2705 Incidental Finding of Gastric Adenocarcinoma on Random Gastric Biopsy: A Call for Methodical Examination of the Gastric Mucosa

Abstract

INTRODUCTION: Gastric cancer is the 5th most common neoplasm and the 3rd most deadly cancer worldwide. Adenocarcinomas account for 95% of cases. It is more prevalent and has a higher mortality in males. We present a case of gastric adenocarcinoma detected incidentally on random gastric biopsy. CASE DESCRIPTION/METHODS: A 73-year old white male underwent upper endoscopy for reflux. He had a 55-pack year smoking history, no significant alcohol use, and normal BMI. Esophagogastroduodenoscopy (EGD) revealed a 4 mm hypopigmented area in the incisura and was otherwise normal. Random gastric biopsies included the area. One of 6 specimens revealed intramucosal adenocarcinoma in a background of intestinal metaplasia, and H. pylori organisms. It involved the lamina propria and was suspicious for invasion. On repeat EGD 11 days later, previous biopsy sites were seen showing some fibrosis, likely given the short interval between endoscopies. Frozen section biopsy of the incisura confirmed cancer. Due absence of a visible lesion, the site was biopsied extensively and tattooed prior to surgical referral. The patient underwent distal gastrectomy with Roux en Y reconstruction and lymphadenectomy. The surgical specimens showed no residual malignancy, negative and viable margins, and benign lymph nodes. Quadruple therapy successfully eradicated H. pylori. DISCUSSION: The incidence of gastric cancer in North America is 5.6 per 100,000, higher than that for esophageal cancer. The 5-year survival rate in the US is 31%, reflecting that most diagnoses are made when the cancer has metastasized. This rate increases dramatically to 94% and 88% when stage IA and IB tumors are surgically treated, respectively. Early gastric cancer can be subtle in appearance and may be missed during routine endoscopy. Retrospective studies comparing examination time for EGD reveal that endoscopists with longer mean exam (longer than 7 min in the US, 3 min in Korea) detect more neoplastic lesions than shorter exams. The European Society of Gastrointestinal Endoscopy to recommends an examination time of 7 minutes from intubation of the esophagus to extubation. This case highlights (1) that a comprehensive systematic exam must be consistently performed to investigate the entire stomach, (2) the importance of NBI with near focus mode to closely examine mucosal vascularization and pit pattern in order to diagnosis of a small malignant lesions, and (3) the need for targeted biopsies to be placed in separate jars.