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ONCOLOGY
GRANDROUNDS
PRESENTER: MARIA KRISTINE S. MENDOZA, M.D.
MODERATOR: EUGENIO REGALA, M.D.
11 JANUARY 2010
RM 205, MEDICINE BLDG.
B.F.
 63year old
 Female
 Married
 Housewife
Aklan
 Date of admission: Dec. 19, 2009
History of Present Illness
4 months
PTA
• CC: Epigastricpain
• Vomiting of partially digested food
• (-) Anorexia, dysphagia, nausea,
early satiety
• Consult Impression: t/c Gastritis
o Calcium carbonate tabs (Tums) prn
o Further work-up recommended: Endoscopy
1 month
PTA
• Increased severity and frequency of
epigastric pain
•Weightloss (≈ 7 kg.)
• (+) Early satiety, easy fatigability
• Consult
oUpper GI endoscopy: chronic gastric ulcer
oCT scan: gastric mucosal thickening
oFOBT: (+)
oMx: Esomeprazole (Nexium) 40mg OD
oRebamipide(Mucosta) 100mg TID
CONSULT
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
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
OB/GYNE HISTORY
• G1P1 (1001)
– M-15 y/o
– I - 28-30 days
– D- 3 days
– A- 4ppd
– S- (-) dysmenorrhea
• Menopause: 53 y/o
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
FAMILY HISTORY
•
•
•
•
•
(+)HPN – Both parents
(-)DM
(-) Asthma
(-) Allergies
(-) Cancer
PHYSICAL EXAMINATION
GEN.
SURVEY
• 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 oC
• Ht: 157cm Wt: 61kg
BMI: 25kg/m2
• Warm moist skin, no active dermatoses (+)pallor
PHYSICAL EXAMINATION
• Pale palpebral conjunctivae, anictericsclerae
HEENT
• 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
PHYSICAL EXAMINATION
CHEST
•
•
•
•
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
PHYSICAL EXAMINATION
ABDOMEN
• 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
PHYSICAL EXAMINATION
EXTREMITIES
• Pulses are full and equal. No limitation of
motion of extremities, no swelling, no pain, no
tenderness of joints, no edema, no cyanosis.
PHYSICAL EXAMINATION
NEURO EXAM
• 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
SALIENT FEATURES
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
ASSESSMENT:
Gastric Malignancy
Anemia
probably secondary to Upper GI bleeding secondary to
1)Gastric malignancy
2)PUD
Hypertension Stage II
Internal hemorrhoids
12/19/09
N.V.
Hgb
RBC
Hct
MCV
83
3.62
0.26
72.2
120-170g/L
MCH
MCHC
RDW
23.00
31.80
16.70
34 + 2 g/dl
WBC
Neutro
Lympho
Monos
6.60
0.57
0.39
0.01
4.5-10
0.50-0.70
0.20-0.40
0-0.03
Eos
0.03
0-0.03
355
0-0.01
150-450
Baso
Platelet
4-6 x 1012/L
0.37-0.54
87+5 U3
1ST HOSP. DAY
• Transfused 1 ‘u’
pRBC
29 + 2 pg
11.6-14.6
• Other
medications:
– Amlodipine
10mg/tab 1 tab
OD
– Esomeprazole
40mg/ tab 1 tab
OD
COURSE IN THE WARD
Normal Value
FBS
92.7
70.9-110mg/dl
Crea
0.68
0.5-1.2 mg/dl
Na
142
137-147mmol/L
K
3.6
3.8-5 mmol/L
1ST HOSP.
DAY
• Kaliumdur
ule, 1
durule TID
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
ENDOSCOPIC FINDINGS
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.
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
Working diagnosis:
GASTRIC SIGNET RING CELL
CARCINOMA
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:4th most common malignancy
2ndleading cause cancer mortality
• 60% of cases from developing countries
• 90% cases are adenocarcinoma
Philippines
• Gastric Cancer
– 8th leading site in both sexes
– 5th in males and 10th in females
Epidemiology
Gastric Cancer Incidence and Mortality Rates per 100,000 Cases
(Age Adjusted) in the United States, 1997-2001
INCIDENCE
Race/Ethnicity
MORTALITY
Male
Female
Male
Female
White
10.8
5.0
5.8
2.8
White
Hispanic
White nonHispanic
African American
18.4
10.3
9.9
5.4
9.7
4.1
5.4
2.6
18.8
9.9
13.3
6.3
Asian/Pacific Islander
21.9
12.4
11.9
7.0
Native American/Native
Alaskan
Latino
15.7
8.9
7.3
4.1
17.8
10.0
9.7
5.3
Environmental Risk factors
•
•
•
•
•
H. pylori infection
Dietary Factors
Cigarette Smoking
Alcohol
Low Socioeconomic Status
Premalignant Conditions
•
•
•
•
•
•
Chronic Atrophic Gastritis
Intestinal Metaplasia
Gastric Dysplasia
Gastric Polyps
Previous Gastrectomy
Gastric Ulcer
APPROACH TO A PATIENT WITH
GASTRIC CANCER
WORK-UP
NCCN Clinical Practice Guidelines in Oncology V.2.2009
•
•
•
•
•
Abdominal CT with contrast
PET/CT or PET scan(optional)
Endoscopic ultrasound(optional)
CBC and chemistry profile
Chest imaging
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
COURSE IN THE WARD
3rd HOSP. DAY
• Referral to Medical Oncology
• Labs and Ancillaries
CBC
12/19/09
12/20/09
12/23/09
12/26/09
Hgb
83
106
118
115
Hct
0.26
0.35
0.38
0.36
WBC
6.60
5.7
4.10
Neutro
0.57
0.68
0.69
Lympho
0.39
0.29
0.31
Monos
0.01
0.01
Eos
0.03
0.02
355
295
Baso
Platelet
281
LABORATORY EXAMINATION
•
•
•
•
•
•
ALP
SGOT
SGPT
TB
DB0.23
IB0.48
74.1 (NV: 36-92 IU/L)
17.9 (NV:16-40 U/L)
11.1 (NV:8-53 U/L)
0.71 (NV: 0.5-1.5 mg/dl)
(NV: 0.10-0.40 mg/dl)
(NV:0.30-1.10 mg/dl)
LABORATORY EXAMINATION
•
•
•
•
•
•
Total protein5.3 (6-7.8 g/dl)
Albumin3.2(4 – 5.5 g/dl)
Globulin
2.2
(1.5-3.4 g/dl)
A/G ratio1.5
(1-3 mg/dl)
Mg
1.8
(1.6-2.5)
iCa
1.33
Tumor markers
• CA 125
• CA 19-9
• CEA
358 (NV: 0-35)
0.60 (NV: 0-39)
3.77 (NV:0-5)
2D Echo
• Concentric LVH with good wall motion and
contractility and normal resting systolic
function
• EF=69%