cancer resection on survival and local recurrence: a pro- pensity score-matched analysis,” International Journal of [21] I. Barrientos-Ruiz, E. J. Ortiz-Cruz, J. Serrano-Montilla, D. Bernabeu-Taboada, and J. J. Pozo-Kreilinger, “Are biopsy Colorectal Disease, vol. 35, no. 3, pp. 413–422, 2020. tracts a concern for seeding and local recurrence in sarco- [8] M. Hasbahceci, A. Akcakaya, B. Guler, E. Kunduz, F. U. Malya, mas?,” Clinical Orthopaedics and Related Research®, vol. 475, and M. Muslumanoglu, “Use of peritoneal washing cytology no. 2, pp. 511–518, 2017. for the detection of free peritoneal cancer cells before and after ;surgical treatment of gastric adenocarcinoma,” Journal of [22] H. Carette, J. C. Faivre, J. Salleron et al., “Irradiation préventive Cancer Research and Therapeutics, vol. 14, no. 6, pp. 1225– en une séance de 10 Gy des sites d’intervention pleurale des patients atteints de mésothéliome pleural malin : étude de 1229, 2018. cohorte rétrospective monocentrique,” Cancer radiotherapie: [9] R. K. Freeman and M. A. Wait, “Port site metastasis after lap- journal de la Societe francaise de radiotherapie oncologique, aroscopic staging of esophageal carcinoma,” The Annals of vol. 21, no. 8, pp. 774–783, 2017. Thoracic Surgery, vol. 71, pp. 1032–1034, 2001. [23] E. Koffi, V. Moutardier, A. Sauvanet, R. Noun, J. F. Fléjou, and [10] E. N. van Dijkum, P. D. Sturm, L. T. De Wit, J. Offerhaus, J. Belghiti, “Wound recurrence after resection of hepatocellular H. Obertop, and D. J. Gouma, “Cytology of peritoneal lavage carcinoma,” Liver Transplantation and Surgery, vol. 2, no. 4, performed during staging laparoscopy for gastrointestinal pp. 301–303, 1996. malignancies: is it useful?,” Annals of Surgery, vol. 228, no. 6, pp. 728–733, 1998. [11] M. S. Cappell, “Risk factors and risk reduction of malignant seeding of the percutaneous endoscopic Gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases,” The American Journal of Gastroenter- ology, vol. 102, no. 6, pp. 1307–1311, 2007. [12] K. Shyamala, H. C. Girish, and S. Murgod, “Risk of tumor cell seeding through biopsy and aspiration cytology,” Journal of International Society of Preventive and Community Dentistry, vol. 4, no. 1, pp. 5–11, 2014. [13] N. Y. Hsu, T. Y. Lin, C. T. Hsu, and P. P. Tsai, “Tumor seeding of the jejunostomy site after transhiatal esophagectomy for esophageal carcinoma,” Diseases of the Esophagus, vol. 12, no. 2, pp. 157–159, 1999. [14] T. Yamakawa, S. Itoh, K. Hirosawa et al., “Seeding of gallblad- der carcinoma along the tract after percutaneous transhepatic choledochoscopy,” American Journal of Gastroenterology, vol. 78, no. 10, pp. 649–651, 1983. [15] W. S. Kim, K. H. Barth, and M. Zinner, “Seeding of pancreatic carcinoma along the transhepatic catheter tract,” Radiology, vol. 143, no. 2, pp. 427-428, 1982. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Rare Abdominal Wall Metastasis following Curative Resection of Gastric Cancer: What Can Be Learned from the Use of Percutaneous Catheters?

Loading next page...
 
/lp/hindawi-publishing-corporation/rare-abdominal-wall-metastasis-following-curative-resection-of-gastric-F9gfYejjpg
Publisher
Hindawi Publishing Corporation
Copyright
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.
ISSN
2090-6706
eISSN
2090-6714
DOI
10.1155/2020/3738798
Publisher site
See Article on Publisher Site

Abstract

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%) [1]. 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 [1]. 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 [2]. 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 [19]. 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% [20]. orifices along the omentum and transvessel migration facili- tated by hypoxic-induced factor-1α [3]. 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 [4]. 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 [21]. 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 [22]. While drained fluid being positive in 9%, in a pool of 184 patients there are several treatment options that may be applied to [5]. 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 [23] 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 [10]. 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 [11]. 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 [12]. Data Availability Enterostomy tubes for either drainage or feeding deliver yet another path for tumor propagation [13]. The most corrobo- Not applicable. rated risk is transhepatic drainage for malignant biliary obstructions [14–16]. The prevalence of catheter tract seed- ing is somewhat disputed, with two reviews displaying rates Conflicts of Interest ranging from as low as 6% to as high as 22% [17, 18]. In addi- tion, soft tissue spread is not unique to GI malignancies; for The authors have nothing to disclose. 6 Case Reports in Oncological Medicine [16] L. Solin and M. Mohiuddin, “Subcutaneous seeding of pan- References creatic carcinom along a transhepatic biliary catheter tract,” [1] M. Riihimäki, A. Hemminki, K. Sundquist, J. Sundquist, and British Journal of Radiology, vol. 56, no. 671, pp. 883-884, K. Hemminki, “Metastatic spread in patients with gastric can- 2014. cer,” Oncotarget, vol. 7, no. 32, pp. 52307–52316, 2016. [17] S. Talukder, A. Behera, C. Tandup, and S. Mitra, “Isolated [2] R. BHAvon, H. J. Stein, and J. R. Siewert, “Surgical manage- implant metastasis in chest wall due to seeding of transpleu- ment of esophagogastric junction tumors,” World Journal of rally placed PTBD catheter tract in a case of hilar cholangio- Gastroenterology, vol. 12, no. 41, pp. 6608–6613, 2006. carcinoma,” BMJ Case Reports, vol. 10, no. 1136, p. 219864, [3] F. Sun, M. Feng, and W. Guan, “Mechanisms of peritoneal dis- semination in gastric cancer (review),” Oncology Letters, [18] L. Wang, N. Lin, F. Xin, Q. Ke, Y. Zeng, and J. Liu, “A system- vol. 93, no. 4, pp. 243–248, 2017. atic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percuta- [4] T. Nishimaki, T. Suzuki, and K. Hatakeyama, “Implantation neous transhepatic biliary drainage for resectable malignant metastasis of esophageal carcinoma to the surgical wound after biliary obstruction,” World Journal of Surgical Oncology, radical esophagectomy,” Surgery, vol. 119, no. 3, p. 359, 1996. vol. 17, no. 1, pp. 116–119, 2019. [5] J. C. Fisher, A. S. Ketcham, R. B. Hume, and R. A. Malmgren, [19] S. Stephens, G. Tollesson, T. Robertson, and R. Campbell, “Significance of cancer cells in operative wounds,” American “Diffuse midline glioma metastasis to the peritoneal cavity Journal of Surgery, vol. 114, no. 4, pp. 514–519, 1967. via ventriculo-peritoneal shunt: case report and review of liter- [6] F. Jörgren, R. Johansson, L. Damber, and G. Lindmark, “Anas- ature,” Journal of Clinical Neuroscience, vol. 67, pp. 288–293, tomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer- [20] K. Cattapan, W. Tanomkiat, S. L. Geater, and N. Kiranantawat, specific survival?,” Colorectal Disease, vol. 13, no. 3, pp. 272– “Procedure-related tumour seeding in lung cancer with malig- 283, 2011. nant pleural effusion: radiological features and outcomes,” [7] T. Sueda, M. Tei, Y. Yoshikawa et al., “Prognostic impact of Journal of Medical Imaging and Radiation Oncology, vol. 62, postoperative intra-abdominal infections after elective colo- no. 5, pp. 619–624, 2018. rectal cancer resection on survival and local recurrence: a pro- pensity score-matched analysis,” International Journal of [21] I. Barrientos-Ruiz, E. J. Ortiz-Cruz, J. Serrano-Montilla, D. Bernabeu-Taboada, and J. J. Pozo-Kreilinger, “Are biopsy Colorectal Disease, vol. 35, no. 3, pp. 413–422, 2020. tracts a concern for seeding and local recurrence in sarco- [8] M. Hasbahceci, A. Akcakaya, B. Guler, E. Kunduz, F. U. Malya, mas?,” Clinical Orthopaedics and Related Research®, vol. 475, and M. Muslumanoglu, “Use of peritoneal washing cytology no. 2, pp. 511–518, 2017. for the detection of free peritoneal cancer cells before and after ;surgical treatment of gastric adenocarcinoma,” Journal of [22] H. Carette, J. C. Faivre, J. Salleron et al., “Irradiation préventive Cancer Research and Therapeutics, vol. 14, no. 6, pp. 1225– en une séance de 10 Gy des sites d’intervention pleurale des patients atteints de mésothéliome pleural malin : étude de 1229, 2018. cohorte rétrospective monocentrique,” Cancer radiotherapie: [9] R. K. Freeman and M. A. Wait, “Port site metastasis after lap- journal de la Societe francaise de radiotherapie oncologique, aroscopic staging of esophageal carcinoma,” The Annals of vol. 21, no. 8, pp. 774–783, 2017. Thoracic Surgery, vol. 71, pp. 1032–1034, 2001. [23] E. Koffi, V. Moutardier, A. Sauvanet, R. Noun, J. F. Fléjou, and [10] E. N. van Dijkum, P. D. Sturm, L. T. De Wit, J. Offerhaus, J. Belghiti, “Wound recurrence after resection of hepatocellular H. Obertop, and D. J. Gouma, “Cytology of peritoneal lavage carcinoma,” Liver Transplantation and Surgery, vol. 2, no. 4, performed during staging laparoscopy for gastrointestinal pp. 301–303, 1996. malignancies: is it useful?,” Annals of Surgery, vol. 228, no. 6, pp. 728–733, 1998. [11] M. S. Cappell, “Risk factors and risk reduction of malignant seeding of the percutaneous endoscopic Gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases,” The American Journal of Gastroenter- ology, vol. 102, no. 6, pp. 1307–1311, 2007. [12] K. Shyamala, H. C. Girish, and S. Murgod, “Risk of tumor cell seeding through biopsy and aspiration cytology,” Journal of International Society of Preventive and Community Dentistry, vol. 4, no. 1, pp. 5–11, 2014. [13] N. Y. Hsu, T. Y. Lin, C. T. Hsu, and P. P. Tsai, “Tumor seeding of the jejunostomy site after transhiatal esophagectomy for esophageal carcinoma,” Diseases of the Esophagus, vol. 12, no. 2, pp. 157–159, 1999. [14] T. Yamakawa, S. Itoh, K. Hirosawa et al., “Seeding of gallblad- der carcinoma along the tract after percutaneous transhepatic choledochoscopy,” American Journal of Gastroenterology, vol. 78, no. 10, pp. 649–651, 1983. [15] W. S. Kim, K. H. Barth, and M. Zinner, “Seeding of pancreatic carcinoma along the transhepatic catheter tract,” Radiology, vol. 143, no. 2, pp. 427-428, 1982.

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: May 14, 2020

References