Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Gastric Adenocarcinoma
Patient Presentation
Demographics: 72-year-old male of Korean descent
Chief Complaint: Unintentional weight loss, early satiety, and epigastric discomfort for 4 months
History of Present Illness: The patient reports 20-pound unintentional weight loss over 4 months. He feels full after only a few bites and has lost interest in food. He has vague epigastric discomfort but denies severe pain. He recently noticed that his stools appear dark. He has never had an upper endoscopy.
Past Medical History: H. pylori infection treated 15 years ago (cure not confirmed), chronic atrophic gastritis
Social History: Born in Korea, immigrated 30 years ago; heavy smoker (45 pack-years, quit 5 years ago); no alcohol
Family History: Father died of "stomach cancer" at age 65
Physical Examination
- Vital Signs: BP 126/78 mmHg, HR 84 bpm, BMI 19 (previous 24)
- General: Thin, cachectic male
- Abdomen: Mild epigastric tenderness, no palpable masses, no hepatomegaly
- Lymph Nodes: 1.5 cm firm, non-tender left supraclavicular node (Virchow's node)
Workup and Results
- CBC: Hemoglobin 9.8 g/dL (iron deficiency anemia pattern)
- Upper Endoscopy: Large ulcerated mass in the gastric antrum; biopsies obtained
- Histopathology: Intestinal-type gastric adenocarcinoma; H. pylori organisms identified
- CT Chest/Abdomen/Pelvis: 6 cm gastric mass with perigastric lymphadenopathy; no liver metastases
- EUS: T3N2 disease with invasion of muscularis propria and multiple perigastric nodes
Endoscopic view of gastric adenocarcinoma appearing as an ulcerated, irregular mass in the gastric antrum with raised, nodular borders characteristic of malignancy.
Image Source: Wikimedia Commons, CC BY 2.0
Diagnosis
Intestinal-type Gastric Adenocarcinoma (Stage III)
Clinical Correlation
Gastric adenocarcinoma is the third leading cause of cancer death worldwide, with highest incidence in East Asia. H. pylori infection is the dominant risk factor, classified as a WHO Class I carcinogen. The progression from chronic gastritis to atrophic gastritis, intestinal metaplasia, dysplasia, and carcinoma explains the importance of H. pylori eradication. Intestinal-type adenocarcinoma (forming glands) is associated with H. pylori and has a relatively better prognosis than diffuse-type. The Virchow node represents metastatic spread via lymphatics.
Treatment
- Perioperative chemotherapy (FLOT regimen: 5-FU, leucovorin, oxaliplatin, docetaxel)
- Surgical resection: subtotal gastrectomy with D2 lymphadenectomy
- Adjuvant chemotherapy post-operatively
- H. pylori eradication
- HER2 testing (trastuzumab if HER2-positive)
- Nutritional support and B12 supplementation after gastrectomy