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https://upload.medbullets.com/topic/110042/images/gastric_signet_ring_cell_carcinoma_histopatholgy_(1).jpg
Snapshot
  • A 56-year-old man presents to his primary care physician for abdominal pain. His abdominal pain is in the epigastrium and has been persistent. He has had episodes of night sweats and has unintentionally lost 20 pounds over the course of 3 months. He has a past medical history of H. pylori infection and obesity. Physical examination is notable for epigastric abdominal tenderness upon palpation. An upper endoscopy demonstrates an invasive ulcerative lesion in the stomach.
Introduction
  • Overview
    • gastric adenocarcinoma is the most common type of gastric cancer, accounting for more than 90% of cases 
      • other gastric cancer types include lymphoma, stromal, and carcinoid tumor
    • gastric adenocarcinoma can be divided into intestinal and diffuse types
      • intestinal
        • bulky tumors that have glandular structures (similar to adenocarcinoma of the esophagus and colon)
          • the mass can be exophytic or ulcerated
        • commonly found on the lesser curvature of the stomach
      • diffuse
        • infiltrative tumors composed of signet ring cells (mucin vacuoles that push the nucleus to the periphery)  
        • stiffens the gastric wall, leading to a thickened, leather-like appearance (linitis plastica)
  • Epidemiology
    •  incidence
      • varies significantly in the world
        • most common in Japan, Chile, and eastern Europe
    • risk factors
      • Helicobacter pylori
      • Epstein-Barr virus
      • nitrosamine exposure
      • high salt intake
      • smoking 
      • excessive alcohol use
  • Pathophysiology
    • H. pylori infection
      • results in chronic gastritis secondary to increased production of proinflammator proteins
    • Epstein-Barr virus
      • a rare cause of gastric adenocarcinoma
      • unclear how exactly this virus leads to gastric adenocarcinoma
Presentation
  • Symptoms
    • persistent abdominal pain
      • typically epigastric
    • dysphagia
      • in cases of gastric cancers arising more proximally in the stomach or in the esophagogastric junction
  • Physical examination
    • weight loss
      • secondary to insuficcient caloric intake
Imaging
  • Endoscopy
    • indication
      • initial diagnostic study of choice to obtain a tissue diagnosis
  • Barium studies
    • indication
      • although associated with a high false-negative rate, it may be superior to endoscopy in detecting linitis plastica
Differential
  • Gastric lymphoma
    • differentiating factors
      • secondary to B-cell lymphoproliferative disorders
      • associated with mucosa-associated lymphoid tissue 
  • Gastric stromal cancer
    • differentiating factors
      • mesechymal in origin
  • Neuroendocrine (carcinoid) tumor
    • differentiating factors
      • arise from neuroendocrine origin
      • leads to release of vasoactive substances, resulting in cutaneous flushing, bronchospasm, colicky abdominal pain, and diarrhea
        • as well as right-sided cardiac valvular fiborosis
Treatment
  • Treatment is dependent on the stage of the cancer
    • may require resection, adjuvant chemotherapy, and radiation
  • Surgical
    • endoscopic resection
      • indication
        • for local tumors
    • gastrectomy with lymphadenectomy
      • indication
        • for more extensive disease
Complications
  • Virchow node
    • left supraclavicular node involvement secondary to metastasis
  • Krukenberg tumor
    • metastasis to the bilateral ovaries
  • Sister Mary Joseph nodule
    • periumbilical metastasis

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(M1.ON.13.9) A 60-year-old Japanese man presents to your office with epigastric pain following 1-month of unintentional weight loss. He reports that he eats a very traditional Japanese diet, and consumes low-fat smoked fish on a daily basis. On physical exam, you note the skin finding seen in Figure A. If this patient undergoes aggressive surgical treatment for his most likely diagnosis, which of the following may result?

QID: 101066
FIGURES:
1

Cobalamin deficiency

71%

(120/170)

2

Increased prothrombin time

2%

(4/170)

3

Acute cellular rejection

2%

(3/170)

4

Diabetes

12%

(20/170)

5

Esophageal squamous cell carcinoma

13%

(22/170)

M 4 E

Select Answer to see Preferred Response

(M1.ON.13.83) A 70-year-old female presents to your office with nausea, vomiting, and 3 months of weight loss. On physical exam, you observe a finding seen in Figure A. You suspect adenocarcinoma, and you immediately order a biopsy to ascertain the extent of metastatic disease. In which of the following organs would you observe the primary tumor with abundant mucus and signet ring cells on biopsy if metastatic disease were present?

QID: 101140
FIGURES:
1

Stomach

66%

(109/164)

2

Lung

4%

(7/164)

3

Colon

9%

(14/164)

4

Ovary

19%

(31/164)

5

Kidney

1%

(1/164)

M 2 E

Select Answer to see Preferred Response

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