Temple University Hospital Philadelphia, PA, United States
Samik Shah, MD1, Ahmed Lazim, MD1, Salvatore Luceno, MD2, Neena Mohan, MD1 1Temple University Hospital, Philadelphia, PA; 2Temple University, Philadelphia, PA
Introduction: Diagnosis of signet ring cell carcinoma (SRCC) can be challenging, as early gastric cancer (EGC) can be easily missed on endoscopy. Therefore careful inspection by endoscopists is required. The following case is of a patient with conflicting evidence of SRCC, but who ultimately received definitive treatment.
Case Description/Methods: A 60 year old female presented with 8 years of epigastric pain and 20 lb weight loss over 1 year. CBC and CMP were normal. CT abdomen/pelvis with IV contrast 5 months ago showed questionable mild distal gastric wall thickening without lymphadenopathy. She reported an unremarkable EGD 5 years ago.
An EGD was performed showing LA Grade A esophagitis, moderate gastritis, and a thickened pre-pyloric fold. Biopsies were taken of the body, antrum and thickened fold, revealing SRCC. Oncology ordered staging CTs which were negative for metastasis. She then underwent EGD/EUS. Biopsies were taken of the entire stomach and thickened prepyloric fold. Due to wall thickening, cancer was staged as T3N0M0. Repeat mucosal biopsies were negative for malignancy. Thus, a peritoneal lavage was performed, which showed no malignant cells. The decision was made to repeat EGD/EUS with FNA. Numerous repeat gastric biopsies were taken. FNA of the 8mm prepyloric wall was performed. All pathology results returned negative for malignancy. At tumor board meeting, the T3 diagnosis was not upheld, and the patient was recommended for gastrectomy. A distal gastrectomy with D2 lymph node dissection was performed, with pathology revealing SRCC of focal gastric antral and body mucosa, with viable margins negative for carcinoma. All resected lymph nodes were negative. The patient’s carcinoma was staged as T1N0M0, with no chemotherapy required.
Discussion: In this case, the patient had a positive biopsy from a thick gastric fold, but subsequent sampling via EGD/EUS and peritoneal lavage could not confirm SRCC. Based on the initial pathology, distal gastrectomy was pursued. This surgery was conclusively diagnostic and therapeutic. A 2014 meta-analysis revealed that 11.3% of upper GI cancers are left undiagnosed on endoscopy up to 3 years prior to diagnosis. Endoscopic characteristics to help identify EGC include pale, flat lesions without ulceration/elevation/depression, gland and microvasculature irregularities on narrow band imaging, and elongated/expanded architecture (“stretch sign”). This case illustrates that EGC can be easily missed, and diagnosis requires careful endoscopic evaluation.
Figure: Figure 1A. Endoscopic image of thickened prepyloric fold from first EGD Figure 1B. H&E stain demonstrating signet ring cell carcinoma from first gastric biopsy
Disclosures: Samik Shah indicated no relevant financial relationships. Ahmed Lazim indicated no relevant financial relationships. Salvatore Luceno indicated no relevant financial relationships. Neena Mohan indicated no relevant financial relationships.
Samik Shah, MD1, Ahmed Lazim, MD1, Salvatore Luceno, MD2, Neena Mohan, MD1. P1012 - A Case of Gastric Signet Ring Cell Carcinoma: Challenges in Diagnosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.