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Case Report | Discussion

Case report:

A-36-yrs old female patient, presented with chief complaints of pain in the epigastrium since one month. The pain was continuous and dull aching – being occasionally - colicky. The pain increased after meals. The patient was a non-diabetic and non-hypertensive. There was no history of nausea, vomiting, constipation or melena. On examination, general condition of the patient was fair and vital parameters were normal. On abdominal examination, an ill defined lump, approximately measuring 5 X 5 centimeters was felt in epigastric region, which is non-tender and movable.

Upper GI Barium series was done, which showed narrowing of pyloric and antral region extending for 5cm. The lesion was eccentric and shouldering was also noted at this level, indicating a malignant growth at the region of antrum and pylorus.(Fig 1)

Fig. 1

Further evaluation was done with plain and contrast enhanced CT scans, which showed thickening of stomach wall and growth at antrum and pyloric region, measuring approximately 8.5cm in length and 2cm in thickness with almost complete occlusion of the lumen. There was obliteration of surrounding peripancreatic fat planes with enlargement of the celiac group of lymph nodes in perigrastric and retropancreatic region. The largest lymph node measured 1.5cm in diameter. A hypodense lesion was seen in segment IV of the liver measuring 1.5cm in diameter suggestive of liver metastasis. ( Fig .2, 3,4,5).

Fig. 2	Fig. 3
Fig. 4	Fig. 5

Upper gastro-intestinal endoscopy was performed which showed growth at antrum. Endoscopic Biopsy of the mass was taken. A laparotomy with a midline incision was performed. In view of non-resectibility of the mass, a gastro-jejunostomy was done to by pass the lesion along with biopsy from the lesion was taken. Patient is now started on chemotherapy

Histopathology of the mass showed adenocarcinoma of stomach.

Discussion

The stomach is the site of variety of malignant neoplasms. They are primary carcinoma, gastric lymphoma, mesenchymal tumours and metastatic carcinomas. The most common of these are carcinoma and lymphoma.

Primary carcinoma of the stomach may be present as:

1. early gastric cancer
2. malignant ulcer
3. advanced carcinoma
4. linitis plastica

Early gastric cancer is defined as a lesion that has not invaded the muscularis propria and is confined to the gastric mucosa. The most subtle form is that of a flat or slightly depressed lesion accompanied by converging folds.

In the early stages, most malignant ulcers are early gastric cancers that have ulcerated in their central region. In it’s more advanced stages, a malignant ulcer is carcinomatous mass that has ulcerated, with the mass being obvious radiologically.

In advanced gastric cancer, the tumour assumes an appearance typical of large gastrointestinal malignancies most often with an easily appreciated element of the mass or bulk. A large ulceration may be present, but the mass like aspect dominates the appearance of the lesion. The radiograpical appearances of advanced carcinoma are generally those of a large, irregular mass often involving most of the stomach and at there margins their may be a distinct angular demarcation or ‘shelf’. The surface of the lesion may be highly irregular, resembling the appearance of cauliflower and one or more ulceration may be visible within the lesion. If located in the antrum, the neoplasm may encircle and obstruct the outlet of the stomach.

Linitis plastica is a term reserved for those carcinomas characterized primarily by infiltration of the stomach wall and simulation of a fibrotic reaction rather then by the presence of mass or ulceration. Radiologically, linitis plastica presents as a contracted stomach lacking the normal rugal fold pattern. The surface of the tumour may have a smooth or a finely granular surface atypical of other forms of malignancy. The diameter of the lumen is decreased in the affected area with obvious rigidity of the stomach wall, lack of distensibility and absence of peristalsis.

Carcinoma of stomach is most often seen on CT scans as thickening of the gastric wall. Less often, a discrete mass may project from the wall into the lumen of the stomach.

The major benefits of CT Scanning in patients with gastric carcinoma are in preoperative staging, the planning of treatment, determination of success of therapy and detection of recurrences.

Preoperatively, the most reliable indication of the spread of the tumour beyond the serosa is obliteration of the pregrastric fat planes. The tumour may spread by direct extension to adjacent structures including the oesophagus, gastrocolic ligament, gastrohepatic ligament, gastrosplenic ligament and pancreas. Further extension may involve any of the lymph node groups in the upper abdominal region. The most common sites of distant metastases are the liver and peritoneal cavity.