Metastatic Gastric Cancer Presenting as Periorbital Edema

Abstract

A 53 year old male presented with recent labs and imaging concerning for periorbital cellulitis. The patient was initially admitted by ophthalmology and managed with antibiotics. He displayed minimal improvement with antibiotics, leading to the addition of systemic steroids. His condition deteriorated the following day when he developed hematemesis. Antibiotics were therefore escalated with the addition of IV Pantoprazole, and steroids were discontinued. EGD showed a large, non-bleeding ulcer with a visible vessel in the gastric body. Small, clean-based ulcers were also seen in the body and antrum. Diffuse, friable mucosa was noted throughout the stomach and biopsies were taken due to concern for malignancy. Right orbital biopsy and CT chest/abdomen/pelvis was also ordered to further evaluate for malignancy. CT showed bilateral pulmonary emboli, retroperitoneal soft tissue infiltrates, and bladder and colonic wall thickening. The patient's hematemesis recurred, necessitating repeat EGD with epinephrine injections and bipolar cautery in order to achieve hemostasis. Gastric biopsies revealed invasive and poorly differentiated Signet Ring Cell Carcinoma (SRCC) with a background of severe ulcerated gastritis and H. pylori. Antibiotics were de-escalated and tailored to treat H. Pylori. Colonoscopy was performed given CT findings of circumferential stenosis within the ascending and transverse colon. Colonic and right orbit biopsies were consistent with metastatic SRCC. The patient was discharged home after the initial work up with future plans for orbital radiation, chemotherapy initiation, and repeat EGD. The number of cases of gastric SRCC has steadily increased over the last few decades, despite an overall decline in incidence in gastric cancer worldwide. SRCC is a distinct diffuse-type gastric adenocarcinoma based on its histological and clinical features. Patients typically present in advanced stages and carry a poor prognosis. Synchronous SRCC is rare, although the colon appears to be the most common synchronous cancer associated with gastric SRCC. Gastric SRCC has a predilection for metastasis to the peritoneum, lung, bladder, and in rare cases the optic nerve. H. Pylori may be associated with SRCC; treatment of H. Pylori improves mucosal healing and may aid in interventional therapies. This case represents a unique presentation of an advanced stage synchronous gastric and colonic SRCC.2661_A Figure 1. Periorbital edema of the right eye.2661_B Figure 2. Malignant ulcer with visible vessel and active bleeding. Friable mucosa surrounding ulcer.2661_C Figure 3. Orbital biopsy showing metastatic signet ring cell carcinoma (H&E, 400x).