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Journal of Clinical Oncology, Vol 25, No 31 (November 1), 2007: pp. 5026-5028 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.13.3215
Metastatic Gastric Carcinoma in a 19-Year-Old ManDepartment of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
Department of Pathology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea A 19-year-old marine was transferred from a military hospital with refractory shock and hypoxia. He had been well until 6 weeks before the transfer, when he began to have dry cough, febrile sense, lower back pain, and abdominal pain. He lost 15 kg over the following month. He was diagnosed with miliary tuberculosis on the basis of his symptoms and chest x-ray findings, and he received antituberculosis medication of isoniazid, rifampin, pyrazinamide, and ethambutol 7 days before the transfer. His dyspnea and weakness worsened despite medication, and his oxygen saturation was 90% while receiving oxygen supply via a facial mask (10 L/min), and systolic blood pressure dropped to 70 mmHg on the day of transfer. His abdomen was mildly distended without signs of peritoneal irritation. There were no palpable peripheral lymph nodes. The digital rectal examination was normal with no blood stains and irrigation of Levin tube revealed no signs of active bleeding. CBC revealed WBC of 20,680/mm3 (69% neutrophils, 24% lymphocytes); hemoglobin of 5.4 g/dL; and platelets of 190,000/mm3. Serum lactate dehydrogenase level was 559U/L. Prothrombin time and activated partial thromboplastin time were prolonged, and D-dimer was elevated. Chest radiography revealed multiple miliary nodular opacities in the entire lung field (Fig 1A). A computed tomography scan, which was taken the day before transfer, showed multiple massive conglomerated lymph nodes in the bilateral hilar areas, anterior mediastinum, lesser curvature side of the stomach, left gastric, celiac trunk, and superior mesenteric arteries, small mesentery root, aortocaval and para-aortic areas, and bilateral iliac chains (Fig 1B). The inferior vena cava was compressed by enlarged lymph nodes. Under the clinical impression of possible malignant lymphoma involving the abdominal lymph nodes and lungs, probably combined with bacterial sepsis, he was treated with empirical antibiotics, transfusion, intravenous dexamethasone, and mechanical ventilation. Despite transfusion of 27 pints of RBCs, together with platelet concentrates and fresh frozen plasma, his hemoglobin level was below 7 g/dL, and he showed rapidly progressive metabolic acidosis, disseminated intravascular coagulation, and refractory shock. He died 40 hours after admission. We performed an autopsy in order to uncover the cause of his death. On gross examination, we observed multiple conglomerated lymph nodes with extensive necrosis in the mediastinum and abdomen. There was an ulcerative lesion in the lesser curvature of upper body of the stomach, and a large amount of recent hematoma filled the lumen of the stomach and whole small intestine (Fig 2A). Microscopic examination revealed a 4.5 x 3.5 x 0.7 cm-sized poorly differentiated adenocarcinoma and a cancer invasion into the serosa (Fig 2B). There were disseminated metastatic adenocarcinomas in the lung parenchyma, peribronchial lymph nodes, bone marrow, and perirenal adipose tissue. By immunohistochemistry, cytokeratin and carcinoembryonic antigen were positive, and leukocyte common antigen was negative in the cancer cells (Figs 2C and 2D). No micro-organism was cultured in blood and lung tissue specimens. Taken together, the cause of his death was advanced gastric carcinoma with multiple metastases, with the direct cause of death being multiorgan failure induced by massive gastrointestinal bleeding within 6 weeks of his initial presentation.
Tumors of the stomach usually affect patients after their 50s, with peak incidence being between 50 and 70 years and are rare in young subjects.1 It has been reported that patients younger than 30 years of age occupy 1.1% to 3.3% of all patients with gastric carcinoma.2-4 Whether gastric carcinoma in young patients differs from that in elderly patients is controversial. It is reported that poorly differentiated adenocarcinoma and signet ring cell carcinoma were more frequently detected in younger patients, but survival rates between the young and elderly patients were not significantly different.3 Similarly, many investigators have also reported that there are similar survival rates in the two age groups when the same tumor stages are compared.5-7 In contrast, some authors have reported an inverse relationship between age and prognosis in gastric carcinoma. It is found that most young patients with gastric cancer revealed metastases at the time of diagnosis and showed poor prognosis.8 In addition to prognosis, other clinicopathologic and genetic differences were reported between the two groups. It has been suggested that gastric adenocarcinomas of young patients have a poorer prognosis, possess more aggressive histopathological features, exhibit higher frequencies of reduced expression of E-cadherin and β-catenin, and reveal lower prevalence of microsatellite instability–positive phenotype than tumors in older patients.9 Furthermore, it is reported that gastric carcinomas of young and elderly patients have different genomic profiles, indicating different pathogenic mechanisms of the disease for young and elderly patients.10 These results suggest that the pathways of gastric carcinogenesis differ between young and old patients. There have been quite a few case reports of young patients with rapidly progressive gastric cancer. However, to the best of our knowledge, our case represents the most aggressive and lethal form of gastric cancer, with massive lymph node metastases and disseminated lung metastases mimicking malignant lymphoma and miliary tuberculosis. Although very rare in young subjects, especially under the age of 30 years, gastric cancer should be included in the differential diagnosis of abdominal lymphadenopathy and multiple lung nodules. Rapid work-up is essential to young patients with gastric cancer because such cases can be lethal within a few days as was in our case. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
REFERENCES 1. Crew KD, Neugut AI: Epidemiology of gastric cancer. World J Gastroenterol 12 : 354 -362, 2006[Medline] 2. Deutsch F, Zilberstein B, Yagi OK, et al: Gastric carcinoma in a 13-year-old girl. Gastric Cancer 7 : 178 -182, 2004[Medline] 3. Wang JY, Hsieh JS, Huang CJ, et al: Clinicopathologic study of advanced gastric cancer without serosal invasion in young and old patients. J Surg Oncol 63 : 36 -40, 1996[CrossRef][Medline] 4. Nakamura T, Yao T, Niho Y, et al: A clinicopathological study in young patients with gastric carcinoma. J Surg Oncol 71 : 214 -219, 1999[CrossRef][Medline] 5. Medina-Franco H, Heslin MJ, Cortes-Gonzalez R: Clinicopathological characteristics of gastric carcinoma in young and elderly patients: A comparative study. Ann Surg Oncol 7 : 515 -519, 2000[CrossRef][Medline] 6. Kokkola A, Sipponen P: Gastric carcinoma in young adults. Hepatogastroenterology 48 : 1552 -1555, 2001[Medline] 7. Kim DY, Ryu SY, Kim YJ, et al: Clinicopathological characteristics of gastric carcinoma in young patients. Langenbecks Arch Surg 388 : 245 -249, 2003[CrossRef][Medline] 8. Bloss RS, Miller TA, Copeland EM III: Carcinoma of the stomach in the young adult. Surg Gynecol Obstet 150 : 883 -886, 1980[Medline] 9. Lim S, Lee HS, Kim HS, et al: Alteration of E-cadherin-mediated adhesion protein is common, but microsatellite instability is uncommon in young age gastric cancers. Histopathology 42 : 128 -136, 2003[CrossRef][Medline] 10. Buffart TE, Carvalho B, Hopmans E, et al: Gastric cancers in young and elderly patients show different genomic profiles. J Pathol 211 : 45 -51, 2007[CrossRef][Medline]
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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