Case report. Primary squamous cell carcinoma of the stomach

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1 136 Gstric Cncer (1999) 2: S. Mrushi et l.: Primry squmous cell crcinom of the stomch 1999 y Interntionl nd Jpnese Gstric Cncer Associtions Cse report Primry squmous cell crcinom of the stomch Shigeru Mrushi, Hiroshi Yno, Tkushi Monden, Hideo Tteishi, Toshiyuki Knoh, Tkshi Iwzw, Shigeo Mtsui, Yoshiki Nkno, Msktsu Kinut, Hidenori Tkhshi, nd Jun Okmur Deprtment of Surgery, Osk Teishin Hospitl, Krsugtsuji, Tennoji-ku, Osk , Jpn Astrct: Primry squmous cell crcinom (SCC) of the stomch is extremely rre; only 32 cses re found in the Jpnese literture. The pthogenesis of this neoplsm remins oscure nd controversil. Furthermore, the optiml tretment, including djuvnt chemotherpy, remins uncler. We report herein cse of SCC of the stomch in 70-yer-old mle with mzing effectiveness of neodjuvnt chemotherpy, low-dose FP chemotherpy. To our knowledge, no cse of this disese hs ever een reported tht ws given neodjuvnt chemotherpy nd histologiclly showed its effectiveness. Our cse demonstrted striking effectiveness of chemotherpy in the neoplsm oth rdiologiclly nd histologiclly. Key words: squmous cell crcinom, stomch, neodjuvnt chemotherpy Introduction Squmous cell crcinom (SCC) of the stomch is defined s pure SCC neoplsm rising in gstric epithelium. It is extremely rre nd its incidence rnges etween 0.04% nd 0.09% [1,2] of ll gstric cncers. Only 31 cses were found in the Jpnese literture nd only out 80 cses re known in the world [3]. Until now, there hs een no djuvnt chemotherpy recommended tht demonstrted effectiveness in the course of the tretment. Cse report A 70-yer-old mn who suffered non-insulin-dependent dietes mellitus nd Korskoff disese ws referred to Offprint requests to: H. Yno Received for puliction on Dec. 7, 1998; ccepted on Mrch 23, 1999 our hospitl ecuse of gstric neoplsm nd pyloric stenosis. He hd no complint. Before his dmission, it ws reveled tht he hd Fe-deficient nemi, nd his physicin exmined him nd found the tumor. Becuse of the pyloric stenosis, he took only wter orlly nd ws supplied with IVH on his dmission. He hd no symptoms such s dominl pin, nuse, vomiting, or melen. His height ws 153 cm nd his weight 41kg; his weight hd not chnged. He hd severe emcition nd his nutrition ws poor. On physicl exmintion, no norml sign ws found except his nemic conjunctive plper. Lortory vlues on dmission showed nemi (RBC /mm 3 ; H 9.8 g/dl; Ht 29.5%), low luminemi (serum lumin 3.2 g/dl), leucocytosis (WBC 10000/mm 3 ), nd high serum SCC vlue, 14.0 (norml, 0 2 ng/ml). Gstric fluoroscopy with Gstrogrfin illustrted round nd elevted lesion on the ntrum of the stomch (Fig. 1). The surfce of the lesion ws slightly rough nd the mrgin ws not cler. Endoscopic exmintion reveled type 1 tumor on the lesser posterior wll of the ntrum; the top of the surfce ws ulcerted nd covered y fur (Fig. 2). The scope could not e pssed through the pylorus ring ecuse of the stenosis. It ws proved SCC y iopsy. In ddition to this lesion there were some hyperplstic polyps on the corps of the stomch. CT scn showed solid nd enhnced tumor round the ntrum nd duodenl ul (Fig. 3). Its dimeter ws out 5cm nd possile involvement into the pncres hed ws shown. An ngiogrphy showed hypervsculr tumor tht mesured 7 cm nd ws supplied with min feeding rtery from the rnch of the gstroduodenl rtery (Fig. 4). The portl vein ws ptent. Despite of the result of the iopsy, which produced dignosis of SCC, these rdiologicl findings still mde us suspect tht this tumor ws derived not from epithelil cells ut from interstitil cells, such s leiomyosrcom or mlignnt lymphom.

S. Mrushi et l.: Primry squmous cell crcinom of the stomch 137 Fig. 1. Left: Gstric swllow efore low-dose FP chemotherpy shows n elevted lesion round pylorus ring (rrowheds).

Left: Endoscopic exmintion efore chemotherpy shows type 1 lesion whose top is ulcerted nd covered with fur.

2 S. Mrushi et l.: Primry squmous cell crcinom of the stomch 137 Fig. 1. Left: Gstric swllow efore low-dose FP chemotherpy shows n elevted lesion round pylorus ring (rrowheds). Right: UGI series fter chemotherpy show remrkle reduction of the tumor (white rrowheds) Fig. 2. Left: Endoscopic exmintion efore chemotherpy shows type 1 lesion whose top is ulcerted nd covered with fur. After chemotherpy (), endoscopy shows remrkle reduction of the tumor We scheduled n elective opertion, ut the ptient s condition ecme worse nd he rn spike fever; WBC in peripherl lood rose to 20000/mm 3, nd he cquired monilisis in the orl cvity. His condition ws so poor tht we could not perform the opertion. After he recovered from these complictions, we strted lowdose 5-FU CDDP chemotherpy [5-fluorourcil (5- FU), 500 mg/ody/dy plus cispltin (CDDP), 5 mg/ ody/olus, 5 dys/week 6 cycles], which ws dministered vi peripherl vein. No side effect occurred, nd he completed ll the cycles of chemotherpy without ny compliction. The rdiologicl studies fter chemotherpy showed remrkle reduction of the tumor (Figs. 1, 3). Endoscopic exmintion showed tht the tumor hd een remrkly reduced nd the duodenum could e oserved without invsion of the tumor (Fig. 2). Serum SCC level fell within norml limits (1.4 ng/ml). At lprotomy, there ws 3-cm gstric tumor in the ntrum with no dherence to djcent tissues. A rdicl

138 S. Mrushi et l.: Primry squmous cell crcinom of the stomch Fig. 4. Angiogrphy shows hypervsculr tumor (rrowheds) in the ntrum of the stomch or pncres hed.

Prole invsion into the pncres hed is lso seen. Lower: CT scn fter chemotherpy shows remrkle reduction of the tumor distl gstrectomy (D2 lymph node dissection) with cholecystectomy ws performed.

On pthologicl exmintion, there ws 2.5 1.5cm, type 1 tumor in the ntrum with n ulcer on its top (Fig. 5). There were lso some polyps in the ntrum nd corps.

3 138 S. Mrushi et l.: Primry squmous cell crcinom of the stomch Fig. 4. Angiogrphy shows hypervsculr tumor (rrowheds) in the ntrum of the stomch or pncres hed. The feeding rtery (rrow) diverges from the gstroduodenl rtery. Tumor size ws out 7 cm Fig. 3. Upper: CT scn efore chemotherpy shows round, solid, nd enhnced lesion of out 5 cm round the pylorus ring. Prole invsion into the pncres hed is lso seen. Lower: CT scn fter chemotherpy shows remrkle reduction of the tumor distl gstrectomy (D2 lymph node dissection) with cholecystectomy ws performed. His postopertive course ws uneventful nd he ws dischrged. He is well, nd is now tking Tegfur-Urcil (UFT) 300 mg/ dy orlly; there is no evidence of recurrence fter follow-up period of 10 months. On pthologicl exmintion, there ws cm, type 1 tumor in the ntrum with n ulcer on its top (Fig. 5). There were lso some polyps in the ntrum nd corps. The tumor ws growing nd expnding minly in the sumucosl lyer. On histologicl exmintion, modertely differentited squmous cell crcinom with invsion to the musclris propri ws seen (Fig. 6). In ll sections, there ws neither denocrcinom nor squmous dysplsi. Sections stined with CEA, CA19-9, PAS, Alcin lue, nd Fig. 5. Photomcrogrph of the tumor shows type 1 tumor, whose top is ulcerted nd covered with fur, in the ntrum. Size is cm mucicrmin showed no evident of component of denocrcinom. The sections stined with cytokertine 5, 6, 8, 17, nd 19 were positive, stressing tht the cncer cells were derived from epithelil cells. These findings confirmed tht it ws pure SCC of the stomch nd tht there ws no evidence of trnsition from denocrcinom or squmous dysplsi. All the polyps in the ntrum nd corps were enign hyperplstic polyps; 6 lymph nodes were involved (2/3) with pure SCC nd 8 lymph node ws lso involved (1/3) with pure SCC. Lymph vessel involvement ws seen (ly2). The conclusive stge ws III. The curility ws B nd there ws no residul tumor (R0). The cncer cells in most of the tumor chnged into necrotic

4 S. Mrushi et l.: Primry squmous cell crcinom of the stomch 139 Discussion c Fig. 6 c. Photomicrogrphs of the surgicl specimen. Pure nd modertely differentited squmous cell crcinom (SCC) is surrounded with mrked inflmmtory cell infiltrtion. H&E, 100. Vcuoltion or llooning of cncer cells with pyknosis of nuclei. H&E, 400. c Most of the SCC ws chnged into cogultive necrosis of the tumor. H&E, 40. These findings re comptile with grde 2 of histologicl chnges grnultion nd the remining cncer cells were dying, surrounded with infiltrting lymphocytes (Fig. 6,c). We could conclude tht the preopertive chemotherpy hd remrkle effect on the tumor oth rdiologiclly nd histologiclly. The lesion descried ws primry squmous cell crcinom of the stomch, ecuse it ws pure SCC of the stomch nd no other neoplstic lesion ws found in the series of exmintions. SCC of the stomch is defined s tumor tht consists entirely of SCC on the Jpnese Clssifiction of Gstric Crcinom [4]. In SCC involving the esophgel junction, the evidence of its gstric origin should e present. This disese is extremely rre, nd the incidence hs een reported s 0.04% to 0.09% [1,2]. Since Rörig [5] first descried this disese in 1895, only out 80 cses of true SCC of the stomch hve een reported in the world literture [3]. In Jpn, only 31 cses hve ever een reported nd our cse ws the 32nd cse of SCC of the stomch (Tle 1). The clinicopthologicl fetures of these 32 cses, including our cse, re reviewed. Age rnged from 29 to 81 yers (men, 60.7). Men were ffected out four times s often s women. Most ptients were symptomtic, most frequently with epigstrlgi (53.1%). The loction of the tumor ws on the crdi of the stomch in more thn hlf of ll cses. The size of the tumor rnged from 2.5 to 13 cm (men, 6.4 cm). Depth of invsion ws T4 (SI) or t4 (si) in out one-hlf of ll cses. Becuse of the deep invsion of these cses, surgicl or conclusive stge ws IV or IV in more thn 40% of ll cses in spite of rre involvement into liver or peritonel dissemintion. Therefore the surgicl curility tended to e poor in mny cses. We could consider from these clinicopthologicl fetures tht surgicl resection lone might e indequte for the tretment for SCC of the stomch nd tht we should dd djuvnt therpy efore or fter the surgery. A stndrd chemotherpy for this disese hs not yet een estlished, however, nd no cse hs previously received neodjuvnt chemotherpy nd een studied concering the effectiveness of chemotherpy to SCC of the stomch. It ws certin tht there were some cses who received chemotherpy postopertively, ut the effectiveness ws still uncler in ll cses. To our knowledge, our cse is the first tht received chemotherpy nd showed the mzing effectiveness of chemotherpy histologiclly. The pthogenesis of SCC of the stomch hs een rgued in mny reports, nd there re severl theories out its development: SCC of the stomch origintes from (1) foci of heterotopic squmous epithelium, (2) squmous metplsi, (3) totipotentil stem cells, nd (4) overgrowth of squmous element in primry denocrcinom. In recent reports [6,7], denocrcinom-relted ntigen such s CA19-9 ws found in SCC of the stomch nd these uthors elieved the fourth theory, tht the tumor origintes from denocrcinom nd chnges to SCC. As for our cse,

5 140 S. Mrushi et l.: Primry squmous cell crcinom of the stomch Tle 1. Clinicopthologicl fetures of squmous cell crcinom of the stomch in the Jpnese literture Cse Reported Size Depth of invsion Lymph node Distnt Postopertive Effect of Surgicl Residul tumor no. Author yer Age Sex Loction (cm) (involved orgn) metstses metstses chemotherpy chemotherpy curility clssifiction Prognosis 1 Set M A n.m. SE n1 No MMC 60 mg Unknown c B R0 1 y 7 m live 2 Ymgiw F M n.m. Si n.m. Multiple Autopsy 3 Uchid F CM 10 se n.m. No Nothing n.m. n.m. 4 y 4 m live 4 Kitmur M M 6.5 ss n.m. No Nothing n.m. n.m. 5 y no recurrence 5 Shimizu M A 6 si (pncres) n1 No Nothing C R2 3 m deth 6 Nkizumi F C 6 se n0 No HA: MMC, NC PD n.m. n.m. 10 m deth leomycin 7 Ktok M AM n.m. si (pncres, N2 H1 5-FU, NC PD C R2 5 m deth colon) Bleomycin, MMC 8 Mukid M C 8 si (liver, N4 No Nothing C R2 n.m. diphrgm) 9 Dnnour M C 4 si (diphrgm) N2 No Nothing C R2 1 y deth 10 Mtsuzki F C 5 n.m. n.m. n.m. Nothing n.m. n.m. 6 y no recurrence 11 Tkhshi M C 7 si (spleen) n2 No Nothing B R0 Unknown 12 Kmetni F CM 6.5 si (pncres) N3 No Nothing C R2 1 m deth 13 Tnk M M 6 SE N2 No Nothing n.m. n.m. 4 m deth 14 Htym M C 4 mp n0 No Nothing n.m. n.m. 3 y no recurrence 15 Htym M C n.m. se n0 No Nothing n.m. n.m. 4 y no recurrence 16 Htym M C 8 si n0 No Nothing n.m. n.m. 11 y no recurrence 17 Ozeki M AM 10 Si (pncres) N4 No Nothing C R2 n.m. 18 Kneko M C 4 ss n0 No Bleomycin Unknown c A R0 2 y no recurrence 100 mg 19 Mizutni M M 7 si (pncres, n2 No Nothing B R1 8 m deth colon) 20 Miki M M 10 si (pncres, n0 H1 Nothing C R2 1 y 2 m deth liver) 21 Onod F A 4.5 mp N2 No Nothing n.m. n.m. 6 m deth 22 Kurose M M 4.7 si (colon) N2 H2 HA: ADM, PR (liver) C R2 1 y 2 m deth CDDP, ÆPD Etoposide 23 Nkchi F A 4.5 mp n1 No CDDP 190 mg NC PD C R2 7 m deth 24 Nkchi M C 13 si (diphrgm) n0 No CDDP 250 mg Unknown c B R0 2 y no recurrence 25 Shimizu M M 4.5 ss n0 No 5-FU, CDDP Unknown c A R0 n.m. 26 Tnk M C 7 si (diphrgm) n4 No CDDP 80 mg NC PD C R2 6 m deth FARM 27 Imhri M MC 8 sm n0 No Nothing A R0 n.m. 28 Koide M C 6 ss n2 H3 HA: 5FU, PR (liver) C R2 3 m deth epiadm, ÆPD MMC 29 Aoki M M 6.5 ss n0 No CDDP 100 mg Unknown c A R0 1 y no recurrence orlly 30 Wtne M C 5 si (pncres) n1 No CDDP 50 mg Unknown c B R0 2 y 4 m live 5FU 250 mg 31 Nozw M C 5 se n4 No Nothing C R2 4 m deth d 32 present M A 2.5 mp n2 No Orlly Remrkly B R0 8 m no recurrence cse reduced n.m., not mentioned; HA, intrheptic rtery injection; totl, totl gstrectomy; distl, distl gstrectomy; Prox, proximl gstrectomy; PR, prtil response; NC, no chnge; PD, progressive disese; y, yer; m, month Jpnese Clssifiction of Gstric Crcinom TNM-UICC c we cnnot evlute the effect ecuse there is no residul tumor d Cused y cererl infrction

6 S. Mrushi et l.: Primry squmous cell crcinom of the stomch 141 there could e identified no histologicl sign of denocrcinom in the tumor or squmous mtplsi in the gstric mucos round the SCC. Therefore, we cn speculte the pthogenesis of this cse might e (1) foci of heterotopic squmous epithelium or (3) totipotentil stem cells. We should ccumulte more cses with SCC of the stomch nd investigte them histologiclly or geneticlly to determine the histopthogenesis of SCC of the stomch. Conclusion Squmous cell crcinoms of the stomch re very rre, nd no cse of this disese hs een reported tht ws given chemotherpy nd histologiclly demonstrted the effectiveness of the chemotherpy on the neoplsm. We think, ecuse of the present cse, tht low-dose FP chemotherpy might e very effective for SCC of the stomch nd my improve the prognosis of ptients with this disese. References 1. Won OH, Frmn J, Krishnn MN, Iyer SK, Vuletin JC. Squmous cell crcinom of the stomch. Am J Gstroenterol 1978;69: Hoshi K. Specil types of the gstric cncer. Jpn J Clin Oncol 1983;18(8): Schw G, Wetscher G, Dietze O, Schmid K, Pointer R. Primry squmous cell crcinom of the stomch in seventeen-yer-old oy. Jpn J Surg 1992;22: Jpnese Reserch Society for Gstric Cncer. Jpnese clssifiction of gstric crcinom. First English edition. Tokyo: Knehr, Rörig R. Primres Cncinoid des Mgens. Thesis. Wurzurg: P. Scheiner, Shimizu Y, Tnk T, Nke A, Mtsui S, Shimode Y, Yoshid J, et l. A cse of squmous cell crcinom of the stomch. J Jpn Surg Assoc 1993;54: Aoki T, Nknishi K, Kmiizumi Y, Tkgi T, Miyt M, Ymshiro K. A cse of squmous cell crcinom of the stomch. J Jpn Gstroenterol Surg 1996;29:

BENIGN ulceration along the greater curvature of the pars media of the

BENIGN ulceration along the greater curvature of the pars media of the BENIGN ULCERS OF THE GREATER CURVATURE OF THE STOMACH Report of Two Cses CHARLES H. BROWN, M.D. Deprtment of Gstroenterology nd ANTHONY D. INTRIERE, M.D.* BENIGN ulcertion long the greter curvture of the