P1026 - A Fleeting Intramucosal Signet Ring Cell Carcinoma of the Stomach: What to Do Next?

Aiya Aboubakr, MD¹, Donevan Westerveld, MD², David Wan, MD^3
1New York Presbyterian-Weill Cornell Medical Center, New York, NY; ²New York-Presbyterian-Weill Cornell Medical Center, New York, NY; ³New York Presbyterian Weill Cornell Medicine, New York, NY

Introduction: Gastric cancer remains the third leading cause of cancer deaths globally. Signet-ring cell carcinoma (SRCC) refers to a histologic subtype of gastric cancer that tends to affect younger and female patients, but whose clinical characteristics and prognosis remain poorly understood. Standard management includes either endoscopic or surgical resection. We present the case of an incidentally found SRCC in a patient who underwent endoscopic examination for microcytic anemia and rectal bleeding.

Case Description/Methods: A 57-year-old man with a gastroesophageal reflex disease and hypertension presented with 4 episodes of bright, red, blood per rectum. Rectal exam revealed scant, bright, red blood, and no palpable internal or external hemorrhoids. Initial laboratory values were notable for Hgb 10.8, MCV 75.7, RDW 19.9. CT angiography identified no acute gastrointestinal bleeding. Subsequent upper endoscopy with narrow band imaging (NBI) for evaluation of microcytic anemia revealed erythematous mucosa in the gastric body with subtle mucosal granularity and erythematous duodenopathy (Figure 1A, 1B); random biopsies of the antrum and body were placed in the same jar. Colonoscopy revealed diverticulosis. Biopsies of the stomach was notable for gastric antral mucosa with chronic active H. pylori-associated gastritis, and a focus of signet-ring adenocarcinoma in the superficial lamina propria (Figure 1C, 1D). A PET-CT did not identify any discrete gastric area of hypermetabolic activity or any evidence of hypermetabolic metastasis. He was treated with triple therapy, and two subsequent repeat endoscopies with multiple biopsies failed to identify the lesion. After discussion with oncology and gastroenterology, patient favored close endoscopic surveillance with confocal microscopy and possible endoscopic submucosal dissection, rather than gastrectomy.

Discussion: Signet-ring cell carcinoma (SRCC) of the stomach is a histologic subtype characterized by the presence of mucin-producing cells. While its clinical characteristics compared to non-signet ring cell gastric cancers are not well studied, early detected tumors are thought to have comparable prognosis. Standard management is primarily surgical resection, with recent advances in minimally invasive techniques such as endoscopic mucosal resection or submucosal dissection becoming available options alongside gastrectomy. The role of adjuvant chemotherapy and targeted therapy are currently being investigated.


Figure: Figure 1. Endoscopy with Narrow Band Imaging: (a) gastric body, (b) pre-pyloric stomach. Surgical pathology: (c) Active gastritis. Insert: H pylori (arrows), (d) Single focus of signet-ring adenocarcinoma (arrows).


Disclosures:
Aiya Aboubakr indicated no relevant financial relationships.
Donevan Westerveld indicated no relevant financial relationships.
David Wan indicated no relevant financial relationships.


Aiya Aboubakr, MD¹, Donevan Westerveld, MD², David Wan, MD³. P1026 - A Fleeting Intramucosal Signet Ring Cell Carcinoma of the Stomach: What to Do Next?, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.