2682 The Evolution and Cure of Multifocal Gastric Cancer

Abstract

INTRODUCTION: Gastric cancer incidence and mortality has continued to steadily decline but remains the second leading cause of cancer death worldwide. Predominantly, gastric cancers are known to arise from a single lesion whereas gastric cancer arising from multiple lesions is uncommon. We present a case of a 67 year-old female who was initially found with gastritis in the antrum that evolved into a multifocal gastric cancer within 1 year. CASE DESCRIPTION/METHODS: The patient was a 67 year-old female who was first seen in Hepatology clinic for chronic hepatitis C with early fibrosis. After successful treatment, she underwent upper endoscopy for non-specific gastric symptoms. EGD showed gastritis in the antrum and biopsy revealed intestinal metaplasia and H-Pylori was negative so repeat endoscopy was recommended in a year. Upon returning for repeat endoscopy, evaluation revealed a small antral erosion and a raised area of erythematous mucosa in the fundus. Unexpectedly, biopsies revealed extensive intestinal metaplasia and high-grade dysplasia in both lesions. The patient was immediately referred to an academic center for upper endoscopic ultrasound and mucosal resection. Both studies were unremarkable, so the patient returned to our facility and underwent upper chromo-endoscopy. By this time, the antral erosion had markedly increased in size and became an ulcer with circumferential induration and staining centrally with methylene blue. There was also methylene blue uptake in two other erosions within the fundus. Repeat biopsy of the ulcers now showed nascent well-differentiated adenocarcinoma associated with high-grade dysplasia. Whole body computerized tomography showed no evidence of metastasis so patient underwent total gastrectomy. Surgical pathology revealed multiple foci of intestinal type gastric adenocarcinoma in the background of high-grade dysplasia and intestinal metaplasia. All lymph nodes and margins were negative. DISCUSSION: There have been less than 50 cases of multifocal gastric cancer reported in the literature with even fewer cured by total gastrectomy. Upper gastrointestinal endoscopy remains the gold standard for diagnosing gastric lesions. Generally, surveillance isn’t recommended for findings of intestinal metaplasia. However, our case serves to highlight the importance of diligent endoscopic surveillance and tissue sampling, even if findings convey low suspicion. Our patient was successfully cured of multifocal gastric cancer, a disease that usually carries a very poor prognosis.

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