Gastric Adenocarcinoma with Bone Marrow Infiltration: Case Report and Review of the Literature

Case Presentation

Austin Surg Case Rep. 2017; 2(1): 1016.

Gastric Adenocarcinoma with Bone Marrow Infiltration: Case Report and Review of the Literature

Siaperas P¹, Skarpas A¹*, Chorti M², Theanou A¹, Karanikas I¹ and Velimezis G¹

¹Surgical Department of Sismanoglion General Hospital, Athens, Greece

²Pathology Department of Sismanoglion General Hospital, Athens, Greece

*Corresponding author: Skarpas A, 2nd Surgical Department of Sismanoglion General Hospital, Athens, Greece

Received: June 01, 2017; Accepted: June 26, 2017; Published: July 03, 2017


This case report describes a 77-year-old woman who initially was admitted in the ER department, complaining for diffuse abdominal pain, anorexia, weight loss and bone pain, while her blood tests showed coexistent anemia & severe thrombocytopenia. During her inpatient stay, she presented with hematemesis, hematochezia and petechiae, in the form of Diffuse Intravascular Coagulation (DIC).

Diagnostic work-up included upper gastrointestinal endoscopy and biopsy which revealed a diffuse gastric non-signet ring cell type adenocarcinoma, bone marrow biopsy which showed bone marrow infiltration from cancer cells with epithelial origin and diffuse necrosis, and bone scan which revealed multiple lytic bone lesions throughout the bony skeleton.

This case is significant, primarily for its importance in the differential diagnosis when approaching a patient with bone pain and lytic bone lesions and also because it points out an increasing incidence of diffuse type gastric cancer, and the severity of a coexisting infiltration of the bone marrow at the time of diagnosis.

Keywords: Gastric cancer; Bone marrow infiltration; Bone marrow metastasis; Lytic bone metastasis; Stomach cancer; Hematochezia; Diffuse type; Non-signet ring cell type; Chemotherapy

Case Presentation

This case report describes a 77-year-old woman, ex-smoker, with a history of high blood pressure and COPD, who presented in the ER department with diffuse abdominal pain, anorexia, fatigue, weight loss and diffuse bony pain, which started 15 days ago. She denied further symptoms, such as fever, night sweats, vomiting, hematochezia or melena. She also mentioned a history of bilateral fracture of the hip bones (1 & 4 years ago).

Physical examination revealed pale skin color and diffuse petechiae in the extremities and abdominal region, normal bowel movement and tenderness during palpation of the right upper quadrant of the abdomen. Rectal digital examination was negative for blood. Initial laboratory evaluation in the ER, showed anemia (Hgb 7.7g/dL - Ht 23,7%), MCH 27, 4pg, MCV 84, 3fl, MCHC 32, 5g/dL, low platelet count (42000K/μl), total bilirubin 1, 55mg/dl, indirect bilirubin 1, 10mg/dl, LDH 548 U/L and high alkaline phosphatase (1261).

Patient was admitted in Medical ward for further diagnostic evaluation. While being inpatient, a set of laboratory tests were performed: direct & indirect Coombs which were both negative, PT 14, 9sec, INR 1, 34, aPTT 35, 31sec, D-Dimmers >36581.8, fibrogen 1.7, serum protein electrophoresis, which returned positive for a small increase of the a1 band, haptoglobin 0.1g/l, Quantative determination of IgG/M/A was within normal range, Ca 19-9 >5000, PO4- 2, 9mg/ dl, Ca+ 9,1mg/dl, RET% 2, 83, ESR 30mm, FOBT positive. An x-ray of the skull, thorax and the upper extremities was also requested, which were normal.

Because of high D-Dimmers, low fibrogen and low PLT count, DIC syndrome was considered from the hematologists, as was, micro vascular hemolytic anemia of unknown origin. Differential diagnosis was suspicious of metastatic cancer or Paget’s disease. GI endoscopy was postponed initially due to low PLT count. CT scan imaging was performed, showing thickening of the gastric wall mainly located in the lesser curvature of the stomach and hyper-condensation formats, diffusely scattered in the vertebrae and bones. A bone scan was suggested to be performed when the patient was clinically stable. Hematologists proposed to treat DIC, with transfusion of fresh frozen plasma and blood transfusion when HGb<10.

Two days after admission to the medical ward, patient had an episode of hematemesis and an emergency gastroscopy was ordered, which revealed intense gastritis with no obvious source of bleeding. No biopsy was taken due to low platelet count. Three days later patient had massive melena. At that point surgical evaluation was done, which insisted in attempting again GI endoscopy and biopsies. Both upper and lower endoscopy was successfully performed, showing abnormal deformity of the gastric antrum, with no signs of active bleeding. Multiple biopsies were taken from the lesion. Colonoscopy was completely normal. Gastric biopsies showed gastric carcinoma, and since patient was continuously bleeding, having massive melenas, surgery was decided. Surgical operation was performed with upper midline incision, and findings included a prescribed antral mass, which was completely excised, performing Billroth-II gastrectomy with gastrojejunal anastomosis. Post surgical course was uneventful; however, the patient was still often needed blood and platelet transfusion, suggesting that disease was also infiltrating the bone marrow. Thus, bone marrow needle biopsy and bone marrow scan were also performed. Patient returned to the medical ward for aftercare and plan for further therapy.

The final pathologic review of the surgical specimen revealed a diffuse type (Laurent), gastric adenocarcinoma showing intense desmoplastic stroma with limited focal lymphocytic infiltration and extensive lymphocytic dispersion. Infiltration of the entire gastric wall was observed, while 5 out of 20 lymph nodes were positive. Immunohistochemistry straining was positive for CK-7, CEAp, e-Cadherin and CDX-2 and focal expression of CK20. Bone marrow specimen from needle biopsy was fully infiltrated from neoplasmatic cells with epithelial origin and diffuse necrosis. Bone scan revealed diffuse metastatic disease with lytic bone lesions throughout the bony part of the skeleton (Figure 1).