Second case report of a metachronous double primary gastric cancer

Abstract

A 72-year-old man was referred to the authors' hospital in December 1999 with a 2–3-month history of dyspepsia, abdominal bloating and loss of appetite. Upper gastrointestinal endoscopy with biopsy revealed a moderate active atrophic gastritis with widespread intestinal metaplasia. Gastric biopsies also showed the presence of Helicobacter pylori which was subsequently treated with standard triple therapy. His symptoms improved with H. pylori eradication treatment and a subsequent 6-month follow-up endoscopy with biopsy showed no evidence of residual gastritis or H. pylori infection. He re-presented with similar symptoms 18 months later and a repeat upper gastrointestinal endoscopy showed a diffuse lesion in the gastric fundus. Histological biopsy showed features consistent with a highgrade diffuse non-Hodgkin's lymphoma of the stomach (Figure 1). There was no evidence of further H. pylori infection. A subsequent staging whole body computed tomography scan and laparoscopy revealed no other lymphoid tissue involvement. Omental biopsies undertaken at laparoscopy showed focal infiltration by malignant non-Hodgkin's lymphoma. Immunohistochemistry showed the cells to be CD20 (a B-cell lymphoid marker) positive and CD3 (a T-cell lymphoid marker) negative, confirming the tumour to be a non-Hodgkin's lymphoma of B-cell type. Immunohistochemistry of bone marrow aspirates showed no evidence of infiltration. He was treated with 6 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) chemotherapy in November 2001. A carbon-13-urea breath test in December 2001 was negative. Repeat gastroscopy 4 months after starting chemotherapy showed only erosive gastritis at the gastro-oesophageal junction with no histological evidence of residual lymphoma. Subsequently, the patient's body weight started to increase and his initial symptoms resolved. A surveillance gastroscopy in October 2002 showed a new ulcerative lesion at the incisura of the stomach. Initially, this was thought to be a recurrence of the non-Hodgkin's lymphoma. However, subsequent histology of this lesion showed features of a gastric mucinous adenocarcinoma with signet ring features (Figure 2). He then underwent a subtotal gastrectomy and histological examination of the resected stomach confirmed the presence of a gastric adenocarcinoma with no residual non-Hodgkin's lymphoma. He made a good postoperative recovery and was further treated with chemoradiotherapy. Unfortunately the patient developed a recurrence of the adenocarcinoma in the gastric remnant 3 years later. He is currently alive and has declined any further treatment.