Very early-onset peritoneal recurrence following curative total gastrectomy for Borrmann 4 gastric cancer
A 39-year-old man with progressive weight loss of 10 kg during the past 6 months was referred to Departement of Surgery in June 2012. No definite abnormal findings in the stomach or duodenum were observed on gastrofiberscopy (GFS) 1 year ago at Yeouido St. Mary's Hospital (). However, diffuse engorged gastric folds with ulcerations at the mid body and greater curvature side of the stomach, suggesting a Borrmann-4 AGC were found during the current GFS (). A biopsy confirmed signet ring cell carcinoma. An abdominal computed tomography (CT) scan also showed diffuse gastric wall thickening, compatible with the GFS findings without definite regional lymphadenopathy (cT4aN0M0) (). Positron emission tomography (PET) CT found no active lesions in the abdomen including the stomach and liver. However, a mild hypermetabolic focus at the medial aspect of the left iliac bone was noted, which was equivocal to confirm the bone metastasis (). Tumor markers were all within normal limits including carcinoembryonic antigen of 0.6 ng/mL (normal range, 0-5 ng/mL), alpha fetoprotein of 1.6 ng/mL (normal range, <8.1 ng/mL) and carbohydrate antigen 19-9 of 6.68 U/mL (normal range, 0-37 U/mL).\nAn open total gastrectomy and splenectomy with D2 lymph node dissection was carried out for the R0 resection. No definite metastatic focus was detected during the operation, including definite metastatic lymphadenopathy in the entire abdominal cavity. No peritoneal washing cytology was performed. The postoperative course was uneventful until postoperative day 4 when he resumed soft meals.\nA pathological examination revealed Borrmann-4, 13.0 cm × 11.0 cm sized serosa-exposed signet ring cell carcinoma with 50 metastatic lymph nodes out of 84 retrieved lymph nodes resulting in pT4aN3bM0, stage IIIc according to Union of International Cancer Control seventh edition. There was no microscopic cancer cell involvement on either resection margin, resulting in a R0 resection.\nFive days following the gastrectomy, localized abdominal pain on the left upper quadrant with nausea and vomiting developed. A 500-mL volume of turbid whitish fluid without bile contents were aspirated via a reinserted Levin tube. An abdominal CT scan and Gastrografin swallowing radiography showed a markedly dilated jejunal Roux-limb with an abrupt cutoff near the jejuno-jejunostomy site (). All attempts to improve the intestinal obstruction, including nasojejunal decompression and correction of the fluid and electrolyte imbalance were unsuccessful. A re-exploration was considered to relieve the intestinal obstruction.\nA reoperation to relief the Roux-limb obstruction via a laparoscopic approach was performed at postoperative day 8. Adhesions were observed around the jejunojeunostomy site and the mesocolon compressed the Roux-limb just proximal to the jejunojejunostomy. Laparoscopic adhesiolysis relieved the Roux-limb obstruction without any problem. However, we incidentally found some whitish peritoneal nodules on the left diaphragmatic surface that were not present at the initial operation (). One of peritoneal nodules was excised for histologic examination, revealing a metastatic adenocarcinoma with signet ring cell features (). The patient tolerated the reoperation well and was transferred to the Department of Internal Medicine for systemic combination chemotherapy of capecitabine and cisplatin (XP).\nDuring the follow-up examination performed in December 2012, 6 months after the operation and after the eight cycle of XP chemotherapy, a CT scan showed newly developed ill-defined soft tissue density in the common hepatic space and retropancreatic space, suggesting nonspecific postoperative changes or a tumor recurrence. Then, the chemotherapy regimen was changed to oxaliplatin-based FOLFOX. In addition, no interval change in the 1.7 cm sized sclerotic bony lesion in the left iliac bone was observed on a serial bone and CT scan.\nThe patient tolerated a regular diet and chemotherapy relatively well until January 2013. Then, abrupt vomiting developed. A CT scan and an upper gastrointestinal series showed markedly distended jejunal limb due to cancer recurrence. Bypass jejunojejunostomy was performed to relieve the jejunal obstruction at the jejunojejunosotmy site. Marked carcinomatosis and ascites were found during the operation. After the jejunojeunal bypass, the symptoms were relieved temporarily, but the patient suffered from poor oral intake and a large volume of ascites. The patient died on March 9, 2013. He had survived 9 months following the initial operation.