Pages

Tuesday, February 9, 2016

A Case Of Gastric Carcinoma

A 72-year-old Japanese immigrant was brought in by his family with complaints of difficulty in eating, vague abdominal pain, and weight loss. Endoscopy and biopsy confirmed gastric adenocarcinoma. Liver metastases were found on abdominal CT. The family and the patient chose only comfort measures and the patient died 6 months later.


Case Discussion:  

Introduction: Gastric cancer is a malignant neoplasm of the stomach, usually adenocarcinoma..

Epidemiology:  The median age at diagnosis is 70 years and median age at death from gastric cancer is 73 years.
• Stomach cancer occurs in 10.8 per 100,000 men and 5.4 per 100,000 women in a year. In 2008, the United States prevalence was 37,739 men and 28,271 women, with a lifetime risk of 0.88%.
• High rates of stomach cancer occur in Japan, China, Chile, and Ireland.

Pathophysiology: Eighty-five percent of stomach cancers are adenocarcinomas with 15% lymphomas and GI stromal tumors.
 Adenocarcinoma is further divided into two types:
~ Diffuse type—Characterized by absent cell cohesion, these tumors affect younger individuals infiltrating and thickening the stomach wall; the prognosis is poor. Several susceptibility genes
have been identified for this type of cancer.
~ Intestinal type—Characterized by adhesive cells forming tubular structures, these tumors frequently ulcerate.


Etiology: 
• Most tumors are thought to arise from ingestion of nitrates that are converted by bacteria to carcinogens.
Exogenous and endogenous factors contribute to the process of carcinogenicity by creating gastritis, loss of acidity, and bacterial growth.

Other risk Factors For gastric cancer include:
  • Previous gastric surgery
  • Atrophic gastritis (including
  • Postsurgical vagotomized patients
  • Pernicious anemia 
  • Familial adenomatous polyposis 
  • Hereditary nonpolyposis colorectal cancer 
  • Individuals infected with certain H. pylori bacteria (cytotoxinassociated gene A) are at increased risk of gastric adenocarcinoma
  • Smoking, 
  • Low socioeconomic class, 
  • Lower educational level, 
  • Exposure to certain pesticides (e.g., those who work in the citrus fruit industry in fields treated with 2,4-dichlorophenoxyacetic acid [2,4-D], chlordane, propargite, and triflurin10),
  • Radiation exposure, and
  • Blood type A.

~ Gastric cancer spreads in multiple ways:2
 Local extension through the gastric wall to the perigastric tissues, omenta, pancreas, colon, or liver.
 Lymphatic drainage through numerous pathways leads to multiple nodal group involvement (e.g., intraabdominal, supraclavicular) or seeding of peritoneal surfaces with metastatic nodules occurring
on the ovary, periumbilical region, or peritoneal cul-de-sac.
 Hematogenous spread is also common with liver metastases.

Clinical Features:
• Asymptomatic, if superficial and/or early.
• Upper abdominal pain that ranges from vague to severe.
• Postprandial fullness.
• Anorexia and mild nausea are common.
•Nausea and vomiting occur with pyloric tumors.
• Late symptoms include weight loss and a palpable mass (regional extension).
• Late complications include peritoneal and pleural effusions; obstruction of the gastric outlet; bleeding from esophageal varices or postsurgical site; and jaundice.
• Physical signs are also late features and include:
~ Palpable enlarged stomach with succussion splash (splashing sound on shaking, indicative of the presence of fluid and air in a body cavity).
~ Primary mass (rare).
~ Enlarged liver.
~ Enlarged, firm to hard, lymph nodes (i.e., left supraclavicular [Virchow]), periumbilical region (Sister Mary Joseph node), and peritoneal cul-de-sac (Blumer shelf; palpable on vaginal or rectal examination).

Imaging And Endoscopy
• Diagnosis can be made on endoscopy with biopsy of suspicious lesions. 
• Urgent referral for endoscopy (within 2 weeks) is recommended for patients with dyspepsia who also have GI bleeding, dysphagia, progressive unexplained weight loss, persistent vomiting, iron deficiency anemia, epigastric mass, family history of gastric cancer (onset <50 years), or whose dyspepsia is persistent and they are older than age 55 years.
• Double-contrast radiography is an alternative to endoscopy and can detect large primary tumors but distinguishing benign from malignant disease is difficult.
• Although endoscopy is not necessary when radiography demonstrates a benign-appearing ulcer with evidence of complete healing at 6 weeks, some authors recommend routine endoscopy, biopsy, and brush cytology when any gastric ulcer is identified.
• Some gastric polyps (adenomas, hyperplastic) have malignant potential and should be removed.
• Work-up for metastases includes:
~ Chest radiograph.
~ CT scan or MRI of the abdomen and pelvis.
• Endoscopic sonography is useful as a staging tool when the CT scan fails to find evidence of locally advanced or metastatic disease.

Differential Diagnosis:
  • Peptic ulcer—Typical symptoms include epigastric pain (described as a gnawing or burning), occurring 1 to 3 hours after meals and relieved by food or antacids. Patients may also have nausea and vomiting, bloating, abdominal distention, and anorexia. Endoscopy confirms diagnosis 
  • Nonulcer dyspepsia—Includes gastroesophageal reflux disease and functional dyspepsia. Classic symptoms of gastroesophageal reflux disease are heartburn (i.e., substernal pain that may be associated with acid regurgitation or a sour taste) aggravated by bending forward or lying down, especially after a large meal; individual symptoms, however, do not help to distinguish these patients from those with peptic ulcer disease. Endoscopy is considered if symptoms fail to respond to treatment (e.g., histamine-2 receptor agonist, proton pump inhibitor) or red flag signs/symptoms occur (e.g., bleeding, dysphagia, severe pain, weight loss).
  •  Chronic gastritis—Includes autoimmune (body-predominant) and H. pylori-related (antral-predominant) types; mucosal inflammation (primarily lymphocytes) may progress to atrophy and metaplasia. Abdominal pain and dyspepsia are common symptoms and patients may have pernicious anemia.
  • Esophagitis—May be mechanical or infectious (primarily viral and fungal). Symptoms include heartburn (retrosternal wave-like pain that may radiate to the neck or jaw) and painful swallowing (odynophagia) regurgitation of sour or bitter tasting material may occur with obstruction. Barium swallow or esophagoscopy can be used to establish the diagnosis.
  •  Esophageal cancer—Relatively uncommon malignancy of two cell types: squamous cell cancers (largely related to smoking, excessive alcohol consumption, and other agents causing mucosal trauma) and adenocarcinomas (usually arising in the distal esophagus related to reflux disease). Symptoms include progressive dysphagia and weight loss; the diagnosis is confirmed on esophagoscopy and biopsy.
Management: Patients may be best managed by an experienced multidisciplinary team.


Pharmacologic
• Chemotherapy using 5-fluorouracil (FU) and doxorubicin with or without cisplatin or mitomycin C is somewhat helpful. 

Referal For Surgery
• Complete resection including adjacent lymph nodes is recommended. For resectable gastric adenocarcinoma, recommendations are free-margin surgery with at least D1 resection (perigastric lymph nodes) combined to removal of a minimum of 15 lymph nodes.

Radiotherapy
Radiation is useful for palliation for pain

Prognosis: 
Surgical morbidity (e.g., anastomotic leaks, infection) occurs in approximately 25% of patients and operative mortality is approximately 3%

• Five-year relative survival for localized disease is 61.5%, for spread to regional nodes is 27.8%, and for metastatic disease is 3%.
• Median survival for grade of tumor decreases from well-differentiated tumors (22.6 months) to undifferentiated (7.6 months).

3 comments:

  1. Hello, my name is Betty. i was diagnosed of HIV virus 4 years back. Before then, i was dating this Derrick guy. we had something great going on. Our love life only lasted for 8 months. the sixth and seven month of our relationship, i began feeling very weak every now and then. But i never suspected anything until I kept on experiencing different symptoms like having sore throats, constant headache, body weakness e.t.c. I decided to go for a medical check up. I was tested HIV positive. when the doctor broke the news to me, it was as if my whole world had crumbled. it dawned on me then that Derrick has been lying to me. i was very mad to an extent i almost committed suicide. But there was nothing i could do, other than weep and weep. ever since then, i have been spending heavily on medications, going from one medical clinic or the other so I can look healthy. Though since i was a kid, i love herbs a lot. i take herbal tea with grandma while growing so i am quite familiar with herbs. early last year, i was on the internet and on a particular health blog, to check for herbal medication as alternative. I saw many comments and read many testimonies. Until i came across a particular testimony on how Dr.ugo cured a patient from herpes simplex virus using pure natural herbs. i reached out to the doctor because I also was thinking Herpes had no cure. I told him about my HIV status.He encouraged me not to panic that he will help me get my deliverance. he prepared some herbs and sent them to me. The herbs were in four 70ml bottles and I took them morning and night. i used as he directed, and in less than three weeks, i started having appetite to eat plenty of food and i gained back my strength. the fourth week,I consumed all the herbal meds. He encouraged me to go for a test which i did. This time, the result was negative. I quickly contacted the doctor and informed him of the news. I immediately asked him to prepare for Derrick too. He did and sent it. Today, me and Derrick are HIV free. All thanks goes to God Almighty for healing us through Dr.Ugo. if you are having any kind of sickness at all, Dr.Ugo is the right person to talk to and i assure you, you will be glad you did. His email: ugoherbalhome@gmail.com you can also write him on WhatsApp +2348104990619.

    ReplyDelete
  2. Nice blog
    Have been totally convinced that HIV,and many others dangerous diseases can be best cured using the Herbal Medicine. Dr.Akpu the great and powerful herbalist cured me with his Herbal remedy. I'm Linda,15 years from Texas. I was born with HIV. I lost parents at my teenager age when I was 4th. I had to grew up with my mum only Sister, whom I loved so much. She was so worried about my life as my condition was her mature problem in life. I had taken lots of antiviral treatment to get ride of the virus not believing what there said HIV has no cure. I was on the internet when i came across blogs of testimony about a lady who where cured of a 7 years diagnose of Herpes by this powerful Herbalist, Dr.Akpu.I wrote down his mail @ Dr.akpupowerherbscenter@gmail.com
    I told my Aunt,luckily it was the same Dr,we where referred to few months back by my pastor in church whom members have being testifying about of his cure We did contacted him and explained my problem to him.He prepared the medicine and sent to me with details of how to use and apply. After a while, I began to feel more strong than never before, I felt so lucky and happy when my Doctor congratulated me that he could found no HIV virus again in me. I knew I was free cos my body was so strong. His herbal medicine should have saved my parents life, i said!
    Thanks so much for reading my article, you should share your testimony if you have cure as well
    Dr.akpupowerherbscenter@gmail.com
    Is the solution

    ReplyDelete
  3. I started on COPD Herbal treatment from Ultimate Health Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 4 months, it reversed my COPD. My severe shortness of breath, dry cough, chest tightness gradually disappeared. Reach Ultimate Health Home via their website at www.ultimatelifeclinic.com I can breath much better and It feels comfortable!

    ReplyDelete