2679 An Unusual Presentation of Invasive Gastric Adenocarcinoma

Abstract

INTRODUCTION: Gastric cancer rarely occurs before the age of 40, but it’s incidence rises thereafter and peaks in the seventh decade of life. Most patients with gastric cancer in the United States are symptomatic and already have advanced disease at the time of presentation. We present a case where neither the patient history nor physical exam provided any early indication to the diagnosis of gastric adenocarcinoma. CASE DESCRIPTION/METHODS: A 32-year old Jamaican female was admitted for right lower quadrant abdominal pain since five days. Pain was constant, sharp, radiating from the pelvis to lower back. Review of systems was positive for dyspnea on exertion and 35-pound weight loss over past 3 months. She denied any past medical or surgical history, alcohol and tobacco use. Family history was significant for breast cancer in an aunt. On physical exam patient was afebrile, blood pressure and pulse were 120/76 mmhg and 86/min respectively. She had right lower quadrant tenderness on deep palpation but rest of the physical exam was unremarkable. CT thorax, abdomen and pelvis was negative for PE but demonstrated mediastinal, hilar, retroperitoneal and mesenteric lymphadenopathy. Infectious and autoimmune workup were unremarkable. Endoscopic intervention revealed a 7 cm ulcerated friable gastric mass near the pylorus and internal hemorrhoids on colonoscopy. Biopsy of the mass revealed poorly differentiated gastric adenocarcinoma. Hospital course was complicated with pericardial tamponade. Pericardial biopsy revealed metastatic poorly differentiated carcinoma. Patient was not a candidate for chemotherapy as she was spiking fevers on antibiotics. After over a month long hospital course, patient succumbed to multi-organ dysfunction related to her malignancy. DISCUSSION: Greater than 50% of patients present with unresectable locally advanced or metastatic gastric adenocarcinoma. The American Society for Gastrointestinal Endoscopy recommends endoscopic surveillance for high-risk individuals. Mass endoscopic/radiologic screening is not recommended in United states. Patients with advanced stage IV disease as in our patient, are usually referred for palliative therapy depending on their functional status. Our case illustrates an unusual presentation of a primary gastric mass, however with careful history, physical examination and timely endoscopic intervention, we can possibly prevent the significant delay in diagnosis and allow for timely management of gastric adenocarcinoma.