Shinshu Med J, 59 ⑵ :81〜88, 2011

Two Cases of Early Carcinoma of a Reconstructed Gastric Tube after
Esophagectomy Treated Extendedly with Endoscopic Submucosal Dissection
Naohiko KOIDE ＊, Akira SUZUKI , Taiji AKAMATSU
and Shinichi MIYAGAWA
1） Department of Surgery, Shinshu University School of Medicine
2） Department of Gastroenterology, Shinshu University School of Medicine

We report two cases of gastric tube carcinoma (GTC)treated with endoscopic submucosal dissection (ESD)
after esophagectomy.Case 1 was a 47‑year‑old woman who had received esophagectomy with reconstructionof the gastric tube(GT)for esophageal squamous cell carcinoma.Sixty‑seven months later,endoscopyshoweda carcinoma in the lower part of the GT. The removed tumor showed a 0‑IIc lesion, 10 mm in diameter,
diagnosed as a signet ring cell carcinoma limited to the mucosa. Case 2 was an 83‑year‑old woman who
simultaneously underwent lower esophagectomy for basaloid‑squamous cell carcinoma of the esophagus andcolectomy for ascending colon carcinoma. Sixty‑one months later, endoscopy showed a carcinoma in the
middle part of the GT.The tumor removed by ESD showed a 0‑IIa＋IIc lesion,50 mm in diameter,diagnosed
as a moderately diﬀerentiated tubular adenocarcinoma limited to the mucosa.The clinicopathologic featuresof 48 Japanese cases,including Cases 1 and 2,with GTC were reviewed.An extended indication of endoscopic
resection for gastric carcinoma was present in 12 (25%)including Cases 1 and 2. In conclusion,ESD may besafe for GTC ;however,further investigations may be necessary to conﬁrm the safety and curative potentialof ESD for GTC. Shinshu Med J 59 : 81―88, 2011
(Received for publication October 21, 2010;accepted in revised form December 13, 2010)
Key words:gastric tube, gastric cancer, esophagectomy, endoscopy

Introductionused as a gastric tube(GT)for digestive reconstruction after esophagectomy. Because of the frequent

Esophageal carcinoma has frequently been as-

association of gastric carcinoma in patients withsociated with other primary carcinomas . Gastricesophageal carcinoma, esophagogastroduodenos-

adenocarcinoma is also associated synchronously

copy (EGD) is performed in esophagectomized

and/or metachronously with squamous cell car-patients in order to detect carcinoma in the recon-

cinoma of the esophagus .The clinical outcome ofstructed GT (GTC).

esophageal carcinoma patients following surgical

We herein report two cases of GTC treated withtreatment has recently been improved . In eso-

endoscopic submucosal dissection (ESD) after eso-

phageal carcinoma patients treated with surgery,phagectomy, and review the clinicopathologic fea-

intensive follow‑up in order to detect metastasis

tures of Japanese cases with GTC treated by endos-and recurrence is performed,and long‑term follow‑

copic resection, including polypectomy, endoscopic

up may be necessary. The stomach is frequently

mucosal resection (EM R)and ESD, reported previously.

Corresponding author:Naohiko Koide
Department of Surgery, Shinshu University School ofCase Report

Medicine, 3‑1‑1, Asahi, Matsumoto‑city,
Nagano‑prefecture, 390‑8621, Japan

No. 2, 2011

Case 1:A 47‑year‑old woman was admitted for a81

Koide.Suzuki.Akamatsu et al.

postoperative health check‑up.Sixty‑seven months

GT (Fig. 1A). Biopsy specimens taken from thepreviously,she had undergone esophagectomy via alesion histologically showed signet ring cell car-right thoracotomy with GT reconstruction throughcinoma. Abdominal and chest CT showed neither

the retrosternal route for squamous cell carcinoma

metastasis nor recurrence. This lesion wasof the middle esophagus.The esophageal carcinoma

diagnosed as early GTC.ESD was performed using

histopathologically invaded the submucoal layera hook knife by a gastrointestinal endoscopist.

without node metastasis. The patient has received

After making marks around the gastric lesion,ESD

EGD and computed tomography (CT) every year,

was started (Fig. 1B). A mucosal incision was per-and has shown a favorable course without any

formed around the lesion,and the lesion was dissect-recurrence. Recent EGD

showed a slightly

ed in the submucosal layer in the usual manner.The

depressed lesion (0‑IIc type)in the lower part of thetumor was completely removed en‑bloc without

Fig.1 Endoscopic ﬁndings in Case 1
Ａ :Before endoscopic submucosal dissection (ESD).A slightlydepressed mucosal carcinoma (0‑IIc type)
is observed in the posterior wall of the gastric antrum (arrowheads).Although biopsyspecimens takenfrom the tumor showed signet ring cell carcinoma, those taken from 1 cm away from the tumor
histologically showed no carcinoma cell employing AB‑PAS as well as HE staining.
Ｂ :ESD was started after making some marks around the tumor.
Ｃ :After ESD. The tumor is completely removed by ESD, and neither perforation nor hemorrhage isobserved.
Ｄ :An endoscopicallyresected specimen.In the center ofthe ESD specimen,the slightlydepressed lesion
is observed with a ﬁnely deﬁned horizontal margin.
82

Shinshu Med J Vol.59

ESD for carcinoma of the gastric tube

massive hemorrhage and perforation (Fig.1C).The

moderately diﬀerentiated tubular adenocarcinoma,

removed tumor macroscopically showed a 0‑IIc

50 mm in diameter,limited to the mucosa ;however,lesion (Fig. 1D). Histopathologic examination

lymphatic invasion of the carcinoma cells was ob-

demonstrated signet ring cell carcinoma, 10 mm inserved. The patient is well without any metastasis

diameter, limited to the mucosa without lymphaticor recurrence of GTC 12 months after ESD.

and venous invasion of the carcinoma cells. The

Discussion

lateral and vertical margins were negative for carcinoma cells. The patient is currently well without

GTC was observed in approximately 1‑2% of

any metastasis or recurrence of GTC 41 months

patients with surgery for esophageal carcinoma .

after ESD.

The presence of synchronous or metachronous gas-

Case 2:An 83‑year‑old woman was admitted fortric carcinoma is an issue in the management anda postoperative health check‑up.Sixty‑one months

treatment of patients with esophageal carcinoma.

previously, she had simultaneously undergone sur-

Recently, the clinical outcome of patients withgery for carcinomas of the esophagus and colon.

esophageal carcinoma who have undergone curative

Basaloid‑squamous cell carcinoma of the lower

esophagectomy with extended node dissections has

esophagus, histopathologically invading the sub-been improved, and a second primary carcinoma

mucoal layer without node metastasis,was removed

after esophagectomy is noted in these long‑termby a lower esophagectomy with proximal gas-follow‑ups . These carcinomas arising from thetrectomy via a wide incision of the diaphragm fromreconstructed stomach after esophagectomy havethe esophageal hiatus. A GT was constructed

sometimes been reported in Japan, but have rarely

preserving the right gastric and gastroepiploic

been reported in Western countries. The present

arteries. The digestive tract was reconstructed by

two cases showed a superﬁcial type limited to theesopahgogastrostomy using a circular stapler

submucosal layer of the esophagus, and their clini-

instrument in the mediastinum through the eso-

cal outcome was favorable after previous surgery.

phageal hiatus. Furthermore, adenocarcinoma of

Long‑term follow‑up with EGD is necessary for thethe ascending colon, histopathologically invading

detection of GT disorders after curative surgery forthe submucosal layer without node metastasis,wasesophageal cancer.

synchronously removed employing

right

EMR and ESD have been widely employed forcolectomy. The patient has received EGD, colonos-

early gastric carcinoma, especially mucosal car-copy,and CT of the chest and abdomen every year,

cinoma that is both well and moderately

and remained well without any recurrence over thediﬀerentiated. In spite of the limitation of curative

last year.The last EGD showed a protruding lesion

endoscopic resection of early gastric carcinoma,thewith a depression (0‑IIa＋IIc type) in the middle

prognosis of patients with early gastric carcinoma

part of the lesser curvature of the GT. Biopsy

treated by ESD is likely to be excellent .A consen-

specimens taken from the lesion histologicallysus regarding the safety and curative potential of

showed moderately diﬀerentiated tubular adenocar-

endoscopic treatments for GTC has yet to be rea-

cinoma. Abdominal and chest CT showed neither

ched.However,in esophagectomized patients,addi-

metastasis nor recurrence. This lesion was

tional gastrectomyinvolves several issues regarding

diagnosed as early GTC.ESD was performed using

operative procedures and postoperative complica-

a hook knife, and the lesion was completely

tions .In Case 2,although the tumor size was 5 cm

removed en‑bloc without massive hemorrhage orin diameter, en‑bloc resection without massive

perforation. The removed tumor macroscopicallyhemorrhage or perforation of the GT was safely

showed a 0‑IIa＋IIc lesion with a well‑deﬁned

and completely performed by ESD. Furthermore,margin. Histopathologic examination showed awell‑diﬀerentiated adenocarcinoma limited to theNo. 2, 2011a83

Koide.Suzuki.Akamatsu et al.

mucosa showed lymphatic invasion after ESD.The

diﬀerentiated adenocarcinoma, such as in Case 2,

elderly patient requested no further treatment, in-while signet ring cell carcinoma was observed including surgery and chemotherapy. Case 1 showed

only 3 cases (6.3%), including Case 1. Most of thesignet ring cell carcinoma of the GT, but the hori-

reported cases showed mucosal cancer, but sub-zontal and vertical margins were histologicallymucosal cancer was observed in 5 cases (10.4%).

negative.Endoscopic treatment has been controver-Consequently, extended indications of endoscopic

sial for signet ring cell carcinoma or poorly

treatment for gastric carcinoma were available indiﬀerentiated adenocarcinoma of the stomach, but

12 cases (25%), including the 2 present cases.

mucosal undiﬀerentiated cancer without ulcer

Within 24 months after esophagectomy,13 cases(27.

ﬁndings and smaller than 20 mm in size showed no1%) showed GTC, and 20 cases (41.7%), including

node metastasis .ESD has gradually become avail-Cases 1 and 2, showed GTC over 60 months after

able for speciﬁc histologic types, as an extended

esophagectomy. Therefore, before and after eso-

indication of endoscopic resection for early gastricphagectomy for esophageal cancer, the stomach

carcinoma. Signet ring cell carcinoma, which has

should be carefully examined by EGD. When an

rarely been observed in the GT,treated by EMR or

endoscope can not pass through esophageal cancer,

ESD has been reported in 2 Japanese cases

andwe have to manage and examine the stomach dur-the present Case 1.These three cases underwent no

ing the operation and after surgery ). Local recur-

additional treatment. ESD may have more advan-

rence or insuﬃcient resection was observed intages than surgery for the treatment of early GTC.

12 cases (25%) with additional treatments after

The gastric tube is located in the mediastinum or

EMR. Additional treatment including EMR

thoracic cavity, and this reconstructed stomach

endoscopic laser treatmentshows a narrow cavity compared to the usual stom-

coagulation/ablation treatment

ach.It may therefore be a special condition for ESD

trectomyof gastric carcinoma. Further investigation involv-

plete resection by EMR or the local recurrence ofing a large‑scale study is necessary to assess the

GTC after EMR. ESD is an option to treat earlysafety and curative potential of ESD for GTC after

GTC.

,

or endoscopic, and gas-

were performed in cases with incom-

surgery for esophageal carcinoma, although recent

In conclusion,ESD is a safe modality for mucosalcase series regarding ESD for GTC have been

carcinoma of the reconstructed GT, and ESD may

reported .

be available for cases with extended indications,

We investigated the clinicopathologic features of 48

such as the present cases. However further investi-

Japanese cases, including the two present

gation is necessary to conﬁrm the safety and cura-patients, with GTC in which the histopathologic

tive potential of ESD for large well‑diﬀerentiatedﬁndings were described in detail in papers publishedadenocarcinoma or signet ring cell carcinoma of the

between 1983 and 2009, as retrieved from PubM ed

GT after surgery for esophageal carcinoma.

and Japana Centra Reveo Medicina (Table 1).Most

Acknowledgementsof the previously reported cases were treated by
EMR. GTC removed by ESD was observed in 10

We gratefully acknowledge the large contribu-

cases including the present 2 cases. M ost of thetions to this article by Dr. Tomoaki Suga (Depart-

reported cases showed a tumor size of less than 20

ment of Gastroenterology, Shinshu University

mm in diameter, while 4 cases (8.3%) showed a

School of Medicine) and Dr. Takai Kuroda (Jinai

tumor size of over 20 mm in diameter, including

Hospital).

Case 2. Most of the reported cases showed well‑84

Shinshu Med J Vol.59

ESD for carcinoma of the gastric tube

Table 1 Japanese cases of gastric tube carcinoma treated by endoscopic resection
Features of gastric tube carcinoma
Year Age/Sex

Case

AuthorInterval Treatment(months)

1
2
3
4
5
6
7
8

HiranoMonma
Monma
WatanabeMiyoshiNakataFukushima
Sato

1988
1989
1989
1991
1992
1993
1993
1994

73/M
71/M
78/M
89/F
63/M
65/F
64/M
78/M

118
18
72
54
38
84
120
54

9
10
11
12
13
14
15
16
17

ShimadaShimadaShimadaHanashi
Hanashi
IshidaSong
Hase
Sekita

1998
1998
1998
1998
1998
1998
1998
2000
2001

57/F
81/M
76/M
71/M
78/M
78/?
54/M
83/F
60/M

78
153
21
21
72
132
24
165
47

18
19
20
21
22
23
24
25
26
27

Suzuki
Nakai
Kawamoto
HamasuMatsudaOkamotoOkamotoOkamotoSuganuma
Tanaka

2001
2002
2002
2003
2003
2004
2004
2004
2004
2004

60/M
71/M
63/M
68/M
56/M
72/M
66/M
59/M
63/M
71/M

28
29
30

Tasaki
Takeo
Takeo

2006
2007
2007

50/M
63/M
57/M

31
32
33
34
35
36
37
38
39
40
41
42
43

Takeo
Takeo
Takeo
Motoyama
Yamasawa
Yamasawa
Yamasawa
Koyanagi
Suzumura
Osumi
Osumi
Osumi
Osumi

2007
2007
2007
2007
2009
2009
2009
2009
2009
2009
2009
2009
2009

70/M
58/M
69/M
70s/M
75/M
61/M
75/M
70s/M
62/F
50s/M
60s/M
80s/M
80s/F

11
20
24
20
38
30
221
39
86
72
78
43
74
28
43
62
15
12
33
15
76
104
78
42
26
19
55
12

PE
EMR
EMR
EMR
EMR
EMR
PE
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
EMR
ESD
EMR
EMR
ESD
ESD
ESD
ESD

44
45
46
47
48

Osumi
Osumi
Osumi
Case 1Case 2

2009
2009
2009

80s/M
70s/M
60s/M
47/F
83/F

42
26
31
67
61

ESD
ESD
ESD
ESD
ESD

Site

Size
(mm)

Type

0‑I
lower
?
12×12
0‑IIa
middle8×70‑IIa＋IIc
lower
0‑IIa＋IIc
lower
?
6×8
0‑IIa
middle
15×10
0‑I
lower
20×7
0‑I
upper
12×10
0‑IIa
lower
7
0‑IIc
middle
0‑IIc
lower
?
0‑IIa
lower
?
0‑IIc
?
?
12×12
0‑IIa
middle8×70‑IIa＋IIc
lower
0‑IIc
lower
?
6
0‑I
middle
25
0‑IIa
upper
20
0‑IIa＋IIc
middle
15
0‑IIc
lower
10
0‑IIc
lower
0‑?
lower
?
10
0‑IIa
middle
0‑III
lower
?
16
0‑I
lower
20×13
0‑IIa
lower
10
lower
?
middle?
?
10
middle
?
7
0‑IIa
lower
10
0‑IIc
middle
5
0‑IIc
lower
10×8
0‑IIb
lower
6
0‑IIa
lower
3
0‑IIc
middle60‑IIamiddle120‑IIc
middle
6
0‑IIc
lower
15
0‑IIa＋IIc
lower
0‑IIa＋IIc
middle
?
0‑IIa
?
?
15
0‑IIa
?
60×40
0‑IIa
middle15
0‑IIc
middle
5
0‑IIc
lower
20×15
0‑IIa
middle11×7
0‑IIc
middle0‑IIalower 12.8×11.8
0‑IIa
middle 15.2×13.1
0‑IIa
middle 11.2×9.8
middle 30×17.5 0‑IIa＋IIc
middle 12.8×11.8 0‑IIa＋IIc
14.8×7.9
0‑IIa
lower
10
0‑IIc
lower
50
0‑IIa＋IIc
middleHistology Depth
tub1
tub1
tub1
tub1
tub1
tub1
pap
tub1
tub1
tub1
tub1
?
tub1
tub1
tub1
?
tub1
tub1
tub1
tub1
tub1
tub1
tub2
well
tub1
well
mod
well
tub1
tub1
tub1
sig
tub1
tub1
pap
tub2
sig
tub1
?
tub1
tub1
tub1
tub2
tub1
pap
tub1
tub1
tub1
tub1
tub1
tub1
tub1
sig
tub2

?
m
m
m
m
sm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
?
m
sm2
m
m
m
sm
m
m
m
m
m
m
m
m
m
m
m
sm
?
m
m
m
m
m
m
m
m
m
m
sm2
m
m
m

Additional
treatment
CT

HLC/EI
Laser
Laser

Laser

EM R/AB
Gastrectomy
EMR

Gastrectomy
EMR

Gastrectomy

APC/RT/CT

APC

Interval, between esophageal carcinoma treatment and detection of gastric tube carcinoma ;PE, polypectomy;EM R, endoscopic mucosal resection ;ESD, endoscopic submucosal dissection ;tub1, well‑diﬀerentiated tubular adenocarcinoma ;tub2, moderately diﬀerentiated adenocarcinoma ;pap, papillary adenocarcinoma ;sig, signet ring cell carcinoma ;CT, chemotherapy;HLC, heat lobe coagulation ;EI, ethanol injection ;AB, ablation ;APC, argon plasma coagulation ;RT, radiotherapy;?, not described.

No. 2, 201185

Koide.Suzuki.Akamatsu et al.

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