A Rare Case of Primary Squamous Cell Carcinoma of the Stomach and a Review of the 56 Cases Reported in Japan
A 69-year-old Japanese man was admitted with a 2-month history of dysphagia and tarry stools. The results of physical examination were unremarkable. Routine laboratory tests revealed leukocytosis (11,900 cells/mm3). The tumor marker levels were as follows: SCC antigen, 2.5 ng/ml (normal range, 0~0.5 ng/ml) and CYFRA 21-1, 17 ng/ml (normal range, 0~1.5 ng/ml). Upper gastrointestinal endoscopy revealed erosive esophagitis and a cauliflower-shaped protruding mass located in the gastric cardia. The mass arose from the lesser curvature (). Histological examination of biopsy specimens revealed a well-differentiated SCC. Several biopsy specimens were collected from the gastric mucosa surrounding the tumor. No Helicobacter pylori was detected, but the mucosa of the esophagogastric junction was mildly inflamed. An upper gastrointestinal barium series revealed an elevated mass arising from the lesser curvature of the gastric cardia (). Computed tomography (CT) of the abdomen with intravenous administration of a contrast dye revealed a large heterogeneous mass on the dorsal wall of the stomach, with no evidence of metastatic disease outside the stomach (). Total gastrectomy with splenectomy, distal pancreatectomy, and Rouxen-Y reconstruction was performed, together with a lower thoracic esophagectomy via a left thoracotomy. There was no evidence of regional or distant metastasis. On opening the stomach, an ulcerated mass in the cardia, measuring 7.5×9.0 cm, was observed along the lesser curvature (). Pathological examination of sections of the resected specimen stained with hematoxylin and eosin revealed a well-differentiated SCC with frequent typical keratin pearl formation, mosaic patterns of cell arrangement, and intracellular bridges (). The esophageal and pyloric margins were free of tumor involvement, but tumor cells infiltrated the serosa of the dorsal margin. No nodal metastasis was apparent. The tumor had not invaded the mucosa of the esophagogastric junction. In addition, no squamous cells were detected in the normal portion of the stomach. The clinical stage was stage IIB (T4aN0M0), according to the TNM classification, version 7. Therefore, primary SCC of the stomach was diagnosed. The patient refused adjuvant chemotherapy. However, 18-months after the operation, a CT scan revealed a metastatic tumor that was 4.0 cm in diameter in segment 6 of the liver, accompanied by para-aortic lymph node metastasis. Although the patient immediately received systemic chemotherapy with 5-fluorouracil plus cisplatin and docetaxel plus cisplatin, the recurrent tumors progressed. Liver metastases developed subsequently, and the patient died 36 months after the first operation.