Primary Gastric Malignancy Research Articles

A rare case of primary gastric Hodgkin lymphoma in an adolescent with Nijmegen breakage syndrome

BackgroundNijmegen Breakage Syndrome (NBS) is a rare autosomal recessive DNA repair disorder that increases risk of hematological malignancy. Primary gastric malignancies are exceedingly rare in pediatric patients and not typically high on the differential of abdominal pain.Case presentationA 14-year-old male with NBS presented with persistent abdominal pain and was diagnosed with primary Hodgkin disease of the stomach.ConclusionsIn pediatric patients with predisposition to malignancies, such as those with underlying chromosome instability disorders, all symptoms must be carefully considered.

Solitary metachronous adrenal metastasis after radical resection of gastric large cell neuroendocrine carcinoma: a case report and literature review

Surgical resection is rarely employed for the treatment of metastatic gastric cancer, especially in patients with adrenal metastases, which usually indicate advanced systemic dissemination. Few published case reports have thus described the use of adrenalectomy for adrenal metastases from gastric cancer. In addition, most primary gastric malignancies are gastric adenocarcinomas, and gastric large cell neuroendocrine carcinoma (GLCNEC) is less common and has a poor prognosis. We report the case of a 71-year-old man who was diagnosed with solitary adrenal metastases 10 months after radical resection for GLCNEC and who was treated by adrenalectomy. He was followed-up for 9 months after adrenalectomy, with no further evidence of disease at his last follow-up examination. This case indicates that elective surgical resection may be feasible, even in rare cases of GLCNEC metastases to the adrenal glands, provided that the patient meets certain criteria, including solitary, metachronous tumors less than 4 cm.

S2576 Application of Hemospray for Metastatic Bleeding Gastric Adenocarcinoma: A Case Report

Introduction: TC-325 hemostatic powder (Hemospray) is a mineral-based topical agent that acts as a mechanical barrier over a bleeding site. It is a non-invasive, safe, and effective modality in controlling active GI bleeding, with immediate response. Here, we present a case of bleeding metastatic gastric adenocarcinoma managed with Hemospray after the failure of standard endoscopic therapy. Case Description/Methods: A 64-year-old male presented to the emergency room (ER) for symptomatic anemia. His hemoglobin was 4.6 g/dL. CT imaging showed gastric cardia lesion with multiple hepatic metastases. After blood transfusion, EGD (Figure 1a) showed a cardia lesion with oozing blood from multiple sites. Endoscopic ultrasound with fine-needle aspiration, showing atypical cells. The patient continued to have melena requiring transfusions. CT angiogram was negative. Partial gastrectomy was not performed due to peritoneal carcinomatosis. Endoscopic hemostasis with epinephrine and clips failed (Figure 1b). Hemospray was deployed (Figure 1c) with an immediate response. Later patient underwent left gastric artery embolization (Figure 1d), liver biopsy and peritoneal node sampling that suggested metastatic adenocarcinoma with primary gastric malignancy. The patient and his family opted for palliative care and was discharged. Discussion: Gastric cancer accounts for 2-8% of overall UGIB and 58% bleeding risk compared to other GI malignancies. There are no specific guidelines and only limited evidence was available on managing malignancy-related UGIB. Nonresponsive, inoperable metastatic gastric cancer bleeding is challenging and extremely difficult to manage using conventional hemostasis techniques. Based on our case, we recommend utilizing Hemospray as a first-line, monotherapy or in combination to control bleeding until a definitive treatment, reducing morbidity and mortality.Figure 1.: (A) Submucosal gastric fundal mass distal to gastroesophageal junction with blood oozing from multiple sites (arrows), (B) Image showing endoscopic hemostatic clips placement (arrowheads), (C) Application of Hemospray over the Gastric Mass after unsuccessful attempts using standard-of-care hemostatic methods, (D) Showing embolization of the left gastroepiploic artery.

Metastases to the Stomach: Clinicopathologic Features of Metastases Mimicking Gastric Primaries.

Metastatic involvement of the stomach is a rare event. Our aim in this study was to document the clinicopathological findings in patients with gastric metastases and find out if there are any potentially significant features to be used in the differential diagnosis. Our cohort consisted of 17 histologically verified gastric metastasis cases. Clinical, endoscopic and microscopic features were retrospectively analyzed. The primary sites were the breast, skin, lungs, ovaries, colon, and gluteal soft tissue. Three patients were symptomatic because of the metastatic involvement of the stomach and 9 patients had concomitant metastasis in other sites. Invasive lobular breast carcinoma and malignant melanoma were the most common metastatic malignancies. The most common macroscopic appearance was the diffuse infiltrative type (Borrmann Type 4). Most of the metastatic lesions endoscopically mimicked primary gastric cancer. Furthermore, some of the metastatic lesions, particularly invasive lobular carcinoma of the breast and malignant melanoma, displayed histopathologic features similar to the primary gastric malignancies to a certain extent. The possibility of metastatic involvement of stomach must be kept in mind while dealing with a gastric mass lesion in a cancer patient, even though the clinical and endoscopic features suggest primary gastric cancer. Our study points out the importance of conveying the information about medical history and clinical findings of the patients for correct pathologic differential diagnosis.

Synchronous multiple primary gallbladder and gastric malignancies: Report of two cases and review of the literature

Multiple primary malignancies (MPM) are rare. In particular, synchronous gallbladder and gastric malignancies are extremely rare, are associated with a concealed onset and atypical symptoms, and are highly likely to be overlooked or misdiagnosed. The clinical data of two patients with synchronous gallbladder and gastric malignancies are herein reported and integrated with the relevant literature to retrospectively analyze and summarize the pathogenesis and clinical characteristics of MPM. Case 1 was a male 46-year-old patient who underwent laparoscopic cholecystectomy, and succumbed to extensive tumor metastasis 2 months after the operation. Case 2 was an 80-year-old female patient who was treated with distal gastrectomy for gastric cancer, cholecystectomy, gastrojejunostomy and dissection of 5 suprapyloric, 6 subpyloric, 7 left gastric and 8 common hepatic artery lymph nodes, and succumbed to multiple organ failure induced by extensive tumor invasion within 1 week after the operation. Clinical physicians must pay closer attention to early symptoms of MPM in order to make an accurate diagnosis, perform timely radical surgical treatment and achieve favorable therapeutic outcomes, in terms of significantly increasing long-term patient survival rates.

Inflammatory Fibroid Polyp of the Stomach Mimics Malignancy on 18F FDG PET/CT Imaging

Inflammatory fibroid polyps (IFPs) are rare non-neoplastic and proliferating submucosal lesions of the gastrointestinal tract. The classic IFP, which was first described by Vanek, consists of prominent blood vessels and is characterized by a heavy inflammatory infiltrate, which is rich in eosinophilic granulocytes. The clinical presentation depends on the size and location. Inflammatory fibroid polyps cannot be differentiated from malignancy without histological examination. We report a case of IFP in the stomach that mimicked a primary gastric malignancy showing an increased F-FDG uptake.

A case of two primary gastric malignancies: adenocarcinoma and squamous cell carcinoma of the stomach

D Gastric cancer is the second leading cause of death from cancer worldwide. Despite this fact, there has been an overall decrease in the incidence of gastric cancer over the past few decades.1 Therefore, it is important to understand the different histological manifestations of the disease. The most common form of gastric cancer is adenocarcinoma. In contrast, squamous cell carcinoma of the stomach is rare and has been described in numerous case reports.2,3 In addition, cases of rimary gastric adenosquamous carcinoma also have been eported.4,5 We present a case of a woman with two gastric tumors in separate locations with different histological characteristics; one an adenocarcinoma, the other squamous cell carcinoma. To our knowledge there are no reported cases of two separate gastric primary tumors consisting of these two pathologic diagnoses.

Endoskopik Ultrasonografik İnce İğne Aspirasyon Biyopsisi ile Mediastinal Lenf Nodundan Mide Kanseri Tanısı Konulan Bir Kronik Öksürük Vakası

A 57-year-old woman presented with the complaint of chronic cough. She had no history of hemoptysis, night sweats, anorexia, dysphagia, vomiting or epigastric pain. Computed tomography showed multiple mediastinal lymph nodes (LNs). The bronchoscopic examination showed no endobronchial lesions. Endoscopic ultrasonography easily visualized the mediastinal LNs, and endoscopic ultrasonography-guided fine needle aspiration of subcarinal lymph node provided tissue diagnosis of a mucinous adenocarcinoma consistent with gastrointestinal origin. Although the patient denied any stomach complaints, subsequent gastroscopy revealed a primary gastric malignancy. The current case is unique in that a pulmonary symptom was the presenting sign of an unknown primary carcinoma. In contrast to previously reported cases, the patient had no gastrointestinal or systemic symptoms. Manifestation of metastatic disease process as mediastinal LNs was also unusual. Endoscopic ultrasonography-guided fine needle aspiration enabled the diagnosis of mucinous adenocarcinoma, leading to discovery of the primary gastric malignancy.

“Burned out” testicular seminoma presenting as a primary gastric malignancy

In contrast to primary gastric adenocarcinomas, germ cell tumors are potentially curable even when metastatic. It is therefore essential for clinicians and pathologists to be aware of the spectrum of unusual manifestations of germ cell malignancies. Here we report on a 55-year-old man who presented with clinical and endoscopic features indicative of a primary gastric carcinoma. Surprisingly, the ulcerative mucosal lesion was found to be due to a metastasis from an occult, "burned-out" testicular seminoma. This case describes the radiological and pathological features that helped differentiate this rare situation from the much more common gastric adenocarcinoma, and extends the diagnostic possibilities that must be considered in patients presenting with gastric ulcers.

Improving Evaluation of Primary Gastric Malignancies by Distending the Stomach with Milk Immediately Before 18F-FDG PET Scanning

This study was designed to investigate the feasibility and effectiveness of a modified protocol for (18)F-FDG PET that was proposed to improve the identification of primary gastric malignancies. In the modified protocol, patients were asked to drink 300-500 mL of cow milk to distend the stomach immediately before PET scans instead of fasting all along. For investigation of the influence of ingested milk on (18)F-FDG distributions, 43 nondiabetic patients without documented gastric diseases underwent both empty- and distended-stomach PET scans (79 and 72 scans, respectively) in their serial follow-up studies. For the evaluation of proven gastric malignancies, 24 patients who underwent distended-stomach PET scans were compared with 17 patients who underwent conventional empty-stomach examinations. Ingestion of milk nearly 1 h after (18)F-FDG injection had no significant influence on distributions to the heart (P = 0.16), mediastinum (P = 0.50), and liver (P = 0.49), whereas the percentages of intense and moderate uptake in the stomach changed from 38.0% and 59.5% to 0% and 11.1%, respectively. With the normal gastric wall distended, malignant lesions were observed with higher contrast and clearer outlines, and some of them were detected at a small size (1.2 cm) at an early stage and with mild uptake. Gastric distention with milk just before (18)F-FDG PET is a simple and effective method for improving the evaluation of primary gastric malignancies.

Metastatic Melanoma in a Dialysis Patient with Vomiting Diagnosed by Gastric Polyp Biopsy

Purpose: Gastric polyps are a common incidental finding on upper endoscopy. Although the majority of these polyps are benign, rarely they represent primary gastric malignancy, lymphoma or even metastatic disease. We describe a case of metastatic melanoma without a primary cutaneous lesion diagnosed by endoscopic biopsy of a gastric polyp. Case Summary: A sixty-three year old Irish female with past medical history significant for coronary artery disease, hypertension and end stage renal disease requiring dialysis presented with complaints of intermittent vomiting for two weeks. Her vomiting was not associated with food and she denied nausea, wretching, weight loss, hematemesis or melena. Physical examination including a thorough neurologic, ophthalmic and dermatologic exam was performed which was normal. Comprehensive metabolic panel and complete blood count were within normal limits. An upper endoscopy was performed which revealed multiple 5 mm polyps in the body of the stomach. Histology of the polyps revealed that they were malignant and special stains were positive for vimentin, HMB45, S100, Melan A, and CEA consistent with metastatic melanoma. Computerized tomography (CT) of the chest/abdomen and pelvis were within normal limits. CT of the brain revealed calcified/hemorrhagic lesions consistent with metastatic disease. Conclusion: Gastric polyps are a common finding on upper endoscopy occurring in 2.5% of cases, most of which are hyperplastic. Metastatic disease to the stomach is rare, but has been described with breast cancer, renal cell carcinoma and melanoma. Metastatic melanoma is usually from the skin but, can be secondary to non-cutaneous lesions such as those of ocular and mucosal origin. Primary gastric melanoma has been reported but usually is seen as a large ulcerated mass. In our case no primary lesion could be identified likely, secondary to regression of a primary cutaneous lesion as occurs in 2% of melanoma cases. Our case highlights that although most gastric polyps are benign, gastric cancer and metastatic disease must always be entertained and biopsy should be considered.

Symptomatic gastric heterotopic pancreas: Clinical presentation and review of the literature

Heterotopic pancreas is usually asymptomatic. Associated complications include ulceration, bleeding and obstruction, especially gastric outlet obstruction. Acute and chronic pancreatitis including malignant change have been reported. These lesions are often difficult to differentiate clinically from other gastrointestinal diseases including primary gastric malignancy. Histological examination is mandatory to make a correct diagnosis. Limited surgical excision has been shown to be safe and adequate for heterotopic pancreas. We present a patient with heterotopic pancreas who presented with a non-healing gastric ulcer.

Gastric Distension by Ingesting Food Is Useful in the Evaluation of Primary Gastric Cancer by FDG PET

Gastric carcinoma is the second leading cause of cancer-related death worldwide. Detection and surgical resection of gastric cancer in the early stage provides the only hope for improved survival in patients with gastric cancer. Positron emission tomography (PET) with F-18 2-deoxy-2-fluoro-D-glucose (FDG) has been shown to be essential in the evaluation of a variety of malignancies. However, conventional FDG PET has limited value for detecting a primary tumor of the stomach, mostly because of the relatively high levels of physiological uptake by the contracted stomach. We report 3 cases of primary gastric carcinomas detected successfully by FDG PET after the ingestion of food. The PET images of the stomach after ingesting food were compared with the routine fasting-state whole-body PET images for each patient. When the stomach was distended by food, the malignant lesions were more discernible. These cases indicate that gastric distension by ingesting food may be a simple method that can help to detect a primary gastric malignancy by FDG PET.

Unusual Presentation of Gastric Adenocarcinoma Metastatic to the Orbit

A 69-year-old woman with no history of malignant disease presented with complaints of ptosis, diplopia, and left upper eyelid fullness. Computed tomography showed soft tissue infiltration of the left superior orbit. Biopsy was performed through an anterior orbitotomy. Histopathology revealed a mucinous adenocarcinoma. Subsequent systemic evaluation included esophagogastroduodenoscopy, which revealed a primary gastric malignancy.

Intraoperative radiotherapy for treatment of locally advanced and recurrent esophageal and gastric adenocarcinomas

Intraoperative radiotherapy (IORT) allows delivery of radiotherapy doses in excess of those typically deliverable with conventional external beam radiotherapy. IORT has potential utility in clinical situations, such as treatment of esophageal and gastric malignancies, in which the radiation tolerance of normal organs limits the dose that can be given with conventional radiotherapy techniques. We reviewed the records of 50 patients who received IORT for locally advanced primary or recurrent gastric or esophageal adenocarcinomas deemed unresectable for cure. IORT was given as a single fraction of electron beam radiotherapy (10-25 Gy) after maximal tumor resection: R0 in 42%, R1 in 46%, and R2 in 12%. Forty-eight patients also received external beam radiotherapy (8-55 Gy), 46 received radiosensitizing chemotherapy, and nine received systemic chemotherapy after radiotherapy. Outcomes were estimated with Kaplan-Meier analysis. Median survival was 1.6 years. Overall survival at 1, 2, and 3 years was 70%, 40%, and 27%. Of 42 patients who died, 37 died from cancer progression and three from multifactorial treatment toxicity. Median survival for patients with recurrent disease versus primary disease was 3.0 years versus 1.3 years (P < 0.05), with a delay of metastatic failure in patients with recurrent tumors (P = 0.06). At 3 years, distant metastatic failure was 79%, local failure was 10%, and regional failure was 15%. IORT for locally advanced primary or recurrent gastric malignancies effectively decreases the risk of local failure. For patients with isolated local recurrences, IORT may be effective salvage therapy. However, more effective systemic therapy is needed as a component of treatment.

Spontaneous Gastrosplenic Fistula in Primary Gastric Lymphoma: Surgical Management

Gastrosplenic fistula formation resulting from primary gastric malignancy is rare and should be managed as a matter of emergency. We report a patient who was diagnosed with primary non-Hodgkin's lymphoma and who underwent surgical treatment for gastrosplenic fistula.

New coil concept for endoluminal MR imaging

Our aim was to conduct a prospective study to evaluate staging accuracy of a new coil concept for endoluminal magnetic resonance imaging (MRI) on ex vivo gastric carcinomas. Twenty-eight consecutive patients referred to surgery with a clinically proven primary gastric malignancy were included. Surgical specimens were examined with a foldable and self-expanding loop coil (8-cm diameter) at 1.5 Tesla immediately after total gastrectomy. T1- and T2-weighted and opposed-phase sequences (axial, frontal sections; 3- to 4-mm slice thickness) were acquired. Investigators blinded to any patient information analyzed signal intensity of normal gastric wall, gastric tumor, and lymph nodes. Findings were compared with histopathological staging. On surgical specimens, 2–5 gastric wall layers could be visualized. All gastric tumors (26 carcinomas, two lymphomas) were identified on endoluminal MR data (100%). Overall accuracy for T staging was 75% (18/24); sensitivity to detect serosal involvement was 80% and specificity 89%. N staging correlated in 58% (14/24) with histopathology (N+ versus N−). The endoluminal coil concept is feasible and applicable for an ex vivo setting. Endoluminal MR data provided sufficient detail for gastric wall layer differentiation, and therefore, identification of T stages in gastric carcinoma is possible. Further investigations in in vivo settings should explore the potential of our coil concept for endoluminal MR imaging.

Secondary signet-ring cell tumour of the prostate derived from a primary gastric malignancy

Primary signet-ring cell carcinoma of the prostate is infrequent and even more so as secondary spread of this pathologic sub-type to the prostate. We describe the sixth reported case with a diagnosis of a secondary signet-ring cell tumour of the prostate secondary to a gastric cancer. Five years post-gastrectomy to resect signet-ring cell carcinoma, we detected a secondary intra-prostatic spread with urinary tract obstruction. The physical appearance of the tumour cells was similar to that of the previously-resected signet-cell carcinoma of the stomach. There were no metastases in other sites and the patient was treated with radiotherapy. When confronted with intra-prostatic signet-ring cell adenocarcinoma it is necessary to distinguish between primary and secondary aetiology since this would reflect in the choice of treatment and prognosis.

Primary gastric lymphoma in Jordan with special emphasis on descriptive epidemiology

The aim of this study was to examine the clinicopathological features and epidemiology of primary gastric lymphoma in Jordan as a model for Middle East countries where such data is scarce. From 1991--2002, 219 patients with primary gastric malignancy were managed at our hospitals. Among these there were 19 patients with primary gastric lymphoma. Pertinent data for these patients were analyzed. Primary gastric lymphoma constituted 65.5% of all gastrointestinal lymphoma and 8.7% of all gastric malignancies. Male-to-female ratio was 2.8:1. The mean age was 56 years (range 39--82). The incidence was 0.6/100,000. The proximal third was the most common localisation. Abdominal pain was the commonest presentation. Low-grade MALT lymphomas, high-grade MALT lymphomas, diffuse large cell B lymphomas and T cell lymphoma were found in 21.1, 26.3, 47.4 and 5.3%, respectively. Nine patients had gastrectomy followed by chemotherapy, 6 patients had palliative resection, 3 patients had chemotherapy only and the remaining patient was treated with Helicobacter pylori eradication. The mean follow-up for all patients was 42.2 months. The 5-year survival rates for stages IE (n=5), IIE (n=4), IIIE (n=6) and IVE (n=4) were 100, 67, 27 and 0%, respectively (p=0.0003). The overall 5 years survival was 48.2%. Primary gastric lymphoma in Jordan shares some epidemiological features with western disease. Jordanian patients are detected and treated after a relatively long delay. Advanced stage at diagnosis correlated with poor outcome. There is a need of an earlier diagnosis and subsequent better care.

Metastatic breast cancer masquerading as gastrointestinal primary

Seven patients with metastatic breast cancer presenting as gastrointestinal primary are described. These included six gastric and one colonic lesions. None of the patients had known systemic metastases at the time of diagnosis. The mean age at presentation was 66.7 yr (range 55–78). Median interval between breast cancer and gastrointestinal metastasis diagnosis was 6 yr (range 0.25–12.5). Original breast cancer histology included infiltrating lobular cancer (n = 4), infiltrating ductal cancer (n = 1), and a mixed type (n = 2). All patients with gastric involvement presented with epigastric pain and early satiety; the patient with colonic involvement had heme-positive stool. In three cases of gastric tumor and the one case of colonic tumor presentation, a definitive diagnosis of metastatic breast cancer was only confirmed after surgical resection of a presumed primary gastric or colonic malignancy. In the other three cases, pathological diagnostic confirmation was obtained through endoscopic biopsies and comparison to breast biopsy material, and operative treatment was avoided in favor of systemic cytotoxic therapy. The diagnosis was confirmed through similarities between mammary and gastric histopathology with regard to growth pattern, hormone receptor status, or gross cystic disease fluid protein. A high level of suspicion for metastatic breast cancer and a detailed pathological analysis will help avoid unnecessary surgical treatment in patients with a history of mammary carcinoma presenting with a newly diagnosed gastrointestinal neoplasm.