Alpha-fetoprotein expressing metastastic adenocarcinoma of the esophago-gastric junction responding favorably to capecitabine and oxaliplatin. Anticancer Drugs. 2009;20:75-78. [PMID: 19343004 DOI: 10.1097/CAD.0b013e328312659a]

Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma With Enteroblastic, Yolk Sac Tumor-Like, and Hepatoid Carcinoma Differentiation: A Rare Case and Literature Review

We report a case of a 65-year-old man with alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma that microscopically consisted of a polymorphous blend of enteroblastic, yolk sac-like, and hepatoid carcinoma components of variable proportions. No histological evidence of Barrett's esophagus was identified. Two weeks post-endoscopic mucosal mass resection, the serum AFP level was 1434.6 ng/mL. The patient underwent radiation and chemotherapy but developed metastatic lung lesions. At 18 months post-resection, the patient is alive. AFP-producing esophageal adenocarcinoma is a rare entity. We reviewed reported cases for clinicopathological features, treatment strategies, and prognosis.

Metachronous Liver Metastasis from Alpha-Fetoprotein-Producing Gastric Cancer Successfully Treated with Capecitabine/Oxaliplatin Combination Chemotherapy

A consensus regarding the treatment of recurrent alpha-fetoprotein-producing gastric carcinoma due to its rarity is lacking. We herein describe a case of such a carcinoma that was associated with metachronous liver metastasis. A 73-year-old man was referred for the surgical treatment of a type 2 gastric tumor that extended from the greater curvature of the gastric corpus to the pylorus. As no remote metastases were detected, the patient underwent open total gastrectomy with lymphadenectomy and Roux-en-Y reconstruction. Histopathological examination revealed regional lymph node metastasis and the invasion of the muscularis propria by a moderately differentiated adenocarcinoma. Immunostaining of the primary tumor was positive for alpha-fetoprotein and negative for human epidermal growth factor receptor 2. Serum alpha-fetoprotein levels decreased to within normal limits after eight courses of S-1 monotherapy; however, levels started to increase, and a hypovascular nodule in segment 5/6 of the liver was detected 3.5 years later. Serum alpha-fetoprotein levels returned to the normal range, and the tumor was undetectable after four courses of capecitabine and oxaliplatin therapy. No recurrence was detected at 1.5-year follow-up. This case demonstrates that combined capecitabine and oxaliplatin therapy can successfully treat metachronous liver metastasis from alpha-fetoprotein-producing gastric carcinoma.

An Extremely Rare Presentation of an Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma

Alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma (EAC) is an extremely rare occurrence with very few cases reported in the literature. We report the case of a 76-year-old female who presented with progressive weakness, fatigue, and a decrease in appetite for weeks and who was found to have an AFP-producing EAC with an extraordinarily high AFP level of 46,135 ng/mL. CT angiography revealed abnormal thickening of the esophagus and multiple metastatic masses throughout the liver. Upper endoscopy revealed a large mass in the distal esophagus with extension into the stomach. Biopsy confirmed the EAC. Most cases are unsuccessfully treated with surgery and chemotherapy. Serial measurement of serum AFP may be useful for monitoring clinical status and treatment response.

A case of a long-term survival achieved by surgical treatment and chemotherapy for late recurrence of AFP-producing gastric cancer

Background

Alpha-fetoprotein-producing gastric cancer (AFP-GC) is a relatively rare disease, with a dismal prognosis.

Case presentation

We report the case of a patient with long-term survival after surgery for the recurrence of AFP-GC. A 71-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy with D2 lymphadenectomy (pT3N2M0). Pathological examination of the resected specimen revealed AFP-GC. Fifteen years after the gastrectomy, the patient experienced anorexia and was admitted with a mass located at the mesentery of the small intestine. Following a diagnosis of gastrointestinal stromal tumor of the mesentery, a tumor resection with partial small intestine was performed. The final histopathological diagnosis was AFP-GC’s recurrence in the small-bowel mesentery. Two months later, multiple liver metastases were identified, and serum AFP level was found to be extremely high (17,447 ng/mL). Chemotherapy with S-1+CDDP (SP) was initiated for liver metastasis. However, owing to anorexia and fatigue, SP therapy was discontinued following the patient’s request at the end of two courses. A CT scan at 1 month after the discontinuation of chemotherapy did not reveal liver metastasis, and serum AFP level decreased to the normal range. He is alive at present with no re-recurrence and no elevation of serum AFP level at 7 years after the second surgery without any chemotherapy.

Conclusion

Even if recurrence of AFP-GC is diagnosed, radical resection and chemotherapy are effective, as noted in the present case.

Misdiagnosis of an α-fetoprotein-producing esophageal carcinoma: A case report and literature review

α-fetoprotein (AFP)-producing esophageal carcinoma is a rare type of esophageal cancer, with its characteristics not yet fully clarified. In the present study, a case of esophageal carcinoma was misdiagnosed as an AFP-producing esophageal carcinoma. The patient was a 50-year-old woman who was referred to Qianfoshan Hospital Affiliated to Shandong University in November 2014 with a 3-month history of progressive dysphagia. A chest computed tomography (CT) scan showed thickening of the wall of the esophagus, corresponding regions of luminal stenosis and massive lymph node swelling around the lesser curvature of the esophagus. A laboratory investigation showed that the serum AFP levels of the patient were elevated to 18.97 ng/ml (normal range <12 ng/ml). These laboratory investigation findings combined with the aforementioned pathological diagnosis supported a diagnosis of AFP-producing esophageal carcinoma. An abdominal ultrasound was performed and a cystic low-density measuring 5×4 mm was identified. No metastases were revealed in the liver. The boundary of the focal low density was clear, which indicated a clinical diagnosis of liver cyst. A radical esophagectomy was performed on December 5, 2014. Microscopically, the tumor was a moderately differentiated squamous cell carcinoma invading the serous layer, with no hepatoid features. Immunohistochemistry showed that the cells were diffusely negative for AFP expression. Histopathological examination revealed the absence of hepatoid features. According to these findings, the tumor was diagnosed as a moderately differentiated squamous cell carcinoma. In the present study, the case of a patient with squamous cell carcinoma that was misdiagnosed as an α-fetoprotein-producing esophageal carcinoma was reported, with a review of the literature.

AFP (alpha fetoprotein): who are you in gastrology?

AFP-producing (hepatoid differentiation) gastric cancer (GC) initially reported in 1970 plays an important role in the field of gastrology, which should be distinguished from other solid-type GCs owing to their different biological behavior. This review article aims to summarize the literature related to the role of AFP in gastric cancer and to unveil the underlying mechanism by which AFP-production impacts prognosis of GC patients. The prima facie evidence demonstrated that AFP-producing GC is more aggressive and characterized by a high incidence of venous invasion, lymphatic invasion, and metachronous and synchronous liver metastasis compared with AFP-non producing GC. Furthermore, distant metastasis was frequently observed, leading to a poorer overall prognosis. The underlying molecular mechanism is still obscure and optimal regimen remains undefined well. Nevertheless, our present study advances the knowledge of AFP-producing GC in the field of gastrology. AFP-positivity should be highlighted and an a priori enhancive intervention is needed to improve prognosis in future clinical practice. Personalized medication is strongly suggested.

Effects of transthoracic vs transabdominal hiatal approaches for treatment of esophago-gastric junction adenocarcinoma

AIM: To compare the effects of transthoracic and transabdominal hiatal approaches for the treatment of Siewert types Ⅱ and Ⅲ adenocarcinoma of the esophago-gastric junction.

METHODS: A total of 350 patients who were pathologically diagnosed with Siewert type Ⅱ or type Ⅲ adenocarcinoma of the esophago-gastric junction and underwent surgical treatment at our hospital were included, of whom 148 received surgery via the transthoracic approach (transthoracic group) and 202 received surgery via transabdominal hiatal approach (transabdominal hiatal group). Intraoperative parameters, postoperative recovery and complications were compared between the two groups of patients.

RESULTS: The number of patients receiving multi-visceral resection was more in the transabdominal hiatal group than in the transthoracic group (χ² = 12.744, P = 0.002), but the operative time, intraoperative blood loss, length of esophageal resection and number of patients receiving transfusion were lower in the transabdominal hiatal group (P = 0.039, 0.011, 0.009, 0.000). Postoperative pain score and antibiotic use duration in the transthoracic group were significantly higher than those in the transabdominal hiatal group (t = 5.879, 9.388, P = 0.005, 0.000), and the length of hospital stay, postoperative hospitalization cost, reoperation, and readmission rate showed the same trend (P = 0.027, 0.021, 0.048, 0.025). Although the rates of abdominal cavity infection and anastomotic stenosis showed no statistical differences between the two groups (χ² = 1.524, 0.149, P = 0.217, 0.700), the rates of lung infection, postoperative bleeding and anastomotic leakage were significantly higher in the transthoracic group than in the transabdominal hiatal group (χ² = 9.031, 9.031, 4.215, P = 0.003, 0.040, 0.024).

CONCLUSION: Patients with type Ⅱ or Ⅲ adenocarcinoma of the esophago-gastric junction treated via the transabdominal hiatal approach suffered from less intraoperative trauma and had quicker recovery and lower incidence of complications.