Korean J Gastroenterol.  2024 Dec;84(6):282-287. 10.4166/kjg.2024.091.

Metachronous Schnitzler’s Metastasis of Gastric Adenocarcinoma 13 Years After Curative Resection: A Case Report

• Lim JK
• Kim SB
• Shin HD

• KMID: 2563345
• DOI: http://doi.org/10.4166/kjg.2024.091

Abstract

A 54-year-old man presented with constipation with a six-month duration and a 5 kg weight loss over 10 months. He had undergone a subtotal gastrectomy and chemotherapy for advanced gastric cancer 13 years earlier. A colonoscopy revealed a firm, circular, in-growing mass in the rectum. A computed tomography (CT) scan showed a 3.0×1.2 cm invasive mass near the prostate, abutting the rectal wall and invading the right ureterovesical junction, causing hydroureteronephrosis. A positron emission tomography-CT scan indicated low fluorodeoxyglucose uptake in the rectal or prostate area. The biopsy results showed poorly differentiated carcinoma. An immunohistochemistry study confirmed CK7 positive, CK20 negative, MUC2 negative, and CDX2 focally positive immune phenotype for cancer cells, suggesting a diagnosis of metastatic adenocarcinoma with a gastric origin rather than a prostate and rectal origin.

Keyword

Gastric cancer; Late recurrence; Subtotal gastrectomy; Rectal metastasis; Schnitzler’s metastasis

Figure

• 

  Fig. 1 Colonoscopy findings. (A) In a colonoscopy performed two years earlier, an abnormality in the colon wall at the mid-rectum at the six o’clock position was observed, but it was overlooked at the time, and a biopsy was not performed. (B) Upon endoscope insertion, a firm concentric in-growing mass-like lesion with a significantly narrowed rectal lumen was observed at 10 cm from the AV. (C) The findings observed by retroflexion of the narrowed area show a stenotic area tightly constricted the endoscopic scope. (D) Redness, mucosal nodularity, and shallow ulceration were observed in the stricture area during scope withdrawal.

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  Fig. 2 Abdominopelvic CT findings. (A) Right hydronephrosis due to posterior wall invasion of the urinary bladder is shown. (B, C) A roughly sized 3.0×1.2 mass with focal periprostatic fatty infiltration and an abutting mass in the anterior wall of the rectum was observed, and concentric wall thickening was observed in the mid portion of the rectum. (D) In the coronal view, concentric wall thickening of the rectal wall.

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  Fig. 3 Rectal MRI findings. (A) Eccentric wall thickening of the urinary bladder base and a right dilated distal ureter are observed. (B, C) In addition to strong mucosal enhancement in the mid-rectum, concentric target-like wall thickening was observed, and invasion of the prostate, bilateral seminal vesicles, and mesorectal fascia were observed.

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  Fig. 4 PET-CT findings. (A) This Diffusely increased FDG uptake (SUL max 7.7) along the right renal parenchyma: Possibly induced by obstructive uropathy. (B, C) No significant evidence of well-defined hypermetabolic activity in and around the proximal rectal area: R/O Malignancy low FDG avidity possibly originated from stomach cancer.

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  Fig. 5 Pathology findings. (A) Section showed infiltration of poorly differentiated tumor cells with atypical hyperchromatic nuclei (H&E stain, 200×). (B) Tumor cells were diffusely positive for CK7 (CK7 stain, 200×). (C) Tumor cells negative for CK20 (CK20 stain, 200×). (D) Tumor cells negative for MUC2 (MUC2 stain, 200×).

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