Perforation of the greater gastric curvature by a gastric adenocarcinoma with engulfment of the upper pole of the spleen

Perforated gastric cancer is a rare condition [1]. It has an extremely poor prognosis. There are few data in the literature regarding perforated gastric adenocarcinoma involving the spleen [2]. We report here the case of a 66-year-old woman who was admitted to our department with general deterioration, right hypochondrium pain, and anemia of 7.5 g/dl. An abdominal and pelvic computed tomography was performed, revealing a large necrotic mass with irregular contours of the greater curvature of the stomach, measuring 10.3 × 5.7 cm, and multiple coliomesenteric, epiploic, and retroperitoneal (left lateral renal) lymph nodes. Three hypodense irregularly contoured hepatic nodules in segment IV and in the left liver were found as well, highly suspicious of secondary locations given the context. There was also a cystic splenic nodule, suspected of being a metastatic lesion ([Fig. 1]).

Fig. 1 Abdominal and pelvic computed tomography scan performed before oeso-gastro-duodenal endoscopy. a Arrowhead showing the gastric lesion in the pyloric region. b Arrowhead showing secondary splenic lesion. c Arrowheads showing secondary liver lesions.

An oeso-gastro-duodenal endoscopy was performed under general anesthesia. A blocked gastric perforation (of almost the whole greater curvature) was found at the lower part of the fundus and at the antrum. Inside the cavity, fibrinous debris and the upper pole of the spleen were found ([Video 1]). Cautious biopsies were performed.

Video 1 Diagnostic gastroscopy of gastric adenocarcinoma with perforation and envelopment of the upper pole of the spleen.

Histological examination revealed a very superficial gastric mucosa, with no muscularis mucosa, partly occupied by structures of a poorly differentiated neoplasm. On immunohistochemistry, the neoplastic cells had an epithelial phenotype, and antibodies directed against pankeratin AE1/AE3 and keratin 7 were positive. Carcinoma cells were negative for Cdx2 and HER2 ([Fig. 2], [Fig. 3]).

Fig. 2 Histological section of the gastric biopsies, hematoxylin-eosin stain. a Gastric mucosa infiltrated by adenocarcinoma, magnification × 5. b Adenocarcinoma cells: poorly differentiated appearance, cells in trabeculae or clumps, no glandular formation (the glands visible are those of the residual mucosa); magnification × 20.

Fig. 3 Immunostaining on gastric biopsies. a Immunostaining for anti-pankeratin antibody: strong labeling of normal glands, weaker labeling of adenocarcinoma cells; magnification × 10. b Immunostaining for anti-keratin 7 antibody: strong labeling of adenocarcinoma cells (in favor of upper digestive origin of adenocarcinoma); magnification × 10.

Perforated gastric cancer does not appear in the literature to alter the oncological prognosis if it is treated with two-step surgery [1] [3]. In this case of advanced perforating and metastatic disease, only palliative treatment was considered after discussion in a multidisciplinary team meeting.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB

• References

• 1 Mahar AL, Brar SS, Coburn NG. et al. Surgical management of gastric perforation in the setting of gastric cancer. Gastric Cancer 2012; 15 (Suppl. 01) S146-S152
• 2 Gonçalves R, Saad R, Malheiros CA. et al. Gastric cancer with lesion extending to spleen and perforation into free peritoneum. Rev Assoc Med Bras (1992) 2017; 63: 484-487
• 3 Wang S-Y, Hsu C-H, Liao C-H. et al. Surgical outcome evaluation of perforated gastric cancer: from the aspects of both acute care surgery and surgical oncology. Scand J Gastroenterol 2017; 52: 1371-1376