Gastric cancer in a post pancreaticoduodenectomy patient with ATM mutation – interesting case

Abstract

Background: 50 y old female with past history of ampullary cancer diagnosed 10 years prior. Patient underwent a pancreaticoduodenectomy and pathology was consistent with a poorly differentiated T4 lesion which was node negative and margin negative with lymphovascular and perineural invasion. Patient underwent adjuvant chemotherapy followed by chemo-radiation. She was found to have ATM mutation on genetic panel analysis. She was lost to follow up after completing surveillance for 5 years. She presented with anemia several years later and underwent an endoscopy which revealed an ulcerated mass in the stomach just proximal to the gastrojejunal anastomosis. Methods: She underwent endoscopic ultrasound which revealed a T2 lesion and no significant regional lymphadenopathy. Patient underwent staging scans including a PET-CT which did not demonstrate metastatic disease. She underwent oncologic surveillance with mammography and pap smear and gynecologic examination. She was started on perioperative regimen of FLOT (5-FU/leucovorin/oxaliplatin/docetaxel) and was taken to the operating room after restaging scans. Results: She underwent an exploratory laparotomy, extensive lysis of adhesions, subtotal gastrectomy and roux-en-y reconstruction of the biliopancreatic limb and the alimentary limb as well as completion celiac, hepatic and splenic lymphadenectomy with feeding jejunostomy tube placement. Patient was discharged home with an uneventful postoperative recovery. Conclusion: Final pathology demonstrated poorly differentiated diffuse type gastric adenocarcinoma with submucosal invasion( T1N0) with negative margins . Patient to complete perioperative chemotherapy with FLOT and then proceed with surveillance.