Eur J Cardiothorac Surg 2004;26:1223-1225
© 2004 Elsevier Science NL
Thirteen cases with intramural metastasis to the stomach in 1259 patients with oesophageal squamous cell carcinoma
Yuma Ebiharaa,b,*,
Masao Hosokawab,
Satoshi Kondoa,
Hiroyuki Katoha
a Division of Cancer Medicine, Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
b Keiyuukai Sapporo Hospital, Hokkaido, Japan
Received 10 April 2004;
received in revised form 3 August 2004;
accepted 23 August 2004.
* Corresponding author. Address: Department of Surgical Oncology, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido 060-8648, Japan. Tel.: +81 11 706 7714; fax: +81 11 706 7158. (E-mail: yuma-ebi{at}wc4.so-net.ne.jp).
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Abstract
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Among a total of 1259 patients with oesophageal cancer who underwent surgical resection, intramural metastasis (IMM) was verified in 93 patients (7.4%), of which IMM to the stomach (IMMS) constituted 13 patients (1.0%). In all 13 cases, the primary cancer was located in the middle or lower thoracic oesophagus and all had lymph nodes metastasis, while 12 of the 13 (92.3%) had lymphatic invasion. In our series, as the depth of invasion advanced, the number of patients with IMM or IMMS increased, although even superficial IMMS was revealed. The gross appearance of the metastatic tumours in the stomach resembled submucosal tumours. The possibility exists that metastatsis via a lymphatic duct allows expansive growth in the gastric submucosae. These findings suggest that oesophageal cancer metastasizes to the stomach via a lymph duct. In conclusion, oesophageal cancer with lymphatic invasion may lead to IMM and IMMS. Therefore, careful examination for the existence of IMM, including the stomach, is required.
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1. Introduction
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Squamous cell carcinoma (SCC) of the oesophagus is largely associated with a poor prognosis, and the development and metastasis of this tumour are complicated [1,2]. Direct invasion of adjacent organs such as the aorta, respiratory tract and lungs, and distant metastasis to other organs such as the liver, lungs and bone are commonly found in advanced oesophageal cancer cases. Intramural metastasis (IMM) in the oesophagus has been found in about 10% of oesophageal cancer cases [3,4]. However, IMM to the stomach (IMMS), excluding direct invasion and spread to the stomach, is relatively rare [5]. We report here 13 patients suffering from SCC of the oesophageal in whom IMM and IMMS occurred.
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2. Case report
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Between April 1981 and March 2000, 1259 patients with oesophageal cancer underwent surgical treatment at the Keiyuukai Sapporo Hospital, Japan. The clinicopathologic stage was determined according to the TNM classification system of the International Union Against Cancer [6]. We defined IMM as a metastatic tumour in the oesophageal or gastric wall arising from a primary lesion in the oesophagus, and upon histologic examination, the secondary tumour mass is found to be (1) clearly separate from the primary tumour, (2) located in the oesophageal or gastric wall, (3) not surrounded by endothelium, and (4) not accompanied by an intraepithelial cancerous extension. These features distinguish IMM from a tumour embolus in a vessel, from multiple primary lesions in the oesophagus, and from a protrusion of the invasive primary tumour [7]. Of the 1259 patients, 93 (7.39%) were found to have IMM, of whom 13 had IMMS (13/1259, 1.0%). Table 1 shows the correlation between T factor and IMM, lymphatic invasion and IMMS. Of the 1259 patients, 481 were T1, 197 were T2, 442 were T3 and 139 were T4. In the 93 patients with IMM, 77 (82.8%) were found to have lymphatic invasion. Table 2 shows the clinical features of the 13 patients with IMMS. All were male, with a mean age 60.6 years (range 52–67). In all 13, the location of the primary lesion was the middle or lower thoracic oesophagus, and all had lymph nodes metastasis. Twelve of the 13 patients (92.3%) with IMMS had lymphatic invasion. The histological type of SCC was well-differentiated in six patients, moderately differentiated in six patients, and poorly differentiated in one patient. The depth of tumour invasion was T1 in one patient, T2 in three patients, T3 in eight patients, and T4 in one patient. All of the 13 tumours within the stomach found in resected specimens were located in the upper one-third of the stomach. Metastatic tumour size was larger than that of the primary tumour in five of the 13 patients. The appearance of small tumours was divided into two types, flat and nodular (one patient) or large tumours appearing as either a dome-like mass (five patients) or a Borrmann's type 2-like mass (two patients). Nodules or dome-like masses predominated.
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3. Discussion
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IMM of oesophageal cancer was first reported by Watson [8] in 1933, and has been considered to be an important mechanism of tumour spread. In a previous report, we noted that the incidence of IMM observed by five Japanese research groups varied from 7.0 to 14.3% [9]. The incidence of IMM in our series (7.4%) was also within that range. In particular, gastric IMM of oesophageal cancer is relatively rare and comprises approximately 2% of resected oesophageal cancer cases [5], with 13 IMMS cases (1.0%) in the present study. Watson [8] explained IMM as an extension by way of the submucous lymphatics. Weinberg [10] documented an instance of lymphatic communication between the stomach and oesophagus by the growth of new lymphatic channels into the carcinomatous lesion.
Based on our 1259 cases, we suggest that IMM and IMMS do not correlate with histological type but lymphatic invasion. All our current cases had metastatic tumours located in the upper one-third of the stomach. The gross appearance of the metastatic tumours clearly differed in size from that of the primary tumours in the oesophagus. The metastatic tumours resembled submucosal tumours of the stomach as far as the gross appearance was concerned. The most likely reason metastatic tumours form such submucosal tumours is that metastasis occurs via a lymphatic duct, thereby enabling expansive growth in the submucosae. As the metastatic tumours enlarge, the lack of blood results in formation of a Borrmann's type 2 mass. These findings support Watson and Weinberg's observations. In conclusion, although the depth of an oesophageal cancer may be T1, the possibility of lymphatic invasion still exists, and thus the existence of lymph metastasis and IMM including to the stomach must be carefully determined.
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References
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Abstract
1. Introduction
