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Case 286

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71 year-old female patient, former smoker, refers postprandial fullness, early satiety, weight loss (15kg in 5 months) and adynamia. Physical examination reveals emaciation, pallor and a palpable epigastric mass, hardened and mobile, with 6cm in diameter. Upper gastrointestinal (UGI) endoscopy showed ulcero-infiltrative lesion, with 5cm in extension, occupying the whole circumference of stomach's distal-third. Histology was inconclusive for gastric cancer. Abdominopelvic computerized tomography (CT) was requested, as shown.

After analyzing the clinical data and the images, which one is the most likely diagnosis?

a) Gastric large B-cell lymphoma

25%

b) Diffuse type gastric adenocarcinoma (Lauren classification)

25%

c) Intestinal type gastric adenocarcinoma (Lauren classification)

25%

d) Corrosive antritis

25%
   

Image analysis

Image 1: Abdominal computerized tomography, axial plane, without iodine-based intravenous (IV) contrast, at the level of gastric antrum and body. Gastric wall circumferential thickening at this level, highlighted in red.

 


Image 2: Abdominal computerized tomography, axial plane, after injecting iodine-based IV contrast, at the level of gastric antrum and body. Gastric wall circumferential thickening showing contrast impregnation and causing local reduction on lumen diameter - highlighted in red. Absence of hepatic alterations or regional lymphadenomegaly. Small radiodense concentration inside the gallbladder (red arrow) - cholecystolithiasis.

 


Image 3: Abdominopelvic computerized tomography, coronal reconstruction, after injecting iodine-based IV contrast, at the level of gastric antrum and body. Gastric diffuse parietal thickening (highlighted in pink) mainly in the distal portion and in the antrum region, where it causes reduction on lumen diameter (red arrows).

Highlights

- Gastric cancer (GC) is highly prevalent, with high death rates still and estimated 5 years survival smaller than 10% in advanced cases;
- Clinical manifestations occurs late and are unspecific. When present, they consist of epigastric pain, postprandial fullness, early satiety and weight loss;
- UGI endoscopy with multiple biopsies is the main diagnostic method. If inconclusive, correlation with image exams is needed;
- Lauren histologic classification for adenocarcinoma in intestinal and diffuse types is extremely important to treatment and prognosis definition;
- Surgical resection is the only curative treatment with for GC. Gastrectomy and lymph node dissection extension are determined by the tumor's localization, histological type and stage.

References

- Sabiston textbook of surgery : the biological basis of modern surgical practice / [edited by] Courtney M. Townsend, Jr, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox.—20th ed. Elsevier 2017.
- C. Burgain et al.: Computed tomography features of gastrointestinal linitis. Abdom Radiol. Published Online in January 2016.
- Ferro, RAF; Tomografia computadorizada helicoidal com contraste hídrico no carcinoma gástrico. Estadiamento tumoral pré-operatório e aspecto tomográfico dos tipos histológicos de Laurén. Masters dissertation. FM-UFMG 2007.
- Cutsem EV, Sagaert X, Topa B, Haustermans K, Prenen H; Gastric Cancer; Lancet 2016, 26: 2654–2664.

Author

Eduardo José Paolinelli Vaz de Oliveira, 5th year medical student at Universidade Federal de Minas Gerais.
Email: eduardopaolinelli[at]gmail.com

Supervisor

Marco Antônio Gonçalves Rodrigues, MD, Ph.D., Associated Professor and Doctor of the Department of Surgery at the Medical School of Universidade Federal de Minas Gerais. Coordinator of the Esophagus, Stomach and Duodenum Group of the Alfa Institute of Gastroenterology (UFMG).
Email: magro.mg[at]terra.com.br

Reviewers

Bruno Santos, Giovanna Vieira, Lucas Bruno Rezende, Ariádna Andrade, Dr. José Nelson Mendes Vieira, MD, Ph.D., Dr. Viviane Parisotto, MD, Ph.D.

Translated by

Bruno Campos Santos, 4th year medical student at Universidade Federal de Minas Gerais.
E-mail: bruno_campos[at]outlook.com

Test question

(Medical Residence 2017 - Universidade Federal de São Paulo) 65 year-old female, referring epigastric pain for 3 months, performed an UGI endoscopy which found ulcerative lesion with 2,2cm in gastric fundus. Histologic report confirmed indifference gastric adenocarcinoma, with signet-ring cells. CT showed just gastric lesion, without metastasis. 
Patient should be submitted to:

a) Total gastrectomy with D2 lymphadenectomy

25%

b) Neoadjuvant chemoradiotherapy

25%

c) Endoscopic mucosectomy

25%

d) Subtotal gastrectomy with D2 lymphadenectomy

25%

e) None

25%
   

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