Metastatic Gastric Signet Ring Cell Adenocarcinoma Masquerading as Low Back Pain.

Sarah Burroughs,Edward James,Robert Post

doi:10.7759/cureus.11297

Abstract

This case report describes a 53-year-old Hispanic male who initially presented with acute hip pain. During workup, sclerotic bone lesions of the lumbar spine were identified on computed tomography (CT) in addition to extensive adenopathy involving the chest and abdomen. Upper endoscopy revealed chronic active gastritis, however, biopsies were negative for malignancy. Eventual bone marrow biopsy showed extensive infiltration by sheets of malignant epithelial cells with signet ring cell formation. Not only is this case significant for maintaining a broad differential in patients presenting with bone pain, but it also demonstrates a diagnosis of metastatic signet ring cell adenocarcinoma confirmed on bone marrow biopsy, which was not detected via earlier endoscopy.

Highlights

Gastric cancer is one of the most common cancers worldwide and the leading cause of death until the 1980s
Eventual bone marrow biopsy showed extensive infiltration by sheets of malignant epithelial cells with signet ring cell formation. Is this case significant for maintaining a broad differential in patients presenting with bone pain, but it demonstrates a diagnosis of metastatic signet ring cell adenocarcinoma confirmed on bone marrow biopsy, which was not detected via earlier endoscopy
While metastasis to the bone does occur with gastric cancer, extensive bone marrow infiltration as the initial presentation without preceding gastrointestinal symptoms is rare

Summary

Introduction

Gastric cancer is one of the most common cancers worldwide and the leading cause of death until the 1980s. The presentation of metastatic signet ring cell gastric cancer as bone pain without these preceding symptoms is rare. Tissue diagnosis to confirm gastric cancer is best obtained by upper gastrointestinal endoscopy with biopsies of any suspicious-appearing gastric ulceration or mass. This case highlights the importance of establishing a wide differential when approaching a patient with bone pain, as well as demonstrating the diagnosis of a malignancy via bone marrow biopsy, not otherwise diagnosed on biopsy of the primary site. Bone marrow biopsy of the right iliac crest revealed metastatic signet ring cell adenocarcinoma consistent with gastrointestinal primary (Figure 2). After confirmed signet cell carcinoma diagnosis, the patient began the leucovorin, fluorouracil, and oxaliplatin (FOLFOX) regimen, which he successfully completed and was discharged home He was unable to undergo genetic testing for CDH1 mutation given financial constraints. After extensive discussion with the patient and family, he was discharged home with hospice

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