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Gastric adenocarcinoma with direct liver invasion presented with hepatogastric fistula treated with gastric and hepatic resection: a case report
Apresentação do caso
Case report of a 70 years old female patient admitted with significant weight loss, epigastric pain and nausea. Upper gastrointestinal endoscopy revealed an extensive tumor with ulceration located in the gastric body, antrum and incisura angularis, with a pathologic report of high grade tubular adenocarcinoma. In workup exames, the computed tomography showed a gastric wall thickening with extensive antrum ulceration invading II/III/IV hepatic segments with 9.0 x 5.6 x 5.8 cm with gastric body communication, suggestive of hepatogastric fistula. After multidisciplinary discussion, considering the presence of a hepatogastric fistula, it was opted for upfront surgery with partial gastrectomy, partial hepatectomy and D2 lymphadenectomy. The histological findings showed a high-grade invasive tubular adenocarcinoma, intestinal-type with direct duodenal and liver invasion, with free resection margins, pT4b pN0. In post-operative recovery, after reinstatement of oral food intake, the patient was diagnosed with duodenal fistula, managed by clinical treatment with success. The patient is now being evaluated for adjuvant treatment.
Gastric cancer is the fifth most common malignancy in the world and remains the third cause of cancer-related deaths worldwide. Unfortunately, the diagnosis occurs at later stages leading to poor prognosis. The most common symptoms leading to gastric cancer diagnosis are abdominal pain, dysphagia and weight loss, however, even for locally advanced tumors, the presentation with hepatogastric fistula is considered rare, with few cases reported.
The association of surgery with perioperative chemotherapy has been the primary treatment option for locally advanced stages. However, in the event of a hepatogastric fistula, there is a risk of fistula communication to the abdominal cavity caused by the complete or partial pathologic response of the perioperative chemotherapy, with no consensus regarding the best option for treatment.
Considering the rarity of a hepatogastric fistula in locally advanced gastric tumors, there is no study with published results or in progress for the best management of these patients. Each case must be evaluated on an individual basis, taking into account the patient's performance status, the disease burden and the chances for the patient to complete the treatment, therefore, upfront surgery can be considered a viable option.
Gastric cancer, hepatogastric fistula, gastrectomy
VITORIA YURI MIAZAKI VILLANOVA, NICKSON DELLA GIUSTINA, EVELYN DELLA GIUSTINA, PAULO VICENTE HOFFMANN, ROGER KRUGER DE LIMA, PATRICIA DA COSTA CAMARA