Successful curative surgery for postoperative oesophageal recurrence of oesophagogastric junction cancer

Abstract

A man in his 70s had undergone total gastrectomy for oesophagogastric junction cancer. Three years and 11 months later, he began to vomit after meals and was diagnosed with mediastinal recurrence of oesophagogastric junction cancer. A CT scan showed that the tumour was suspected of infiltrating the aorta and lung. He received two cycles of chemotherapy with S-1 plus cisplatin, resulting in tumour reduction. The patient underwent resection of the lower oesophagus, including the tumour, the left lower lobe of the lung and the pericardium through a left thoracoabdominal incision. This is the first report of a patient surgically resected for postoperative oesophageal recurrence of oesophagogastric junction cancer. Although most postoperative recurrences of oesophagogastric junction cancer are far advanced at the time of diagnosis and prognosis is poor, chemotherapy followed by surgery may improve the prognosis of patients with locoregional recurrence.

Background

Although patients with postoperative recurrence of gastric cancer or oesophagogastric junction cancer are usually treated with chemotherapy, their prognosis remains poor even when administered the latest combination chemotherapy regimens.¹ The 2019 National Comprehensive Cancer Network guidelines for gastric cancer mention that surgical treatment should be considered as an option for resectable locoregional recurrence in medically fit patients; however, most of the recurrent gastric cancers are inoperable because they are far advanced.²

This report describes a patient with oesophageal recurrence of oesophagogastric junction cancer who underwent successful surgery after chemotherapy.

Case presentation

A man in his 70s had been diagnosed with oesophagogastric junction cancer with symptoms of vomiting. The epicentre of the tumour was located 1.5 cm anal to the oesophagogastric junction, making it a Siewert type II cancer of the oesophagogastric junction. Oesophageal invasion was not pointed out. Total gastrectomy was performed via an abdominal approach with extended resection of the lower oesophagus. Pathological findings were SS, N0, por2+tub2, ly3, v3, with a proximal margin of 2.5 cm (figure 1). The patient did not receive regular follow-up examinations at the outpatient clinic.

Figure 1.

Macroscopic examination of the specimen resected at the initial operation, showing a type 3 advanced cancer of the oesophagogastric junction. The epicentre of the tumour was located 1.5 cm below the oesophagogastric junction.

Three years and 11 months after surgery, the patient began to vomit after meals. He was diagnosed with oesophageal stenosis and was referred to our department.

Investigations

An oesophagogram revealed complete obstruction of the lower oesophagus (figure 2). Endoscopy showed that the oesophageal mucosa was normal (figure 3), suggesting stenosis outside the oesophagus. A CT scan showed a tumour of transverse diameter 4.5 cm above the oesophagojejunostomy; invasion of the descending aorta and inferior pulmonary vein was suspected (figure 4A, B). Positron emission tomography–CT showed a strong signal at the site of the tumour, with no signal at other sites. Tumour markers were within normal range, with a carcinoembryonic antigen concentration of 3.8 ng/mL and a carbohydrate antigen 19–9 concentration of 29.0 U/mL.

Figure 2.

Oesophagograms showing complete obstruction of the oesophagus by the tumour at the time of admission.

Figure 3.

Oesophagoscopic image showing obstruction of the lower oesophagus without mucosal abnormality.

Figure 4.

CT images at the time of admission showing (A) the tumour surrounding the descending aorta and (B) indications of tumour invasion of left inferior pulmonary vein.

Treatment

The patient was diagnosed with a mediastinal paraoesophageal recurrence of oesophagogastric junction cancer, with suspected invasion of the descending aorta and left inferior pulmonary vein. As oral intake was impossible, he was started on transnasal enteral nutrition and chemotherapy. Initially judged as unresectable, S-1 plus cisplatin therapy (60 mg S-1 was given orally, two times per day for 3 consecutive weeks, and 60 mg/m² cisplatin was given intravenously on day 8, followed by a 2-week rest period, within a 5-week cycle) was done according to the gastric cancer treatment guideline.^{3 4} After two cycles of S-1/cisplatin therapy, his stenosis improved and the patient began to eat soft foods. The tumour was reduced to a transverse diameter of 3 cm on CT, at which point it was judged resectable with an extended resection.

Surgery was performed 4 weeks after the last intake of S-1. The patient was placed in the right hemilateral position and a left thoracoabdominal incision was made. Despite strong fibrous adhesion between the tumour and the descending aorta, dissection was possible with effort. The tumour had invaded the left inferior pulmonary vein and could not be dissected. R0 resection was made possible by combined resection of left lower lobe of the lung by cutting the left inferior pulmonary vein inside the pericardium. A lower oesophagectomy, including the tumour and oesophagojejunostomy, was performed. The distal stump of the jejunum was elevated and an oesophagojejunostomy was newly made.

Outcome and follow-up

The patient’s postoperative course was fair. He started oral intake on postoperative day (POD) 7 and was discharged from the hospital on POD 20. Pathological examination of the resected specimens showed a poorly differentiated adenocarcinoma infiltrating the proper muscle layer of the oesophagus and surrounding tissue (figure 5). Cancer tissue also infiltrated the walls of the pulmonary vein and pericardium. At the present time, 2 years after surgery, the patient remains well without recurrence.

Figure 5.

Macroscopic findings of the resected specimen, showing that the tumour was present at the proper muscle layer and adventitia of the oesophagus, infiltrating the epicardium and left lung.

Discussion

Patients with postoperative recurrence of gastric and oesophagogastric junction cancers are usually treated with chemotherapy, with surgical treatment much less common.^5–8 Most recurrent lesions are far advanced at the time of diagnosis, making complete resection difficult.^{9 10} Although operations for anastomotic recurrence or oesophageal intramural metastasis of gastric cancer have been reported,^11–13 this patient was the first to undergo surgery for recurrence all around the oesophageal walls. Despite tumour invasion of the descending aorta and left inferior pulmonary vein, extended operation after chemotherapy made it possible R0 resection.

Oesophageal recurrence of gastric cancer is thought to arise from minute residual cancer cells spreading, through lymphatic flow, into the submucosal layer and adventitia of the oesophagus.^{14 15} Obstruction of downstream lymphatic flow by cancer invasion may lead to upstream lymphatic flow from the oesophagogastric junction.¹⁶ During the first operation, our patient underwent total gastrectomy with resection of part of the lower oesophagus by incising the diaphragm via the abdomen. The pathological distance from the tumour to the proximal margin was 2.5 cm and cancer tissue was not observed at the stump, but vascular invasion and lymphatic invasion were prominent in the main tumour. The recurrent tumour was located 5 cm above the oesophagojejunal anastomosis. This tumour comprised the entire thickness of the oesophageal wall, but mucosal invasion was not recognised. These findings suggested that lymphatic spread of the tumour through the lymph flow along the oesophageal adventitia was already present at the time of the initial operation, becoming apparent postoperatively.

The Japanese Gastric Cancer Association guidelines for the treatment of gastric cancer recommend a transabdominal approach for resection of gastric cancer with oesophageal invasion within 3 cm.^{3 17} In our patient, oesophageal invasion of the cancer was diagnosed less than 1 cm preoperatively. The tumour was resected via a transabdominal operation according to the treatment guidelines for gastric cancer. The proximal margin was adequately secured but lymphatic recurrence occurred far proximal to the anastomosis.

Recently, the results of a multicentre prospective study on lymph node dissection of oesophagogastric junction cancer by the Japanese Gastric Cancer Association and the Japan Esophageal Society were reported.¹⁸ Only an abdominal approach has been proposed for oesophagogastric junction cancer with oesophageal invasion of 2 cm or less, but a tumour with marked vessel invasion such as this case may invade the proximal side more. There are still no standard treatment guidelines for the extent of resection of oesophagogastric junction cancer. The findings in our patient may be helpful in considering the oncological features and surgical procedure for oesophagogastric junction cancer.

Learning points.

• Postoperative oesophageal recurrence should be considered a possibility in patients with oesophagogastric junction cancer with significant vessel invasion, even when the epicentre of the tumour is located in the stomach.

• After surgery for oesophagogastric junction cancer, regular checkups should be considered with a recurrence at the anastomosis or remnant oesophagus in mind.

• Although most postoperative recurrences of oesophagogastric junction cancer are far advanced at the time of diagnosis and patient prognosis is poor, prognosis may be improved by chemotherapy and surgery.

• Even for recurrence in the mediastinum with infiltration of surrounding organs, extended resection for R0 surgery could be considered.