M6tastase duod6nale d'un carcinome 6pidermo'ide msophagien : ta propos d'un cas et revue de la l i t t6rature

P. MAMBRINI, F. KLOTZ, J.-M. DEBONNE, M. GUISSET H6pital d'Instruction des Armies A. Laveran, Marseille (France)

A case of duodenal metastasis of an esophageal squamous cell carcinoma

RI~.SUMI~

La localisation de m6tastases au tube digestif est rare. Leur si6ge est plus souvent j6juno-il6al. Les auteurs rapportent un cas de m6tastase d'un carcinome 6pidermo'ide de l'0esophage chez un homme de 47 ans qui avait 6t6 trait6 par radiochimioth6rapie puis chirurgie deux mois auparavant.

Une revue de la litt6rature retrouve le caract6re exeeptionnel de ces m6tastases duod6nales.

SUMMARY

Metastasis in the digestive tract are uncommon. The most frequent sites are the proximal and distal parts of the small bowel. Authors report a case of duodenal metastasis from an esophageal squamous cell carcinoma in a 47 years old man previoulsy treated by radiochemotherapy and surgery.

A review of the literature is presented confirming the exceptional occurrence of duodenal metastasis.

Les m6tastases du tube digestif sont peu fr6- quentes et s'observent essentiellement au cours de m61anomes malins, de carcinomes bronchiques et mammaires. Leur si6ge est le plus souvent j6juno- il6al, plus rarement gastrique et exceptionnelle- ment duod6nal, colique ou 0esophagien [5].

L'existence de telles m6tastases au cours des cancers de l'oesophage est beaucoup plus rare et leur si~ge duodgnal exceptionnel.

Nous rapportons ici une observation de m6ta- stase duod6nale d'un carcinome 6pidermoide 0eso- phagien.

OBSER VA TION

Monsieur J.M., 47 ans, est hospitalis6 en mars 1991 pour dysphagie et alt6ration de l'6tat g6n6ral. L'interrogatoire et l'examen sont sans particularit6, hormis un amaigrissement mod6r6. I1 n'existe aucun ant6c6dent notable en dehors d'une intoxi- cation alcoolique (110 g d'alcool pur par jour) et tabagique (54 paquets/ann6e). La fibroscopie oeso- gastroduod6nale (FOGD) montre une ulc6ration ~esophagienne ~ bords r6guliers de 3 cm de diam6-

tre, situ6e ~ 31 cm des arcades dentaires. L'esto- mac et le duod6num sont normaux. Les biopsies affirment la pr6sence d'un carcinome 6pidermoide bien diff6renci6, infiltrant.

L'endosonographie et la tomodensitom6trie tho- racique montrent une 16sion cesophagienne circon- f6rentielle transmurale, 6tendue sur 4 cm, avec pr6sence d'ad6nopathies satellites suspectes. L'exa- men endosonographique de l'estomac et du duod6- num est normal. Le bilan d'extension ~t distance est n6gatif.

Compte tenu du volume tumoral, un protocole de radio-chimioth6rapie concomitante pr6-op6ra- toire est effectu6, associant une irradiation de 45 Gray en 5 semaines et une chimioth6rapie par 5 Fluoro-uracile, Acide folinique et Cysplatine.

L'endoscopie de contr61e montre la persistance de la 16sion oesophagienne, l'estomac et le duod6- num sont normaux. Les donn6es de l'endosonogra- phie et de la tomodensitom6trie thoracique sont inchang6es. Une 0esophagectomie avec ~esophago- plastic type Akyama est alors effectu6e. L'examen de la pi6ce op6ratoire montre une recoupe oeso- phagienne et gastrique en zone saine et de nom- breux ganglions m6diastinaux envahis.

Tir6s ~ part: P' F. KLOTZ, Service d'H6pato-Gastroent6rologie, H6pital d'Instruction des Arm6es A. Laveran, 13998 Marseille (France).

Mots-cl~s : carcinome 0esophagien, m6tastases, n6oplasmes duod6naux.

Key-words: duodenal neoplasms, esophageal carcinoma, metastasis.

Acta Endoscopica Volume 23 - N ~ 1 - 1993 49

Deux mois apr6s, le patient est r6hospitalis6 pour 6tat cachectique et dysphagie. La radiogra- phie thoracique montre un 6panchement pleural bilat6ral dont la ponction affirme le caract6re m6tastasique. L'6chographie abdominale visualise une m6tastase h6patique. La FOGD montre une plastie gastrique normale et, au niveau de l'extr6- mit6 distale du deuxi6me duod6num, une tumeur sessile polypoide, d'aspect lisse ~ sommet ombili- qu6 de 20 mm de diam6tre (Fig. 1). A l'histologie, il s'agit d'un carcinome 6pidermoide bien diff6ren- ci6. La prolif6ration tumorale est essentiellement sous-muqueuse.

Le patient d6c6de au troisi6me mois post-op6ra- toire dans un tableau de d6tresse respiratoire.

Figure 1

Metastase duodenale d'un carcinome o~sophagien.

Duodenal metastasis of an esophageal carcinoma.

DISCUSSION

Les 16sions n6oplastiques duod6nales sont peu fr6quentes et repr6sent6es en ordre de fr6quence d6croissante par les ad6nocarcinomes duod6naux primitifs, les lymphomes, les tumeurs carcinoides, et les leiomyosarcomes [3].

Les m6tastases duod6nales (dont la d6finition exclut les extensions au duod6num par contiguit6 d'une tumeur de voisinage) sont tr6s rares et essentiellement d6crites au cours des cancers du sein, des m61anomes malins, des carcinomes bron- chiques et des ad6nocarcinomes r6naux [9, 11, 12, 22]. D'exceptionnels cas ont 6t6 rapport6s au cours de cancers du col ut6rin, de l'ovaire, du testicule, des voies a6ro-digestives sup6rieures (larynx, hypopharynx, plancher buccal) et du colon [1, 6, 8, 14, 19].

Au cours des carcinomes 6pidermoides 0esopha- giens, les sites les plus fr6quents de m6tastases

visc6rales sont par ordre de fr6quence d6crois- sante, h6patique, pulmonaire et surr6qalien [2]. La localisation m6tastatique au tube digestif a rare- ment 6t6 rapport6e et concerne le plus souvent l'estomac o0 des m6tastases sont retrouv6es dans 0

15 % des cas des s6ries autopsiques [2, 3, 13, 15]. Leur diagnostic du vivant du malade est tr6s rare variant suivant les s6ries entre 0,17 et 5,35 % des cas; il est alors le plus souvent fait en per- op6ratoire [7, 15]. L'aspect endoscopique de ces m6tastases gastriques est celui d'une tumeur sous- muqueuse, h type de nodule simple ou h sommet ombiliqu6 et ulc6r6, de taille inf6rieure ~t 2 cm dans plus de 50 % des cas, et unique dans 75 % des cas. Leur si6ge est le plus souvent sous-cardial et le long de la petite courbure fundique. Leur d6veloppement est initialement sous-muqueux, avec ou sans atteinte des autres couches de la paroi gastrique [15].

Les autres localisations m6tastatiques au tube digestf des carcinomes 6pidermoides ~esophagiens sont exceptionnelles puisque les s6ries autopsiques rapportent entre 0 et 5 % de m6tastases du gr~le, et quelques m6tastases coliques [2, 4, 13]. Des cas de m6tastases gr~liques ont 6galement 6t6 d~crits du vivant du malade [20, 21].

A notre connaissance, un seul cas de m6tastase duod6nale a 6t6 rapport6 [16]. Celle-ci, d6couverte lors du suivi post-op6ratoire d'un carcinome 6pi- dermoide du tiers sup6rieur de l'oesophage, avait le m6me aspect endoscopique que dans notre observation, hormis un si6ge plus distal (troisi6me duod6num).

Deux 616ments m6ritent d'6tre not6s : - - o n peut distinguer quatre modes diff6rents

d'envahissement gastrique au cours des carcinomes 6pidermoides ~esophagiens : 1) m6tastase intramu- rale; 2)envahissement ~ partir d'ad6nopathies m6tastatiques p6rigastriques ; 3) envahissement direct de la parol gastrlque par contiguit6 ; 4) envahissement de proche en proche par exten- sion intra6pith61iale [10]. L'6choendoscopie peut 6tre utile pour d6terminer de fa~on pr6cise le type d'envahissement [17]. Le pronostic est extr6me- ment p6joratif pour les groupes 1 et 2 L. Ceci est confirm6 par les mauvais r6sultats des ex6r~ses chirurgicales ~ vis6e curative en cas de m6tastase gastrique unique et synchrone o0 la m6diane de survie n'exc6de pas 8 mois [10, 15, 18]. Ainsi la mise en 6vidence de m6tastases gastriques syn- chrones au cours d'un carcinome 6pidermoide 0esophagien est actuellement consid6r6e par la plu- part des auteurs comme une contre-indication une chirurgie d'ex6r6se; il devrait en 6tre de m6me pour les m6tastases duod6nales ;

- - le caract~re exceptionnel des m6tastases duo- d6nales et j6juno-il6ales, confirm6 par de vastes s6ries autopsiques, n'incite pas ~ modifier la stra- t6gie du bilan d'extension des carcinomes 6pider- moides oesophagiens. Tout au plus peut-on recom- mander, chaque lois que possible un examen com- plet du cadre duod6nal lors de la FOGD initiale.

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R~F~RENCES

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2. ANDERSON L.L., LOD T.E. - - Autopsy findings in squamous cell carcinoma of the esophagus. Cancer, 1982, 50, 1587-1590.

3. B A R C L A Y M . C . , S C H A P I R O V. - - Malignant tumors of the small intestine. Cancer, 1983, 51, 878-881.

4. BOSH A., FIAS Z., CALDWELL W.L. - - Autopsy fin- dings in carcinoma of the esophagus. Acta Radiol. Oncol., 1979, 18, 103-112.

5. CARAMELLA E., BRUNETON J.N., ROUX P. - - Metastasis of the digestive tract ; report of 77 cases and review of the litterature. Eur. J. Radiol., 1983, 3, 331-338.

6. C L A Y D E N G . S . , R E Y N O L D S D . - - Metastatic duodeno- jejunal carcinoma from ovarian primary. Post Grad. Med. J., 1982, 58, 722-723.

7. DAGNINI G., CALDISONI M.W., MORIN G. - - Lapa- roscopy in abdominal staging of esophageal carcinoma; report of 369 cases. Gastrointest. Endoscop., 1986, 32, 400- 402.

8. GURIAN M., IRELAND K. PETTY W. - - Carcinoma of the cervix involving the duodenum ; case report and review of the litterature. J. Clin. Gastroenterol., 1981, 3, 291-294.

9. H O U G H T O N A . D . , P H E I L S P. - - Isolated duodenal metastasis from breast carcinoma. Eur. J. Surg. Oncol., 1987, 13, 367-369.

10. KUWANO H., BABA K., IKEBE M. - - Gastric involve- ment of esophageal squamous cell carcinoma. Br. J. Surg., 1992, 79, 328-330.

11. LYNCH-NYHAN A., FISHMAN E.K., KADIR S. - - Diagnosis and management of massive gastrointestinal blee- ding owing to duodenal metastasis from renal cell carcino- ma. J. Urol., 1987, 138, 611-613.

12. MAC NElL P.M., WAGMAN L.D., NEIFELD J.P. - - Small bowel metastasis from primary carcinoma of the lung. Cancer, 1987, 59, 1486-1489.

13. MANDARD A.M., CHASLE J., MARNAY J. - - Auto- psy findings in 111 cases of esophageal cancer. Cancer, 1981, 48, 329-335.

14. PETIOT J.M., LEHUR P.A., GIRARD J.Y. - - Double perforation revealing duodenal an jejuno-ileal metastasis from epidermoid carcinoma of the larynx (letter). Gas- troenterol. Clin. Biol., 1991, 15, 370-371.

15. SAITO T., ISUKA T., KATO 1. - - Esophageal carcinoma metastatic to the stomach; a clinicopathoiogical study of 35 cases. Cancer, 1985, 56, 2235-2241.

16. SIPROUDHIS I., BRETAGNE J.F., RAOUL J.L. - - Metastases gastriques et duod6nales des cancers de l'oeso- phage. Gastroenterol. Clin. Biol., 1990, 14, 888-889,

17. SOUQUET J.C., VALETFE P.J., GUI ITON P. - - Metastases gastriques des cancers 6pidermoides de l'oeso- phage: apport de l'6choendoscopie. Gastroenterol. Clin. Biol., 1989, 13 A , 12 (res.).

18. TAKUBO K., SASAJIMA K., YAMASHITA K. - - Pro- gnostic signifiance of intramural metastasis in patients with oesophageal carcinoma. Cancer, 1990, 65, 1816-1819.

19. VEEN H.F., BRUINING H.A. - - Gastrointestinal blee- ding and malignancy of the testis. Acta Chir. Scand., 1979, 145, 363-365.

20. WAISBERG J., DE OLIVEIRA M.V., ANDERI Junior E. - - Isolated metastasis of squamous cell carcinoma of the esophagus in the terminal ileum ; report of a case. Arq. Gastroenterol., 1985, 22, 79-82.

21. WANG M. PATEL J., CASEY T.T. - - Metastatic squa- mous cell carcinoma from the esophagus occuring as small bowel obstruction. South Med. J., 1985, 78, 884-886.

22. WlLLGEROTH C., HEINRICH P., SPORMANN H. - - Unusual site of a late solitary abdominal metastasis of malignant melanoma. Zentralbl. Chir., 1987, 112, 647-651.

Metastasis in the digestive tract are uncommon. They have been described mainly in association with malignant melanoma, breast and lung carci- noma. The most frequent sites are jejunum and ileum, rarely stomach and exceptionally duodenum, colon or esophagus [5]. The incidence of such metastasis in the course of esophageal cancer is rare and their duodenal location exceptional. We report a patient with squamous cell carcinoma of the esophagus metastatic to the duodenum.

C A S E R E P O R T

A 47-year-old man was hospitalized in March 1991 for dysphagia and poor general condition. The patient's history and physical examination were not striking except for evidence of moderate weight loss. He was an alcoholic (110 g a day) and smo- ker (54 packs a year). Esophagogastroduenoscopy (EGDE) disclosed a smooth-edged ulcerated tumor 3 cm in diameter in the esophagus located 31 cm from the dental arches. The stomach and duode-

num were normal. Histology identified the lesion as well-differenciated, infiltrating squamous cell carci- noma.

Endosonography and thoracic CT-scan visualized a circumferential tumor spanning a 4 cm segment of the esophageal wall with probable malignant lymph node involvement. No remote metastases were found.

Because of the size of the lesion, a preoperative course of concomitant radiation therapy (45 Gy in 5 weeks) and chemotherapy (5 Fluoro-uracile, foli- nic acid and cysplatine) was administered in an attempt to shrink the tumor.

Follow-up endoscopy showed no change in the esophageal lesion. The stomach and the duodenum remained normal. Endosonography and thoracic CT-scan also revealed no change. Esophagectomy followed by an Akyama-type esophagoplasty was performed. Examination of the surgical specimen showed the proximal and distal edges to be normal and involvement of numerous mediastinal lymph nodes.

Acta Endoscopica Volume 23 - N ~ 1 - 1993 51

Two months after surgery the patient was re- admitted suffering from dysphagia and wasting. A chest x-ray showed bilateral pleural effusion and fluid cytology confirmed metastasis. Abdominal ultrasonography visualized a hepatic metastasis. EDGE showed the gastric tube to be normal but revealed a smooth, pitted sessile polyp 20 mm in diameter at the distal end of the second duodenum (Fig. 1). Histology identified the lesion as well- differenciated squamous cell carcinoma. The tumor was essentially submucosal.

The patient died of respiratory distress 3 months after surgery.

DISCUSSION

Malignant tumors of the duodenum are uncom- mon. In order of decreasing incidence, they include primary duodenal adenocarcinoma, lymphoma, car- cinoid tumors and leiomyosarcoma [3].

Duodenal metastasis (which by definition excludes spreading from an adjacent tumor) are also rare. They have been described mainly in association with breast cancer, malignant mela- noma, bronchial carcinoma and kidney adenocarci- noma [9, 11, 12, 22]. A few cases have also been reported with cancer of the uterine cervix, testicles, colon, upper airways (larynx, hypopharynx) and palate [1, 6, 8, 14, 19].

The most frequent sites for metastasis of squa- mous cell esophageal cancer are the liver, lungs and adrenal glands in that order [2]. Secondary tumors in the digestive tract are rarely observed and usually involve the stomach where metastases have been reported in 0 to 15 % of cases at autopsy [2, 4, 13, 15]. Diagnosis during life, which accounts for between 0.17 and 5.35 % of reported cases depending on the series, has usually been made peroperatively [7, 15]. Endoscopically these gastric metastases have the appearance of a simple submu- cosal tumor or a nodular tumor with erosion.

Large tumors appeared as a dome-like lesion. They are less than 2 cm in diameter in 50 % of cases and occur alone in 75 % of cases. There are espe- cially located close to the cardia and along the lesser curvature. This metastasis involved the sub- mucosa with or without invasion to the other layers of the stomach wall [15].

The incidence of squamous cell metastases in other locations in the digestive tract is very low. According to autopsy reports, metastasis in the small intestine ranges from 0 to 5 % and a few cases have been noted in the colon [2, 4, 13]. Several cases involving the small intestine have also been diagnosed in living patients [20, 21].

To our knowledge, only one case of metastasis involving the duodenum has been reported [16]. /t was discovered during postoperative follow-up of a patient with squamous cell carcinoma of the upper third of the esophagus and had the same appea- rance as our case. The only difference was that it was located more distally (third duodenum).

In conclusion, two points deserve emphasis. The patterns of gastric involvement by esophageal squa- mous cell carcinoma can be separated into four groups: 1) intramural metastasis ; 2) involvement via metastatic perigastric lymph nodes ; 3)direct invasion to the gastric wall; 4)intra epithelial spread of esophageal cancer into the gastric muco- sal epithelium [10]. Endosonography can be useful to determine correctly the pattern of involve- ment [17]. In groups 1 and 2 the prognosis is extremely poor ; mean survival time after surgery for esophageal squamous cell carcinoma with soli- tary synchronous gastric metastasis did not exceed 8 months [10, 15, 18]. Most authors consider syn- chronous gastric metastasis as a countraindication for surgery. The same attitude should be applied to duodenal metastasis. Second given the low inci- dence of metastasis in the duodenum and small intestine, there would appear to be little reason to change the investigational work-up for patients with squamous cell esophageal carcinoma. Nevertheless, a thorough endoscopic examination of the duode- num is reasonable whenever possible.

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