METASTASES FROM GASTRIC CARCINOMA TO COLON LESIONS: A CASE REPORT IN THE FORM OF MULTIPLE FLAT ELEVATED CASE PRESENTATION

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1 H.C. Lee, M.T. Yang, K.Y. Lin, et al METASTASES FROM GASTRIC CARCINOMA TO COLON IN THE FORM OF MULTIPLE FLAT ELEVATED LESIONS: A CASE REPORT Hsi-Chang Lee, Min-Ta Yang, 1 Kuang-Yang Lin, 1 Hsing-Yang Tu, 2 Ting-An Zhang, 3 and Pao-Huei Chen 1 Divisions of Internal Medicine, 1 Gastroenterology, 2 Radiology, and 3 Pathology, Taipei Municipal Jen-Ai Hospital, Taipei, Taiwan. Gastric carcinoma is a common malignancy worldwide. Advanced stages of the disease may result in metastases to many other organs of the body. However, colonic metastases are rare. We report a case of gastric carcinoma with symptoms of abdominal fullness and weight loss. The serum carcinoembryonic antigen level was elevated. Esophagogastroduodenoscopy revealed giant folds occupying the whole gastric body and poor expansion of the stomach. Histologic examination of biopsy specimens from the giant fold demonstrated poorly differentiated adenocarcinoma with signet ring-cell differentiation. Total colonoscopy revealed five or six discrete flat elevated lesions in the distal transverse, descending, and sigmoid colons. These lesions were characterized by a clear margin of 3 5 mm in diameter and erosions on the tips. Polypectomy specimens demonstrated signet ring-cell carcinoma, which was histologically similar to the specimens taken from the gastric lesion. We conclude that this was a rare case in which gastric signet ring-cell carcinoma had metastasized to the colon in the form of flat elevated lesions, combined with rapid and wide lymphatic spread to the thorax and abdomen in a clinical course as short as 46 days. Key Words: gastric carcinoma, colonic metastases, flat elevated lesion (Kaohsiung J Med Sci 2004;20:552 7) Gastric carcinoma is a common malignancy worldwide. Advanced stages of the disease may result in metastases to many other organs, most commonly the liver, lung, bone, adrenal glands, and lymph nodes. Colonic metastases are rare. We describe a patient with gastric carcinoma and symptoms of weight loss and an elevated serum level of carcinoembryonic antigen (CEA). The pathologic diagnosis was based on histologic examination of endoscopic biopsy and polypectomy specimens. This report describes the endoscopic features of the colonic metastases from the gastric carcinoma. Received: April 23, 2004 Accepted: July 16, 2004 Address correspondence and reprint requests to: Dr. Pao-Huei Chen, Division of Gastroenterology, Taipei Municipal Jen-Ai Hospital, 10 Jen-Ai Road, Section 4, Taipei, Taiwan. hsichanglee@giga.net.tw 552 CASE PRESENTATION A 41-year-old male, married, senior high-school teacher suffered from abdominal fullness, anorexia, and 4 kg weight loss within 6 months. On August 2, 2002, he visited the outpatient department of a Taipei National Insurance Health Clinic, when an elevated serum level of CEA (117 ng/ml; normal, 0 4 ng/ml) was observed. He was referred to Taipei Municipal Jen-Ai Hospital for further survey. Abdominal ultrasound revealed a marked thickness ( 1.6 cm) in the gastric body wall that suggested gastric cancer (Figure 1). Esophagogastroduodenoscopy revealed giant folds occupying the whole gastric body and poor expansion of the stomach, indicating a submucosal infiltrative lesion (Figure 2). Repeated deep biopsies from the giant fold showed poorly differentiated adenocarcinoma with signet ring-cell differentiation (Figure 3) Elsevier. All rights reserved.

2 Colonic metastases from gastric carcinoma A Figure 1. Ultrasonographic image of the stomach showing marked gastric wall thickness ( 1.6 cm) in the gastric body. B Figure 2. Endoscopic image of the stomach showing giant folds occupying the whole gastric body and poor expansion. Total colonoscopy revealed five or six discrete flat elevated lesions located in the distal transverse, descending, and sigmoid colons. These lesions had clear margins and were 3 5 mm in diameter with erosions on the tips (Figure 4). Histologic examination of polypectomy specimens demonstrated signet ring-cell carcinoma, which was similar to the specimen taken from the stomach (Figure 5). An upper gastrointestinal series demonstrated poor distension of the gastric body and a fixedly widened angle indicating scirrhous gastric cancer. Abdominal computed tomography (CT) with intravenous contrast medium revealed diffuse thickening of the gastric wall at the cardia, fundus, and upper body, a soft tissue-density mass in the lesser omentum, Figure 3. Histologic views of gastric adenocarcinoma. Sheets of neoplastic signet-ring cells can be seen within the lamina propria of the gastric mucosa (hematoxylin & eosin, original magnification 200): (A) antrum; (B) body. and an obliterated fat plane around the pancreatic body, indicating gastric carcinoma with local invasion to the lesser omentum and pancreatic body (Figure 6). On August 13, the patient underwent left supraclavicular lymph node biopsy and metastatic adenocarcinoma was found. Abdominal ultrasound examination on August 22 revealed gastric cancer with pancreatic involvement, left hydronephrosis with hydroureter, ascites, right pleural 553

3 H.C. Lee, M.T. Yang, K.Y. Lin, et al A C B Figure 4. Colonoscopy. Multiple flat elevated lesions ( 0.5 cm) with central erosions in the: (A) transverse colon; (B) descending colon; (C) sigmoid colon. DISCUSSION effusion, and para-aortic lymphadenopathy. Chest CT on August 29 showed bilateral pleural effusion, collapse of the left lower lung, and multiple mediastinal lymphadenopathy. Chemotherapy with high doses of 5-fluorouracil and leucovorin (HDFL) was given on September 3 without any observed side effect. However, chemotherapy was discontinued on day 8 due to leukocytosis and infection. Respiratory distress was noted on September 17. The next day, the patient died of respiratory failure. 554 In 1965, Laurèn characterized two major histologic types of gastric carcinoma, intestinal and diffuse [1]. The patterns of metastases from the two types of gastric carcinoma are different. The diffuse carcinoma shows a wider dissemination than the intestinal type. In addition, peritoneal metastases, lymphatic permeation of the lungs, and Krukenberg tumors are more commonly found in diffuse cases [2]. On the other hand, the intestinal type of carcinoma involves the liver more commonly and extensively. Intestinal metastases are rarely reported from gastric adenocarcinoma. Primary gastric tumors with intestinal metastases are mostly of the scirrhous type and poorly differentiated, with or without signet ring-cell differentiation [3 6]. Such metastases are frequently associated with peritoneal seeding but rarely involve the liver. The most common form of secondary neoplastic involvement of the bowel is peritoneal seeding, which generally originates from ovarian carcinoma. Hematogenous dissemination infrequently occurs in cases found in the small bowel [7], but usually originates from breast carcinoma [8,9], lung carcinoma, and melanoma [10]. It may present as segmental stricture [3,4], mimicking granulomatous colitis [6], or advanced tumor [10]. Most often, the characteristic finding on CT is target-like, concentric bowel-wall thickening

4 Colonic metastases from gastric carcinoma A C B Figure 5. Histologic views of colonoscopic polypectomy. Signet-ring carcinoma cells infiltrate in mucosa and form small nodules in the submucosa. The adjacent colonic crypts are entirely normal. Original magnification: (A) 20; (B) 40; (C) 100. (Hematoxylin & eosin.) Figure 6. Computed tomography scan of the abdomen. Diffuse thickening of the gastric wall at the cardia, fundus, and upper body is clearly visible. 555

5 H.C. Lee, M.T. Yang, K.Y. Lin, et al involving multiple long segments. The sites of metastases in most cases are the ascending colon and rectum [11]. Polypoid colonic metastases usually result from melanoma [12] or spindle-cell renal carcinoma [13]. Polyps can often be identified and may be indistinguishable from ordinary mucosal polyps. Three cases of multiple colonic metastases from poorly differentiated gastric adenocarcinoma, presenting as colonic polyposis, have been reported [14 16]. Our case appeared to be a rare one of gastric signet ring-cell carcinoma with metastases to the colon in the form of multiple flat elevated lesions. REFERENCES 1. Laurèn P. The two histological main types of gastric carcinoma: diffuse and so called intestinal-type carcinoma. Acta Pathol Microbiol Scand 1965;64: Duarte I, Llanos O. Pattern of metastases in intestinal and diffuse types of carcinoma of the stomach. Hum Pathol 1981; 12: Fisher ER, Brown CH. Linitis plastica carcinoma of the stomach with extensive metastases simulating a colonic lesion. Gastroenterology 1952;20: Dixon CF, Stevens GA. Carcinoma of linitis plastica type involving the intestine. Ann Surg 1936;103: Niimi K, Matsuki K, Tomoda S, et al. Two cases of solitary metastases to the large intestine from gastric carcinoma. Gan No Rinsho 1984;30: [In Japanese] 6. Katon RM, Brendler SJ, Ireland K. Gastric linitis plastica with metastases to the colon: a mimic of Crohn s disease. J Clin Gastroenterol 1989;11: Feczko PJ, Collins DD, Mezwa DG. Metastatic disease involving the gastrointestinal tract. Radiol Clin North Am 1993;31: Taal BG, Jager DF, Steinmetz R, et al. The spectrum of gastrointestinal metastases of breast carcinoma, II. The colon and rectum. Gastrointest Endosc 1992;38: Eyres KS, Sainsbury JR. Large bowel obstruction due to metastatic breast cancer: an unusual presentation of recurrent disease. Br J Clin Pract 1990;44: Reintgen DS, Thompson W, Garbutt J, et al. Radiologic, endoscopic, and surgical considerations of melanoma metastatic to the gastrointestinal tract. Surgery 1984;95: Jang HJ, Lim HK, Kim HS, et al. Intestinal metastases from gastric adenocarcinoma: helical CT finding. J Comput Assist Tomogr 2001;25: Sacks BA, Joffe N, Antonioli DA. Metastatic melanoma presenting clinically as multiple colonic polyps. AJR Am J Roentgenol 1977;129: Shousha S, Smith PA, Parkins RA. Metastatic spindle-cell renal carcinoma presenting as multiple intestinal polyps. Dis Colon Rectum 1986;29: Metayer P, Antoneitti M, Oumrani M, et al. Metastases of a gastric adenocarcinoma presenting as colonic polyposis. Report of a case. Dis Colon Rectum 1991;34: Dohden K, et al. Metastases from gastric carcinoma to esophagus, duodenum and large intestine in the form of polyposis, report of a case. Stomach Intestine (Tokyo) 2002;37: [In Japanese] 16. Ogiwara H, Konno H, Kitayama Y, et al. Metastases from gastric adenocarcinoma presenting as multiple colonic polyps: report of a case. Surg Today 1994;24:

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