ONCOLOGY GRANDROUNDS

PRESENTER: MARIA KRISTINE S. MENDOZA, M.D.

MODERATOR: EUGENIO REGALA, M.D.

11 JANUARY 2010RM 205, MEDICINE BLDG.

B.F.

63year old Female Married HousewifeAklan 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 Gastritiso Calcium carbonate tabs (Tums) prno Further work-up recommended: Endoscopy

1 month PTA

• Consult o Upper GI endoscopy: chronic gastric ulcero CT scan: gastric mucosal thickeningo FOBT: (+)o Mx: Esomeprazole (Nexium) 40mg ODo Rebamipide(Mucosta) 100mg TID

• Increased severity and frequency of epigastric pain•Weightloss (≈ 7 kg.)• (+) Early satiety, easy fatigability

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

• 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

GEN. SURVEY

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

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

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

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

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

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

1ST HOSP. DAY• Transfused 1 ‘u’

pRBC

• Other medications:– Amlodipine

10mg/tab 1 tab OD

– Esomeprazole 40mg/ tab 1 tab OD

12/19/09 N.V.Hgb 83 120-170g/L

RBC 3.62 4-6 x 1012/L

Hct 0.26 0.37-0.54

MCV 72.2 87+5 U3

MCH 23.00 29 + 2 pg

MCHC 31.80 34 + 2 g/dl

RDW 16.70 11.6-14.6

WBC 6.60 4.5-10Neutro 0.57 0.50-0.70Lympho 0.39 0.20-0.40Monos 0.01 0-0.03 Eos 0.03 0-0.03Baso 0-0.01Platelet 355 150-450

COURSE IN THE WARD

1ST HOSP. DAY

• Kaliumdurule, 1 durule TID

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

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 CancerCA Cancer J Clin 2005; 55: 10-33

CA Cancer J Clin 2005; 55: 75Stewart: World Cancer Reports IARC Press, Lyon 2003

• Worldwide:4th most common malignancy2ndleading 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

Race/Ethnicity Male Female Male Female

White 10.8 5.0 5.8 2.8

White Hispanic

18.4 10.3 9.9 5.4

White non-Hispanic

9.7 4.1 5.4 2.6

African American 18.8 9.9 13.3 6.3

Asian/Pacific Islander 21.9 12.4 11.9 7.0

Native American/Native Alaskan

15.7 8.9 7.3 4.1

Latino 17.8 10.0 9.7 5.3

INCIDENCE MORTALITY

Gastric Cancer Incidence and Mortality Rates per 100,000 Cases(Age Adjusted) in the United States, 1997-2001

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

• 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

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

CBC12/19/09 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

Baso

Platelet 355 295 281

LABORATORY EXAMINATION

• ALP 74.1 (NV: 36-92 IU/L)• SGOT17.9 (NV:16-40 U/L)• SGPT 11.1 (NV:8-53 U/L)• TB 0.71 (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)

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 125 358 (NV: 0-35)• CA 19-9 0.60 (NV: 0-39)• CEA 3.77 (NV:0-5)

2D Echo

• Concentric LVH with good wall motion and contractility and normal resting systolic function

• EF=69%