• Users Online: 505
  • Print this page
  • Email this page


 
 
Table of Contents
IMAGE CHALLENGE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 312-316

A rare malignancy at the gastrojejunostomy stump


Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Submission03-Jan-2020
Date of Decision29-Feb-2020
Date of Acceptance03-Mar-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Varun Goel
Department of Medical Oncology, Rajiv Gandhi Cancer Institute, Sector 5, Rohini, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_1_20

Get Permissions


How to cite this article:
Chaudhari KA, Talwar V, Goel V, Dash PK, Bothra S, Domadia K, Babu Koyyala VP. A rare malignancy at the gastrojejunostomy stump. Cancer Res Stat Treat 2020;3:312-6

How to cite this URL:
Chaudhari KA, Talwar V, Goel V, Dash PK, Bothra S, Domadia K, Babu Koyyala VP. A rare malignancy at the gastrojejunostomy stump. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 18];3:312-6. Available from: http://www.crstonline.com/text.asp?2020/3/2/312/287193




  Case History and Approach Top


A 65-year old woman presented in July 2016 with a 1-month history of mild-to-moderate dull aching epigastric pain with loss of appetite. She had no history of vomiting, melena, or altered bowel habits. The patient had a history of undergoing gastrectomy and gastrojejunostomy 40 years ago for a gastric ulcer and open cholecystectomy 26 years ago for gallstone disease. Details of surgery and histopathology reports were lost and could not be recovered. Her ECOG performance status (PS) was 1, and examination was normal and with no organomegaly. Blood investigations were unremarkable except for mild anemia and hypoproteinemia.

Contrast-enhanced computed tomography (CT) of the abdomen [Figure 1] showed multiple peripherally enhancing lesions in both lobes of the liver and enlarged conglomerate lymph nodes in the periportal, peripancreatic, perigastric, precaval, preaortic, left paraaortic, and mesenteric regions. Positron-emission tomography-CT (PET-CT) showed a metabolically active gastric lesion, multiple liver space-occupying lesions (SOL), and lymph nodal disease [Figure 2]; the remaining organ systems and structures were unremarkable. Upper gastrointestinal (GI) endoscopy showed ulceration and friability at the gastrojejunostomy anastomosis likely malignant infiltration of gastrojejunostomy anastomosis [Figure 3].
Figure 1: Computed tomography scan of abdomen axial view image showing gastric and liver lesions

Click here to view
Figure 2: Positron emission tomography-computed tomography images showing metabolically active gastric and hepatic lesions with lymph nodal involvement

Click here to view
Figure 3: Ulcerated and friable growth at the gastro-jejunostomy site seen on upper gastrointestinal endoscopy

Click here to view


CT-guided biopsy and fine-needle aspiration cytology and biopsy done from the liver lesion revealed poorly differentiated carcinoma. Immunohistochemistry (IHC) done was positive for cytokeratin (CK), CK7, and GATA-3 and negative for CK20, p40, PAX8, TTF-1, Hep Par1, ER, 34bE12, and mammaglobin. Breast magnetic resonance imaging (MRI) done in view of GATA-3 positivity was normal. A diagnosis of metastatic gastric adenocarcinoma was made based on the above findings. HER2/neu test was negative. The patient was started on palliative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil. Revaluation with PET-CT after three cycles showed progressive disease in the form of new lesions in the liver and new left deep cervical lymphadenopathy, with an increase in the size and metabolic activity of the pre-chemotherapy lesions [Figure 4]. Treatment was then changed to epirubicin-based chemotherapy (epirubicin, oxaliplatin, and capecitabine), but the patient had progressive disease on PET-CT scan after three cycles in the form of increase in the extent and metabolic activity of the liver lesions and left supraclavicular lymph nodes with appearance of new bilateral pulmonary infiltrates and persistence of the other lesions [Figure 4]. Based on the poor response to chemotherapy and poorly differentiated nature of the disease, re-biopsy from the liver SOLs was done [Figure 5].
Figure 4: Positron emission tomography-computed tomography images showing progressive disease on palliative chemotherapy

Click here to view
Figure 5: (a and b) Histopathology slide showing poorly differentiated carcinoma, Immunohistochemistry showing (c) diffuse cytokeratin positivity in all cells, (d) focal positivity of epithelial membrane antigen highlighting adenocarcinoma component, (e) Beta-human chorionic gonadotropin and (f) GATA-3 positivity highlighting choriocarcinoma cells

Click here to view


What is the diagnosis and what should the management plan be? Once you have finalized your answer, please turn to pg. 313 to read on.

Differential diagnosis

The possible differential diagnoses considered were:

  • Metastatic breast cancer in view of GATA-3 expression and beta-human chorionic gonadotropin (β-HCG) positivity on IHC; however, no breast mass was found on MRI of bilateral breasts, and other IHC markers for breast carcinoma were negative
  • Metastatic ovarian choriocarcinoma in view of β-HCG positivity on IHC finding; however, bilateral adnexa and uterus were unremarkable on imaging
  • Primary gastric choriocarcinoma (PGC) in view of exophytic growth at the gastric stump and β-HCG and GATA-3 positivity on IHC
  • Intrahepatic cholangiocarcinoma in view of IHC findings and liver lesions
  • GI stromal tumor and gastric lymphoma could be distant possibilities; however, non-corresponding histopathology and cytokeratin positivity went against these diagnoses.



  Diagnosis Top


Histopathology showed trophoblastic differentiation. Additional IHC was positive for β-HCG [Figure 5]. Serum β-HCG level was markedly elevated at 36,902 mIU/ml. IHC with β-HCG was expressed on 40%-50% of cells; those cells were negative for epithelial membrane antigen (EMA). The diagnosis of PGC with adenomatous component was made based on histopathological evaluation and IHC. Gastric adenocarcinoma is positive for AE1/AE3 and CK7 on IHC. CK20 is usually negative; however, occasionally can be positive. The patient denied any history of previous malignancy, including gestational trophoblastic neoplasia and ovarian malignancy. Imaging of the patient was re-reviewed, and adnexal structures and uterus were normal.

The patient died of gastrointestinal bleed only a few days after the diagnosis of PGC had been established.


  Discussion Top


Choriocarcinoma is a malignant trophoblastic neoplasm that usually manifests during pregnancy. These tumors represent <1% of gynecological malignancies. Choriocarcinoma can be gestational or nongestational. Choriocarcinoma is a β-HCG secreting tumor. β-HCG is used usually for the diagnosis, response assessment, and follow-up.

Nongestational choriocarcinoma can also be gonadal or extragonadal in origin.[1] Extragonadal nongestational choriocarcinoma rarely develops in the mediastinum, retroperitoneum, pineal gland, liver, gallbladder, and urinary tract system. PGC was first described by Davidson in 1905.[2] PGC is an extremely rare and highly malignant tumor; it accounts for around 0.08% of gastric cancers.[3] The diagnosis of PGC is confirmed with high β-hCG levels in serum, choriocarcinomatous component on biopsy, and β-hCG positive cells on IHC. Ectopic production of β-HCG in the serum and its expression have been seen in various nontrophoblastic malignant tumors including pancreatic adenocarcinoma, bronchogenic carcinoma, osteosarcoma, squamous cell carcinoma, colorectal tumors, and carcinoma of the breast, ovary, prostate, kidney, parathyroid, large bowel, bladder and stomach.[4] Gastric choriocarcinomas are red and beefy on gross appearance and show exophytic growth. On histopathology, the tumor shows malignant cytotrphoblasts and syncytiotrophoblasts, usually usually mixed with areas of typical glandular differentiation.[5]

To date, approximately 140 cases have been reported in the medical literature.[6] These were case reports, and the clinical, and the clinical behavior, tumor characteristics, and prognostic parameters of PGC have not been clearly described. To the best of our knowledge, a case of metastatic PGC arising from gastrojejunostomy site has not been reported before. Kobayashi et al.[6] presented a pooled analysis of 53 cases of PGC, in which they reported that the mean age at diagnosis was 62.4 years in men and 52.8 years in women. PGC was more frequently present in the distal third of the stomach (41%). The site of origin often coincided with the site of origin of adenocarcinoma. 70% of the patients exhibited a component of adenocarcinoma in this analysis. The presence of synchronous liver metastasis, residual tumor after operation, and the absence of chemotherapy were significantly associated with a short overall survival.

Frequently, PGC is diagnosed initially as adenocarcinoma due to the coexistence of an adenomatous component, as was the case in our patient. In the pooled analysis by Kobayashi et al., only 8% of patients were correctly diagnosed with PGC on biopsy.

The etiology of PGC is poorly understood though there have been theories about its development. The most accepted hypothesis is the dedifferentiation theory from gastric adenocarcinoma which was suggested by Pick in 1926.[7] This theory suggested that there is retrograde differentiation of adenocarcinoma cells to the embryonal ectoderm level; the cells then acquire the ability to produce trophoblasts. Points that support this hypothesis are similar age at diagnosis and location of the tumor in the stomach as compared to gastric adenocarcinoma. About 70% of PGC have an adenomatous component. PGC has been noted more frequently in the areas where gastric adenocarcinoma is more common.[7] PGC possesses genetic characteristics of both adenocarcinoma and gestational choriocarcinoma.[8] PGC is more prone to hematogenous spread as compared to gastric adenocarcinoma.[9] Diagnosis of PGC requires a high index of suspicion for poorly differentiated histology, especially in patients who are unresponsive to primary chemotherapy. Re-biopsy with extensive IHC study is always encouraged in these cases.

Most of the literature regarding PGC is from case reports, and not much is known about its treatment. In the pooled analysis by Kobayashi et al., patients were treated with various chemotherapeutic regimens with single-agent or multi-agent chemotherapy regimens containing cisplatin, methotrexate, fluorouracil, mitomycin C, actinomycin D, or cyclophosphamide.[6] Takahashi et al.[10] have reported a case of successful treatment of gastric choriocarcinoma with curative intent with EMA/CO regimen followed by radiofrequency ablation of the lung nodule that remained after systemic therapy which led to a complete clinical response. EMA/CO is a multidrug regimen which is commonly used in high-risk gestational choriocarcinoma as the standard of care. It consists of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (Oncovin).


  Conclusion Top


PGC is an extremely rare, highly malignant tumor with poor prognosis. This is the first reported case of metastatic PGC arising from the gastrojejunostomy site. In the case of a poorly responsive gastric tumor, re-biopsy and extensive IHC are encouraged. Optimal treatment for PGC at present is not known, and further evaluation and research are needed in this field.

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.
Schmoll HJ. Extragonadal germ cell tumors. Ann Oncol 2002;13 Suppl 4:265-72.  Back to cited text no. 1
    
2.
Hartz PH, Ramirez CA. Coexistence of carcinoma and chorioepithelioma in the stomach of a young man. Cancer 1953;6:319-26.  Back to cited text no. 2
    
3.
Martins VF, Moreno F, Vizcaíno JR, Santos J. Primary gastric choriocarcinoma: A rare case. Int J Surg Case Rep 2015;14:44-7.  Back to cited text no. 3
    
4.
Meda. Immunohistochemical Study of the Expression of Human Chorionic Gonadotropin- in Salivary Gland Tumors. Available from: http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2018;volume=14;issue=5;spage=952;epage=956;aulast=Meda. [Last accessed on 2020 Jan 10].  Back to cited text no. 4
    
5.
Dye DW, Broadwater R, Lamps LW. Uncommon malignancies: Case 2. Gastric choriocarcinoma. J Clin Oncol 2005;23:6251-3.  Back to cited text no. 5
    
6.
Kobayashi A, Hasebe T, Endo Y, Sasaki S, Konishi M, Sugito M, et al. Primary gastric choriocarcinoma: Two case reports and a pooled analysis of 53 cases. Gastric Cancer 2005;8:178-85.  Back to cited text no. 6
    
7.
Pick L. About the chorioeptheal metastatic from the gastric carcinoma. Klin Wochenschr 1926;5:1728.  Back to cited text no. 7
    
8.
Liu AY, Chan WY, Ng EK, Zhang X, Li BC, Chow JH, et al. Gastric choriocarcinoma shows characteristics of adenocarcinoma and gestational choriocarcinoma: A comparative genomic hybridization and fluorescence in situ hybridization study. Diagn Mol Pathol 2001;10:161-5.  Back to cited text no. 8
    
9.
Shastri A, Daver NG, Hayes TG. Primary gastric chorioadenocarcinoma: A needle in a haystack. Rare Tumors 2011;3:e19.  Back to cited text no. 9
    
10.
Takahashi K, Tsukamoto S, Saito K, Ohkohchi N, Hirayama K. Complete response to multidisciplinary therapy in a patient with primary gastric choriocarcinoma. World J Gastroenterol 2013;19:5187-94.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Case History and...
Diagnosis
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed230    
    Printed18    
    Emailed0    
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal