General Surgery · Year 3 · from General Surgery

Case 2: Gastric Adenocarcinoma

Patient Demographics

  • Age: 68 years
  • Sex: Male
  • Occupation: Retired factory worker

Chief Complaint

"I've lost my appetite and have been losing weight for the past 3 months."

History of Present Illness

The patient presents with a 3-month history of progressive anorexia, early satiety, and unintentional weight loss of 10 kg. He reports vague epigastric discomfort, worse after eating. He has had intermittent nausea but no vomiting. He noticed his stools have been darker recently. He denies dysphagia or odynophagia. He has a history of chronic atrophic gastritis diagnosed years ago.

Past Medical History

  • Chronic atrophic gastritis (diagnosed 15 years ago on biopsy)
  • H. pylori infection (treated, but compliance unknown)
  • Hypertension
  • Type 2 diabetes

Family History

  • Father died of "stomach cancer" at age 72
  • Mother died of stroke

Social History

  • Former smoker (30 pack-years, quit 10 years ago)
  • Minimal alcohol use
  • First-generation immigrant from East Asia

Physical Examination

  • Vitals: BP 134/78 mmHg, HR 82 bpm
  • General: Thin, cachectic male
  • Abdomen:
  • Soft, mild epigastric tenderness
  • No palpable mass
  • No hepatomegaly
  • Lymph nodes: Left supraclavicular node palpable (Virchow's node - concerning)
  • Rectal exam: Guaiac positive stool

Laboratory Results

  • Hemoglobin: 9.8 g/dL (microcytic anemia)
  • MCV: 72 fL
  • Iron studies: Consistent with iron deficiency
  • Albumin: 3.0 g/dL
  • CEA: 12.4 ng/mL (elevated)
  • CA 19-9: 85 U/mL (elevated)

Diagnostic Workup

Upper Endoscopy:

  • Large ulcerated mass in the gastric body along lesser curvature
  • Approximately 5 cm in size
  • Friable, with active bleeding
  • Multiple biopsies taken

Biopsy Result:

  • Invasive adenocarcinoma, intestinal type (Lauren classification)
  • HER2: Negative
  • MSI status: Stable

Endoscopic Ultrasound:

  • Tumor invades through muscularis propria (T3)
  • Several perigastric lymph nodes

CT Chest/Abdomen/Pelvis:

  • Gastric mass with perigastric lymphadenopathy
  • Suspicious left supraclavicular lymph node (1.5 cm)
  • No liver metastases
  • No ascites

PET-CT:

  • FDG-avid gastric mass
  • FDG-avid perigastric and left supraclavicular nodes
  • No other distant disease

FNA of Supraclavicular Node:

  • Metastatic adenocarcinoma consistent with gastric primary

Clinical Stage

cT3N+M1 (Stage IV - due to Virchow's node)

Multidisciplinary Tumor Board

  • Stage IV gastric cancer (M1 due to distant nodal disease)
  • Not candidate for curative resection
  • Palliative systemic therapy recommended
  • Consider palliative measures if bleeding or obstruction

Treatment Plan

  • Palliative chemotherapy: FOLFOX regimen
  • Nutritional support
  • Iron replacement for anemia
  • Goals of care discussion with patient and family

Palliative Considerations

  • Pain management
  • Nutritional support (consider feeding tube if obstruction develops)
  • Consideration of palliative gastrectomy or stenting if symptomatic obstruction
  • Hospice referral when appropriate

Teaching Points

  1. Gastric cancer often presents at advanced stage with nonspecific symptoms
  2. Risk factors: H. pylori, atrophic gastritis, smoking, family history, Asian ethnicity
  3. Left supraclavicular node (Virchow's node) indicates advanced disease
  4. Complete staging essential before treatment planning
  5. Curative surgery only for localized disease
  6. Multimodal treatment for resectable disease; palliative chemo for Stage IV

Clinical Image

Image Description: Endoscopic image demonstrating a large ulcerated gastric mass along the lesser curvature. The irregular, raised borders with central ulceration and friable tissue are characteristic features of gastric adenocarcinoma.

Attribution: Image from Wikimedia Commons, Category:Gastric ulcers. Source: https://commons.wikimedia.org/wiki/Category:Gastric_ulcers

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