1. ONCOLOGY GRANDROUNDS PRESENTER: MARIA KRISTINE S. MENDOZA, M.D. MODERATOR: EUGENIO REGALA, M.D. 11 JANUARY 2010 RM 205, MEDICINE BLDG.

2.  63year old  Female  Married  Housewife  Aklan  Date of admission: Dec. 19, 2009

4. Consult o Upper GI endoscopy: chronic gastric ulcer o CT scan: gastric mucosal thickening o FOBT: (+) o Mx: Esomeprazole (Nexium) 40mg OD o Rebamipide(Mucosta) 100mg TID

5. UPPER GI ENDOSCOPY:11/18/09 Microsections disclose gastric tissue showing ulcerated mucosa associated with granulation tissue formation and necrosis. Dense plasma cells and lymphocytes along with polymorphs are also present DIAGNOSIS: CHRONIC GASTRIC ULCER

6. CT SCAN: 11/21/09

9. REVIEW OF SYSTEMS No pigmentation, itchiness No visual dysfunction, naso-aural discharge No sore throat No neck stiffness, masses or lymphadenopathy No dyspnea, shortness of breath No chest pain, no syncope No diarrhea, constipation No dysuria, frequency, urgency or flank pain No heat-cold intolerance, no polyuria, polyphagia, polydipsia, paresthesia No seizure, motor dysfunction, or hallucinations

10. PAST MEDICAL HISTORY HPN x 5 yrs. (HBP:160/100; UBP:130/90) - Irbesartan 150mg + HCTZ 12.5mg 1 tab once a day Internal hemmorhoidsx 20 yrs. with occasional hematochezia No DM, asthma, allergies, PTB

11. OB/GYNE HISTORY G1P1 (1001) – M-15 y/o – I - 28-30 days – D- 3 days – A- 4ppd – S- (-) dysmenorrhea Menopause: 53 y/o

12. PERSONAL and SOCIAL HISTORY Non-smoker, not exposed to second hand smoke and chemicals Not an alcoholic beverage drinker No illicit drug use Preference for canned foods and grilled meat

13. FAMILY HISTORY (+)HPN – Both parents (-)DM (-) Asthma (-) Allergies (-) Cancer

14. PHYSICAL EXAMINATION Conscious, coherent, ambulatory, not in cardiorespiratory distress BP 140/90mmHg(supine/sitting) CR 94 bpm,reg. (supine/sitting) PR 94 bpm, reg. (supine/sitting) RR 19 cpm Temp 36.5 o C Ht: 157cm Wt: 61kg BMI: 25kg/m 2 Warm moist skin, no active dermatoses (+)pallor GEN. SURVEY

15. PHYSICAL EXAMINATION Pale palpebral conjunctivae, anictericsclerae No nasoaural discharge, no tragal tenderness, moist buccal mucosa, no gingival bleeding, no oral petechiae, nonhyperemic posterior pharyngeal wall, tonsils not enlarged Supple neck, thyroid not enlarged, no palpable cervical lymphadenopathy, no supraclavicularlymphadenopathy HEENT

16. PHYSICAL EXAMINATION I - Symmetrical chest expansion, no retractions P - Equal tactile fremiti P - Resonant on percussion A - Clear and equal breath sounds; Equal vocal fremiti Adynamicprecordium, no lifts, no heaves, no thrills, AB 5th LICS MCL,sustained S1>S2 apex, S2> S1 base, no murmurs CHEST

17. PHYSICAL EXAMINATION Globular abdomen with whitish striae, (+) bulging flanks, normoactive bowel sounds, soft, (+) epigastric tenderness, (+) fluid wave and shifting dullness, (-) succusion splash, no costovertebral angle tenderness, AC:41 in. DRE: (+) perirectal skin tags, no fissures, external sphincter tone intact, (+) 1x1 cm, soft, fleshymass, above thepectinateline, 12 o’ clock position, non-tender, No stool on examining finger ABDOMEN

18. PHYSICAL EXAMINATION Pulses are full and equal. No limitation of motion of extremities, no swelling, no pain, no tenderness of joints, no edema, no cyanosis. EXTREMITIES

19. PHYSICAL EXAMINATION Awake, alert, oriented to 3 spheres Cranial nerves intact Can do alternating pronationsupination test and finger to nose test (-) Romberg test, (-) pronator drift No atrophy; Manual muscle testing (MMT): 5/5 on all extremities No sensory deficit/impairment Deep tendon reflex(DTRs): 2+ on all extremities (-) nuchal rigidity, (-) Babinski sign, (-) Chaddock’s sign, (-) Kernig’s sign, (-) Brudzinski sign NEURO EXAM

20. SUBJECTIVE 63 y/o, female Epigastric pain Vomiting Weight loss Early satiety Easy fatigability OBJECTIVE CT scan: gastric mucosal thickening (+)pallor Pale palpebral conjunctiva (+) bulging flanks (+) epigastric tenderness (+) shifting dullness (+) fluid wave (-) succusion splash (+) soft 1x2 cm mass, above the dentate line, 12 o’ clock position, non-tender

21. ASSESSMENT: Gastric Malignancy Anemia probably secondary to Upper GI bleeding secondary to 1)Gastric malignancy 2)PUD Hypertension Stage II Internal hemorrhoids

22. 1 ST HOSP. DAY Transfused 1 ‘u’ pRBC Other medications: – Amlodipine 10mg/tab 1 tab OD – Esomeprazole 40mg/ tab 1 tab OD

23. COURSE IN THE WARD 1 ST HOSP. DAY Kaliumdur ule, 1 durule TID Normal Value FBS92.770.9-110mg/dl Crea0.680.5-1.2 mg/dl Na142137-147mmol/L K3.63.8-5 mmol/L

24. UPPER GI ENDOSCOPY UGIE is the procedure of choice for the diagnosis of gastric cancer Sensitivity of more than 95% for detection of advanced gastric cancer

25. COURSE IN THE WARD 3rd HOSP. DAY UGI Endoscopy with biopsy – The stomach was observed to be poorly distensible on air insufflation with poor contractility – There was a diffuse infiltrating lesion with friable nodular mucosa that appeared to have involved the cardia down the antrum of the lesser curve – Multiple bites for biopsy IMPRESSION: GASTRIC MALIGNANCY, BORRMAN IV

26. BORRMAN CLASSIFICATION

27. ENDOSCOPIC FINDINGS

28. EGD with Biopsy DIAGNOSIS: SIGNET RING CELL CARCINOMA The specimen consists of multiple light brown, soft tissue fragments altogether measuring 1 x 0.8 x 0.5 cm. Microsections disclose fragments of gastric mucosa composed of nests of neoplastic cells with eccentric nucleis and large cytoplasmicmucin vacuole.

29. EGD with Biopsy DIAGNOSIS: SIGNET RING CELL CARCINOMA Other areas show cord and nests of neoplastic cells with large hyperchromatic nuclei, prominent nucleoli and scant to fair amount of cytoplasm

30. Working diagnosis: GASTRIC SIGNET RING CELL CARCINOMA

31. Gastric Cancer CA Cancer J Clin 2005; 55: 10-33 CA Cancer J Clin 2005; 55: 75 Stewart: World Cancer Reports IARC Press, Lyon 2003 Worldwide:4 th most common malignancy 2 nd leading cause cancer mortality 60% of cases from developing countries 90% cases are adenocarcinoma

32. Philippines Gastric Cancer – 8 th leading site in both sexes – 5 th in males and 10 th in females

33. Epidemiology Race/EthnicityMaleFemaleMaleFemale White10.85.05.82.8 White Hispanic 18.410.39.95.4 White non- Hispanic 9.74.15.42.6 African American18.89.913.36.3 Asian/Pacific Islander21.912.411.97.0 Native American/Native Alaskan 15.78.97.34.1 Latino17.810.09.75.3 INCIDENCEMORTALITY Gastric Cancer Incidence and Mortality Rates per 100,000 Cases (Age Adjusted) in the United States, 1997-2001

34. Environmental Risk factors H. pylori infection Dietary Factors Cigarette Smoking Alcohol Low Socioeconomic Status

35. Premalignant Conditions Chronic Atrophic Gastritis Intestinal Metaplasia Gastric Dysplasia Gastric Polyps Previous Gastrectomy Gastric Ulcer

36. APPROACH TO A PATIENT WITH GASTRIC CANCER

37. WORK-UP Abdominal CT with contrast PET/CT or PET scan(optional) Endoscopic ultrasound(optional) CBC and chemistry profile Chest imaging NCCN Clinical Practice Guidelines in Oncology V.2.2009

38. COURSE IN THE WARD 3rd HOSP. DAY CT scan with contrast of the whole abdomen – Gastric wall thickening at the antrum, body and both curvatures of the stomach – There was also mesenteric fat stranding with nodularities which may represent mesenteric lymph nodes – Moderate ascites with associated mild bowel wall thickening – Small splenic cyst, superior aspect – Prominent medial limb of the left adrenal gland to consider metastatic process – Diverticulosis in the descending colon

39. COURSE IN THE WARD 3rd HOSP. DAY Referral to Medical Oncology Labs and Ancillaries

40. CBC

41. LABORATORY EXAMINATION ALP74.1(NV: 36-92 IU/L) SGOT17.9(NV:16-40 U/L) SGPT11.1(NV:8-53 U/L) TB0.71 (NV: 0.5-1.5 mg/dl) DB0.23(NV: 0.10-0.40 mg/dl) IB0.48(NV:0.30-1.10 mg/dl)

42. LABORATORY EXAMINATION Total protein5.3  (6-7.8 g/dl) Albumin3.2  (4 – 5.5 g/dl) Globulin2.2 (1.5-3.4 g/dl) A/G ratio1.5 (1-3 mg/dl) Mg1.8 (1.6-2.5) iCa1.33

43. Tumor markers CA 125358  (NV: 0-35) CA 19-90.60 (NV: 0-39) CEA3.77 (NV:0-5)

45. 2D Echo Concentric LVH with good wall motion and contractility and normal resting systolic function EF=69%