A 61-year-old Hispanic female retail worker, for whom the only pertinent past medical history was intermittent social alcohol consumption, presented to the emergency department with epigastric pain. Symptom onset began three weeks prior to her initial presentation and had been progressively worsening. Her chief complaints were associated with heartburn, decreased appetite, weakness, and 60-pound unintentional weight loss over the past six months. The patient attributed all of the symptoms to her physically and mentally demanding occupation. She denied a personal history of nausea, vomiting, dysphagia, hematemesis, hematochezia, melena, or screening colonoscopy. Her family history was negative for any gastrointestinal diseases or malignancies.
Vital signs and measurements were unremarkable. A detailed physical examination was nonrevealing. Serum laboratory analysis was notable for a significant anemia, as well as a low vitamin B12 and iron deficiency ( Table 1). She was urgently managed with a restrictive transfusion strategy by one unit of leukoreduced packed red blood cells, which improved her symptoms and hemoglobin. Abdominopelvic imaging was obtained by computerized tomography (CT) scans with contrast, which were primarily equivocal ( Figure 1). Subsequently, she underwent esophagogastroduodenoscopy (EGD) for further evaluation. Esophageal findings included moderate esophagitis and salmon-colored mucosa at the gastroesophageal junction suggestive of Barrett's esophagus. Beyond the esophagus, a large 7-cm hiatal hernia was evident. An extensive, deep ulcer was noted to involve the entirety of the incisura and pre-pyloric area, as well as extended along the lesser curvature ( Figure 2). Multiple biopsies of the ulcer were obtained to evaluate for malignancy, as well as random gastric biopsies to evaluate for Helicobacter pylori colonization. Helicobacter pylori immunohistochemical (IHC) stain was ultimately negative. Due to the tumor's size, gross appearance, ulcerations, and bleeding erosions noted on EGD a malignant process was suspected. Based on the suspicions for an underlying malignant gastric neoplasm and the presence of a vitamin B12 deficiency, serum serologic testing for PA was obtained. Laboratory testing was positive for anti-IF confirming the diagnosis of PA ( Table 1).
Microscopically, antral mucosa demonstrated mild chronic gastritis. Histopathology revealed a diffuse-type, invasive poorly differentiated adenocarcinoma. IHC staining was only positive for pancytokeratin. The malignant-appearing cells lacked immunoreactivity for synaptophysin, CD45, and HER2 ( Figure 3). Together with histopathology and this IHC profile gastric adenocarcinoma was confirmed. She underwent a positron emission tomography (PET) scan for staging. The PET scan showed a localized but advanced gastric neoplasm associated with regional PET-avid lymphadenopathy. ( Figure 4). Thus, she was diagnosed with Stage II gastric adenocarcinoma ( Figure 5).
She was started on intravenous vitamin B12 and iron replacement (dose given in Figure 5). Her remaining symptoms improved slowly while she observed in post-operative period with twice-daily oral 40 mg pantoprazole and daily polyethylene glycol. She continued to improve following intravenous vitamin B12 and iron replacement and transitioned to a scheduled oral cyanocobalamin 1000 microg daily regimen. Oral iron supplementation was discouraged due to the propensity of oral iron medication to be significantly irritative to the gastric mucosal lining. She was dismissed from the hospital and established care with a local oncologist. Due to the nature of her disease, chemotherapy was recommended. The patient initiated treatment with the FLOT regimen (oxaliplatin, leucovorin, docetaxel, fluorouracil) for her advanced, invasive poorly differentiated gastric adenocarcinoma ( Figure 5). However, the patient did not tolerate chemotherapy well and only was able to endure one cycle. She wished to stop all therapies and was transitioned to hospice care. Two weeks after stopping chemotherapy, the patient expired.