MedStar Georgetown University Hospital Washington, DC, United States
Charmaine Ilagan, MD1, Camille H. Boustani, MD1, Mark Real, MD1, Walid Chalhoub, MD1, Norio Azumi, MD, PhD1, Rashmi Samdani, MD2 1MedStar Georgetown University Hospital, Washington, DC; 2MedStar Southern Maryland Hospital Center, Clinton, MD
Introduction: Gastric cancer is the fourth leading cause of cancer deaths worldwide, with over 1 million cases diagnosed each year. Gastric Signet Ring Cell Carcinoma (SRCC) is associated with a poor prognosis due to its aggressive course. We present a rare case of primary gastric SRCC metastasizing to the colon at the site of prior anastomosis for colon cancer.
Case Description/Methods: An 87-year-old female, with history of atrial fibrillation on apixaban and stage IIIB colon cancer status post resection in 2016, presented to the hospital after an episode of near syncope with associated melena. Labs on admission were notable for a hemoglobin of 6.5 g/dL. Esophagogastroduodenoscopy (EGD) and colonoscopy were performed. EGD revealed thickened rugal folds in the fundus and body of the stomach. Colonoscopy revealed a nodular area at the ileocolic anastomosis site, with biopsies taken to rule out recurrent malignancy. Positron Emission Tomography (PET) scan was suggestive of fluorodeoxyglucose (FDG) avid diffuse neoplasm of the stomach with abnormal FDG uptake at the ileocolic anastomosis site, highly suspicious for a recurrent primary malignancy versus a metastatic implant. The gastric biopsy revealed poorly differentiated adenocarcinoma, diffuse type, with signet ring cells. Biopsy of the polypoid lesions of the prior colonic anastomotic site shared similar histology and immunophenotype of gastric primary (CK7+, CDX2- and CK20-) compatible with metastases. In comparison to current biopsies, the colonic resection from 2016 was a moderately differentiated mucinous colonic adenocarcinoma. American Joint Committee on Cancer (AJCC) stomach staging was clinical stage IV (cT4b c N1 cM1). After discussing the benefits and risks of treatment, the patient was started on FOLFOX chemotherapy regimen for a total of 6 cycles and has completed 3 cycles so far.
Discussion: Colonic anastomotic sites in the setting of prior colon cancer are more prone to locoregional recurrence. Mucosal metastases of gastric cancer in a colonic anastomosis are rare. Only one case has been reported in literature so far. The most common metastases sites for gastric cancer include lymph nodes, liver, peritoneum, lung, and bone. Intestinal metastases are often seen in advanced gastric cancers. Recognition of an anastomotic tumor as a second primary and not a recurrence is important for optimal management as locoregional recurrences are often amenable to surgical resection.
Figure: Figure 1 (A. High power view of poorly differentiated carcinoma with signet ring cells in gastric rugal folds (H and E, 200x); B. High power view of metastatic poorly differentiated carcinoma with signet ring cells in colonic anastomotic site (H and E, 200x); C. High power view of CK7 stain highlighting the neoplastic cells (200x); D. CT imaging showing irregular nodular wall thickening just distal to the ileocolonic anastomosis; E. PET CT showing segmental abnormal FDG uptake is seen at the ileocolic anastomosis in the right superior abdomen, corresponding to an ill-defined lobulated soft tissue; F. Endoscopic view of irregular nodularity at the ileocolonic anastomosis.)
Charmaine Ilagan indicated no relevant financial relationships.
Camille Boustani indicated no relevant financial relationships.
Mark Real indicated no relevant financial relationships.
Walid Chalhoub indicated no relevant financial relationships.
Norio Azumi indicated no relevant financial relationships.
Rashmi Samdani indicated no relevant financial relationships.
Charmaine Ilagan, MD1, Camille H. Boustani, MD1, Mark Real, MD1, Walid Chalhoub, MD1, Norio Azumi, MD, PhD1, Rashmi Samdani, MD2. P2262 - Metastatic Gastric Signet Ring Cell Carcinoma in a Colonic Anastomotic Site : A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.