Gastric Adenocarcinoma
Case # 004
Date: September 16th, 2009

History

16 year old female with 6 months of progressive periumbilical and epigastric abdominal pain not associated with meals, position, or time of day. Over the last 3 weeks, it has been associated with 4 episodes of non-bilious, non-bloodly vomiting. Hgb was 3.6 on admission and occult blood in stool was positive although patient and family denied hematochezia/melena. Non-specific markers of malignancy, CEA and CA-125, were found to be elevated.

Images


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Single abdominal ultrasonagraphic image upon presentation to the ER demonstrates a mutlicystic mass anterior to the pancreas.



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Axial CT demonstrating hypoechoic heterogenous mass arising from the posterior gastric wall and extending into the gastric cavity.


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Axial CT demonstrates gastric mass extending posteriorly and encasing celiac axis.

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Axial CT demonstrating para-aortic lymphadenopathy.


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Axial CT demonstrating hypoechoic heterogenous mass arising from the posterior gastric wall and extending into the gastric cavity.



Diagnosis

Gastric Adenocarcinoma, poorly differentiated, stage IV.

Case Discussion

PET-CT was subsequently performed:
1. Intensely hypermetabolic focus seen in the anterior abdomen, corresponding to a large mass which appears to abut the posterior wall of the stomach with a non-hypermetablic component in its right aspect, consistent with a malignant process with a necrotic component.
2. Several Intensely hypermetabolic lymph nodes as mentioned above in the gastrohepatic mesentery, anterior to the body of the pancreas, aortocaval, and paraaortic region, compatible with lymph node metastases.


Differential Diagosis for the above history and findings:
  • Gastrointestinal stromal tumor
  • Lymphoma
  • Solid, Pseudopapillary pancreatic neoplasm
  • Pancreaticoblastoma
  • Gastric Adenocarcinoma
  • Neuroendocrine tumor
  • Rhabdomyosarcoma

Upon presentation, patient was hemodynamically stable although severely anemic from presumed GI blood loss. She was transfused 5 units of PRBC's and pain was controlled with morphine IV. The surgical team was consulted and they rec'd conservative management. They deemed the mass inoperable due to celiac axis encasement. The gastroenterology team was then consulted for esophagogastroduodenoscopy which revealed multiple duodenal ulcers, enlargement of the gastric antrum and duodenal bulb as well as changes consistent with H. Pylori Gastritis. A biopsy was not taken as to not risk perforation of the posterior wall of the stomach. Instead, endoscopy with ultrasound was performed and pathology revealed poorly differentiated gastric adenocarma.

Gastric adenocarcinoma is exceedingly rare in the pediatric population. The average age of onset within children is 15 years of age. Symptoms depend on the location of the tumor and include dysphagia, abdominal pain, distenstion, anorexia, weight loss, hematemesis, melena, hematochezia, or a palpable mass on physical exam.

Causes of Gastric Adenocarcinoma:
  • De novo degeneration
  • In association with polyposis sydromes
  • Second primary after chemotherapy and radiotherapy treatment of lymphoma
  • Vitamin B12 deficiency
  • Gastritis associated with H. Pylori

Treatment strategies are adopted from adult protocols, depend on stage, and include surgical resection, radiation therapy, neoadjuvant chemotherapy and other palliative options. Generally, stages 1-3 are considered operable whereas stage 4 is not.

CT Findings for Gastric Adenocarcinoma(1):
  • A polypoid mass with or without ulceration
  • Focal wall thickening with mucosal irregularity or focal infiltration of gastric wall
    • Subtypes
      • Infiltrating carcinoma is suggested by wall thickening, loss of normal rugal fold pattern, and soft tissue stranding
      • Scirrhous carcinoma is suggested by a markedly enhancing thickened wall (contrast study)
      • Mucinious carcinoma is suggested by decreased attenuation of a thickened wall with calcifications



Resources

1. StatDx: www.statdx.com, Gastric Adenocarcinoma