St. Luke's University Health Network Bethlehem, PA
Hammad Liaquat, MD1, Lisa Stoll, MD, MPH2, Gurshawn Singh, MD1, Roderick M. Quiros, MD1, Ayaz Matin, MD1; 1St. Luke's University Health Network, Bethlehem, PA; 2Saint Luke's, Bethlehem, PA
Introduction: Synchronous malignancy in patients with pancreatic cancer is uncommon and associated with poor prognosis. Data about coexistence of various gastric cancer histological subtypes in patients with pancreatic tumors is limited in the literature. We present a case of incidental finding of gastric antral cancer in a patient who underwent resection for pancreatic carcinoma.
Methods: A 76 year old female with history of GERD and DVT presented with chronic left upper quadrant abdominal pain with radiation to left lower quadrant. The pain was intermittent, not associated with meal intake or change of posture but was progressively worsening in intensity and becoming more frequent. Patient had intermittent nausea, controlled heartburn, normal bowel movements and ten pound weight loss over the past few months. She had no history of alcohol intake, smoking cigarettes or family history of cancer. Abdominal CT showed a multiloculated cystic lesion in the pancreatic body along with pancreatic duct (PD) dilation which was also seen on endoscopic ultrasound (4.7 cm lesion and 1.5 cm PD diameter) (Image 1). Fine needle aspiration biopsy of the lesion showed pancreatic adenocarcinoma. Serum CA 19-9 was 223 U/mL. Further imaging did not show any metastatic disease. Colonoscopy was normal. Subsequently, patient underwent extended Whipple procedure. Pathological evaluation of pancreatic tissue revealed pancreatic adenocarcinoma associated with high-grade intraductal papillary mucinous neoplasm while antral gastric tissue showed signet ring cell carcinoma (SRCC) of the stomach involving mucosa and submucosa (Image 2). Patient underwent EGD which showed erosion proximal to the gastrojejunostomy junction (Image 3). Biopsy of the area also showed SRCC. Patient was started on chemotherapy and radiation treatment which she was unable to tolerate and was ultimately hospitalized with profound fatigue and failure to thrive. After discussion with patient and family, goals of care were switched to comfort care. The patient subsequently passed away. Discussion: The overall incidence of gastric cancer is decreasing while gastric SRCC frequency continues to increase. SRCC can present as early gastric cancer or as more advanced aggressive malignancy which metastasizes rapidly. It tends to occur more commonly in females with median age of 61.9 years. To our knowledge, synchronous SRCC in a patient with pancreatic cancer is an extremely rare finding.
Image 1: CT Abdomen shows 4.7 cm multiloculated cystic lesion of the pancreatic head/body (A). EUS shows heterogenous solid and cystic mass, similar in size as seen on CT scan, in the pancreatic body (B), while pancreatic duct dilated to 15 mm (C).
Image 2: H & E stain(10X) of pancreatic tissue (A) showing well defined malignant glands (arrows) confirmed to be pancreatic adenocarcinoma due to loss of expression of DPC4 immunohistochemistry stain (10X) in (B) and weak to absent nuclear expression on CDX2 immunohistochemistry stain (10X) in (C). H & E stain(20X) of gastric antral tissue showing poorly differentiated adenocarcinoma with signet ring features (D). DPC4 immunohistochemistry stain (20X) showing intact expression (E) and CDX2 immunohistochemistry stain (20X) showing intact nuclear expression (F) within the gastric carcinoma.
Image 3: Area of erosion seen proximal the gastrojejunostomy junction (A). Biopsy taken from the area resulting in minor bleeding (B).
Disclosures: Hammad Liaquat indicated no relevant financial relationships. Lisa Stoll indicated no relevant financial relationships. Gurshawn Singh indicated no relevant financial relationships. Roderick Quiros indicated no relevant financial relationships. Ayaz Matin indicated no relevant financial relationships.