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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 3  |  Page : 107-109

Gastric cancer and intrahepatic cholangiocarcinoma: Gastrectomy followed by left hepatectomy to achieve R0 resection


Department of Hepatopancreaticobiliary Surgery and Organ Transplantation, Fortis Hospital Mulund, Mumbai, Maharashtra, India

Date of Submission24-Oct-2018
Date of Decision16-Jan-2019
Date of Acceptance31-Mar-2019
Date of Web Publication17-Jun-2019

Correspondence Address:
Dr. Alex Emmanuel Elobu
Department of Hepatopancreaticobiliary Surgery and Organ Transplantation, Fortis Hospital Mulund, Mulund-Goregaon Link Road, Mumbai - 400 078, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_112_18

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  Abstract 


Gastric cancer is the fifth most common cancer and the third leading cause of cancer deaths globally. Its incidence is highest in Asia and lowest in Africa. In 1.1%–4.7% of all gastric cancer cases, at least one other primary tumor may be found. We present the case of a 55-year-old male from West Asia who underwent proximal gastrectomy for Stage IIB gastric adenocarcinoma. One year into postoperative surveillance, routine abdominal imaging revealed a liver tumor. A left hepatectomy was performed, histology of which revealed cholangiocarcinoma. Cholangiocarcinoma though rare may occur following a diagnosis of gastric cancer, thus the strong need for routine abdominal imaging during surveillance of these patients. Any suspicious lesions discovered during follow-up need to be vigilantly evaluated so that patients are offered appropriate and timely treatment.

Keywords: Cholangiocarcionoma, double primary tumors, gastric cancer


How to cite this article:
Elobu AE, Thorat A, Kweyamba V, Rai R. Gastric cancer and intrahepatic cholangiocarcinoma: Gastrectomy followed by left hepatectomy to achieve R0 resection. Formos J Surg 2019;52:107-9

How to cite this URL:
Elobu AE, Thorat A, Kweyamba V, Rai R. Gastric cancer and intrahepatic cholangiocarcinoma: Gastrectomy followed by left hepatectomy to achieve R0 resection. Formos J Surg [serial online] 2019 [cited 2019 Oct 19];52:107-9. Available from: http://www.e-fjs.org/text.asp?2019/52/3/107/260437




  Introduction Top


Gastric cancer is the fifth most common cancer and the third leading cause of cancer deaths worldwide, with the highest incidence in East Asia and lowest in Africa.[1] In 1.1%–4.7% of all gastric cancer cases, at least one other primary tumor may be found.[2],[3] The most common tumors accompanying gastric cancers are colon, lung, and hepatocellular cancers.[2],[3],[4] The occurrence of biliary tract cancer, especially intrahepatic cholangiocarcinoma, is exceedingly rare at only 1.6% of all gastric cancer cases.[2] Conversely, the occurrence of other cancers together with cholangiocarcinoma is only rare. Literature search yielded a few other case reports of cholangiocarcinoma occurring together with colon cancer or thyroid cancer.

Possible explanations for this phenomenon include shared risk factors such as inflammatory bowel disease, diabetes mellitus (DM), alcohol consumption, autoimmune disease, infections, and improved treatment outcomes for the first diagnosed cancer.[3],[5],[6]

We present a rare case of Stage IIB gastric adenocarcinoma with intrahepatic cholangiocarcinoma. This case emphasizes the need for proper surveillance of patients with gastric cancer.


  Case Report Top


We present the case of a 55-year-old male of West Asian origin who first presented 3 years earlier with upper gastrointestinal bleeding. He had fairly well-controlled type II DM and denied using alcohol or tobacco. Serology for hepatitis B surface antigen, hepatitis C antibody, and HIV was nonreactive. CA 19-9 and CEA levels were normal at 25.2 U/ml and 3.33 ng/ml, respectively.

Gastrointestinal endoscopy revealed a large tumor along the greater curvature of the body of the stomach, a biopsy of which showed focally invasive adenocarcinoma in the background of dysplasia. Abdominal computed tomography (CT) scan showed a gastric tumor limited to the stomach without enlarged lymph nodes, ascites, or other abnormality. Positron emission tomography (PET) CT showed hypermetabolic eccentric thickening along the greater curvature of the body and fundus of the stomach without locoregional lymphadenopathy or distant metastases.

With a diagnosis of Stage IIB gastric adenocarcinoma, he received neoadjuvant chemotherapy with docetaxel and capecitabine followed by radical proximal gastrectomy with esophagogastric anastomosis. Histology of the resected specimen confirmed pT4aN0 gastric adenocarcinoma with tumor-free resection margins. He was discharged on the 10th day to follow up with biannual abdominal CT scan.

Twelve months later, abdominal CT revealed an ill-defined thickening in the left lobe of the liver with peripheral enhancement and washout on delayed films which had not been seen on prior imaging. PET CT scan showed mild metabolic activity in the same area. The peripheral enhancement with washout raised a suspicion of primary or secondary liver malignancy. On the other hand, the ill-defined nature of the lesion also raised a suspicion of scar tissue following the initial gastrectomy. Tumor markers CA 19-9, CEA, and α-FP were within normal range at 24.1 U/ml, 1.63 ng/ml, and 2.3 ng/ml, respectively. Because of this diagnostic uncertainty, a percutaneous CT-guided core needle biopsy was done. Its histology showed periportal fibrosis with no evidence of malignancy. A multidisciplinary team (MDT) discussion with the patient opted for watchful waiting strategy. Repeat CT scan after 3 months showed a discrete liver nodule in the left lobe with normal gastric remnant [Figure 1]. After considering that this was a solitary liver nodule without overt peritoneal seeding or ascites in an otherwise-fit 55-year-old patient, a decision was made in favor of left hepatectomy. Histology of the resected specimen showed moderately differentiated cholangiocarcinoma [Figure 2] with tumor-free margins.
Figure 1: Computed tomography scan showing a discrete liver nodule (arrow) in the left lobe with normal gastric remnant

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Figure 2: Histology of the resected gastric cancer specimen (a: left) and cholangiocarcinoma specimen (b: right)

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One year later, the patient is well with a performance score of 80%. Repeat abdominal CT scan showed gastric and liver remnants without any tumor.


  Discussion Top


We present a rare case of a 55-year-old male from West Asia who was diagnosed with and treated for metachronous intrahepatic cholangiocarcinoma following an earlier diagnosis of and treatment for gastric cancer. Double primary tumors are found in 1.1%–4.7% of all gastric cancer cases with colorectal, lung, and hepatocellular cancers being the most common. The occurrence of biliary tract cancers with gastric cancer is exceedingly rare and accounts for <1.6% of all gastric cancer cases. Commonly, these double primary tumors occur in males of >60 years unlike in our patient who was 55 at the time of diagnosis.[2],[3]

Ongoing scholarly work suggests that shared risk factors such as DM, obesity, alcohol consumption, autoimmune disease, and Helicobacter pylori infection between gastric cancer and cholangiocarcinoma may explain their concurrence.[5],[6] Studies have linked gastric and biliary cancers at genetic, molecular, and cell growth regulation levels.[7] It is also believed that the improved gastric cancer survival seen in recent years has allowed patients to live long enough to develop other unrelated diseases including cancers of other body sites.[3] Perhaps, our patient's being diabetic put him at greater risk of both left gastric and biliary cancers.

Current cancer treatment guidelines recommend imaging such as CT scan of chest, abdomen, and pelvis or PET CT scan every 6 months for at least 2 years and then annually up to 5 years as part of surveillance for patients treated for gastric cancer [8] in order to catch recurrences or new diseases early. Moreover, studies have shown that compliance with gastric cancer treatment guidelines significantly improves outcomes.[9] It is during such surveillance in line with treatment guidelines that our patient was diagnosed with a liver tumor that later turned out to be cholangiocarcinoma.

Surgery of liver metastases or double primary tumors may confer survival benefit in well-selected gastric cancer patients. Surgical resection is generally contraindicated in patients with gastric serosal invasion, peritoneal metastases, three or more liver tumors, or tumor diameter >5 cm.[10] Our patient was considered a suitable surgical candidate because he had a tumor-free gastric remnant and a single liver nodule of 4.3 cm × 3.1 cm. Also, he did not have ascites or peritoneal metastases. Furthermore, given the uncertainty of the diagnosis following preoperative imaging and histology, an MDT recommendation for left hepatectomy was made.


  Conclusion Top


Cholangiocarcinoma though rare may occur following a diagnosis of gastric cancer, thus the strong need for routine abdominal imaging during surveillance of these patients. Any suspicious lesions discovered during follow-up need to be vigilantly evaluated so that patients are offered appropriate and timely treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.  Back to cited text no. 1
    
2.
Kim JY, Jang WY, Heo MH, Lee KK, Do YR, Park KU, et al. Metachronous double primary cancer after diagnosis of gastric cancer. Cancer Res Treat 2012;44:173-8.  Back to cited text no. 2
    
3.
Kim JW, Jang JY, Chang YW, Kim YH. Clinical features of second primary cancers arising in early gastric cancer patients after endoscopic resection. World J Gastroenterol 2015;21:8358-65.  Back to cited text no. 3
    
4.
Bae JS, Lee JH, Ryu KW, Kim YW, Bae JM. Characteristics of synchronous cancers in gastric cancer patients. Cancer Res Treat 2006;38:25-9.  Back to cited text no. 4
    
5.
Murphy G, Michel A, Taylor PR, Albanes D, Weinstein SJ, Virtamo J, et al. Association of seropositivity to Helicobacter species and biliary tract cancer in the ATBC study. Hepatology 2014;60:1963-71.  Back to cited text no. 5
    
6.
Kirstein MM, Vogel A. Epidemiology and risk factors of cholangiocarcinoma. Visc Med 2016;32:395-400.  Back to cited text no. 6
    
7.
Canu V, Sacconi A, Lorenzon L, Biagioni F, Lo Sardo F, Diodoro MG, et al. MiR-204 down-regulation elicited perturbation of a gene target signature common to human cholangiocarcinoma and gastric cancer. Oncotarget 2017;8:29540-57.  Back to cited text no. 7
    
8.
Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver 4). Gastric Cancer 2017;20:1-19.  Back to cited text no. 8
    
9.
Worhunsky DJ, Ma Y, Zak Y, Poultsides GA, Norton JA, Rhoads KF, et al. Compliance with gastric cancer guidelines is associated with improved outcomes. J Natl Compr Canc Netw 2015;13:319-25.  Back to cited text no. 9
    
10.
Liao YY, Peng NF, Long D, Yu PC, Zhang S, Zhong JH, et al. Hepatectomy for liver metastases from gastric cancer: A systematic review. BMC Surg 2017;17:14.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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