30th July 2010, Volume 123 Number 1319

James McKay

Case report

Mr M, a 70-year-old man, was referred for surgical review for heartburn, reflux and early satiety. Past surgical history included a pylorectomy and gastrojejunostomy (GJJ) in 1965 for a pyloric peptic ulcer.

Gastroscopy revealed a large incarcerated hiatus hernia, severe oesophagitis,Helicobacter pylori gastritis and a normal gastrojejunostomy.

CT confirmed the hernia, which was laparoscopically repaired with a 180-degree posterior wrap, resulting in marked symptom improvement. Six months later, symptoms had returned in addition to weight loss and post-prandial vomiting.

Barium swallow and endoscopy confirmed complete gastric outlet obstruction and CT showed marked dilatation of GJJ limbs from the previous anastomoses.

Laparotomy revealed a distended, thick-walled stomach, palpable tumour at the GJJ, serosal deposits and an incidental caecal mass. Distal gastrectomy, resection of previous GJJ and en-bloc extended R) hemicolectomy was performed.

Histology confirmed intestinal-type gastric adenocarcinoma with synchronous metastasis to a caecal tubulovillous adenoma.

Discussion

Metastatic spread of gastric cancer is not uncommon, but colonic metastases are rare.1Niimi et al2 reported two cases of large bowel metastases of gastric cancer; one localised to sigmoid colon, the other with rectal and transverse colon lesions but none sited in a polyp.

Ogiwara et al3 reported a case with multiple colonic polyps shown as metastatic deposits of poorly differentiated adenocarcinoma; the primary being gastric cancer resected 11 years previously. Lee et al1 reported a case of colonic metastases from gastric cancer in the form of 5 or 6 flat slightly elevated lesions throughout the colon with a signet-ring pathology similar to the gastric tumour.

The closest case we could find to Mr M was published by Tiszlavicz4 of a 69-year-old man with diffuse type gastric cancer, where post-mortem found widely disseminated disease with a metastasis in an adenomatous polyp of the caecum.

As to why a polyp would be an isolated site for a metastatic deposit is unknown, and even more unusual about Mr M is it being present on the mucosal and not serosal surface as may be expected with transcoelomic spread. The pathogenesis of such a lesion could not be adequately explained other than hypothesising that the spread is likely haemotogenous/lymphatic in nature with certain cell expression factors/adhesion molecules in the adenomas that allow the tumour cells to settle and grow there. This may be more so with the intestinal-type gastric tumours given their histological morphology is described as being like that of intestinal mucosa?

Mr M is, to our knowledge, the first known report of intestinal-type gastric cancer with metastatic spread to a tubulovillous caecal adenoma.

Author Information

James McKay, Senior House Officer, Department of General Surgery, Nelson Hospital, Nelson, New Zealand

Acknowledgements

The author thanks Mr Alf Deacon for his verification of conclusions and for his helpful advice.

Correspondence

James McKay.

Correspondence Email

james.mckay21@gmail.com

References

  1. Lee HC, Yang MT, Lin KY, et al. Metastases from gastric carcinoma to colon in the form of multiple flat elevated lesion: a case report. Kaohsiung J Med Sci. Nov 2004 20(11):552-7.
  2. Niimi K, Matsuki K, Tomoda S, et al. 2 cases of solitary metastasis to the large intestine from gastric carcinoma. Jap J Can Clin. Oct 1984. 30(13):1720-5.
  3. Ogiwara H, Konno H, Kitayama, et al. Metastases from gastric adenocarcinoma presenting as multiple colonic polyps: report of a case. Surg Today. 1994. 24(5):473-5
  4. Tiszlavicz L. Stomach cancer metastasizing into a solitary adenomatous colonic polyp. Orvosi Hetilap. Jun 10 1990 131(23):1259-61.