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A 51-Year-Old Man with Gastric Cancer and Lung Nodules

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A 51-Year-Old Man with Gastric Cancer and Lung Nodules T h e new england journal o f medicine case records of the massachusetts general hospital Founded by Richard C. Cabot Nancy Lee Harris, m.d., Editor Eric S. Rosenberg, m.d., Associate Editor Jo-Anne O. Shepard, m.d., Associate Editor Alice M. Cort, m.d., Associate Editor Sally H. Ebeling, Assistant Editor Christine C. Peters, Assistant Editor Case 29-2007: A 51-Year-Old Man with Gastric Cancer and Lung Nodules Edward T. Ryan, M.D., Suzanne L. Aquino, M.D., and Richard L. Kradin, M.D. Presentation of Case Dr. Allison L. McDonough (Internal Medicine): A 51-year-old man with a history of From the Division of Infectious Disease gastric cancer was admitted to the hospital because of a new pulmonary lesion. (E.T.R.) and the Departments of Radiology (S.L.A.) and Pathology (R.L.K.), Massa- The patient had been in good health until approximately 5 years before admis- chusetts General Hospital; and the De- sion, when he had a decreased appetite and epigastric discomfort; evaluation at partments of Medicine (E.T.R.), Radiology another facility revealed a hiatal hernia, gastroesophageal reflux, and a duodenal (S.L.A.), and Pathology (R.L.K.), Harvard Medical School. ulcer. Testing for Helicobacter pylori was positive. Omeprazole and metoclopramide were administered, and the hiatal hernia was surgically repaired. Pain, persistent N Engl J Med 2007;357:1239-46. gastroesophageal reflux, and weight loss developed approximately 2.5 years before Copyright © 2007 Massachusetts Medical Society. admission. A primary care physician at this hospital prescribed combination therapy (lansoprazole, amoxicillin, and clarithromycin) for 2 weeks to treat the H. pylori infection; this therapy was repeated 3 months later because of noncompliance, but the symptoms persisted. At that time, the hematocrit was 38.8%, and the remainder of the complete blood count was normal. The phosphorus level was 1.3 mg per deci- liter (0.4 mmol per liter; reference range, 2.6 to 4.5 mg per deciliter [0.8 to 1.5 mmol per liter]), the lipase level was 77 U per liter (reference range, 13 to 60), and the amylase level was 164 U per liter (reference range, 3 to 100). Electrolyte levels and the results of renal- and liver-function tests were normal. Ultrasonography of the abdomen was normal. Abdominal pain recurred intermittently, and 2 years before admission, upper gastrointestinal endoscopy revealed distal esophagitis; a nonbleeding linear ulcer- ation, 10 mm in the greatest dimension, in the gastric antrum; marked edema in the prepyloric antrum; a nonbleeding, cratered ulcer, 12 mm in diameter, in the pyloric channel; and partial gastric-outlet obstruction. Pathological examination of biopsy specimens from the pylorus revealed poorly differentiated adenocarci- noma with signet-ring cells. Thiazine staining of biopsy specimens was negative for H. pylori. Computed tomography (CT) of the abdomen showed thickening of the wall of the antrum, without evidence of local invasion or intraabdominal metastases. A subtotal gastrectomy was performed. Pathological examination revealed a poorly differentiated signet-ring–cell adeno- carcinoma of the pylorus, 4.0 cm in the greatest dimension, leading to a diagnosis of stage II cancer (T2,N1,MX), with 2 of 12 lymph nodes positive for tumor and n engl j med 357;12 www.nejm.org september 20, 2007 1239 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2007 Massachusetts Medical Society. All rights reserved. T h e new england journal o f medicine perineural invasion, with no vascular or lym- small parenchymal cysts in the lungs, with no phatic invasion. The tumor had invaded the sub- evidence of metastatic disease in the abdomen serosa but did not involve the serosal surface. The or pelvis. The patient had pain in the abdominal proximal, distal, and radial margins were free wall at the site of the surgical scar, early satiety, of tumor. Reactive gastropathy with mild nausea, fatigue, and weight loss. He appeared chronic inflammation and intestinal metaplasia thin and chronically ill, with a weight of 56.7 kg. was present. Thiazine staining for H. pylori was There was clubbing of all digits, and a small, negative. The hematocrit was 37.7%, the white- tender, firm nodule consistent with a keloid was cell count was 12,000 per cubic millimeter, with palpated in the surgical scar. The hematocrit was 12% eosinophils (normal range, 0 to 8%), and 40.1%, and the white-cell count 7700 per cubic the remainder of the complete blood count was millimeter, with 9% eosinophils. The remainder normal. The phosphorus level was 2.2 mg per of the complete blood count was normal. Mea- deciliter (0.7 mmol per liter), and the calcium surements of serum electrolytes and liver-func- level was 8.8 mg per deciliter (2.2 mmol per li- tion tests were normal. The urea nitrogen level ter). The results of renal- and liver-function tests was 21 mg per deciliter (7.5 mmol per liter), the were normal. The patient was referred for an on- creatinine level 1.0 mg per deciliter (88.4 μmol cology evaluation but did not keep the appoint- per liter), and the lipase level 163 U per liter. ments. Upper gastrointestinal endoscopy revealed mild Eleven months before admission, the patient reactive gastropathy and a nodule, 1 cm in diam- came to the emergency department of this hos- eter, in the gastric body; biopsy specimens of the pital because of a 3-month history of back and nodule and of gastric and small-intestine mu- chest pain, as well as bilateral sharp, pleuritic, cosa at the anastomosis site showed both acute subscapular pain that had occurred occasionally. and chronic inflammation. He had had early satiety since his abdominal sur- Two weeks before admission, a CT scan of the gery. A chest radiograph showed a nodule, 4 mm abdomen and pelvis was unchanged, but CT of in diameter, with the density of metal that was the chest showed a new nodule, 4.5 mm in diam- overlying the fifth posterior rib; the nodule was eter, in the lower lobe of the left lung, with a rim thought to represent a foreign body outside the of ground-glass opacification. The small ground- chest cavity. The radiograph was otherwise nor- glass nodules and cysts were unchanged as com- mal. The hematocrit was 40.2%. The remainder pared with those on the previous scans. He was of the complete blood count and measurements admitted to this hospital. of electrolytes and renal function were normal. The patient did not have cough, hemoptysis, One month later, the patient was seen by pul- bone pain, or headaches, and his weight had been monary and gastroenterology specialists. He re- stable for the previous 4 months. His medications ported that his weight had increased after his included metoclopramide, omeprazole, and cyclo- partial gastrectomy but that he had lost weight benzaprine; he had no allergies. He had been in recent months. The subscapular pain had re- born in Brazil and had immigrated to the United solved spontaneously, and he had no respiratory States more than 20 years earlier. He visited symptoms, fever, or chills. Physical examination Brazil approximately annually, and 7 years earlier, showed that he was a thin, anxious man with he had lived in Japan for 1 year. He was married to mild temporal wasting. The weight was 58.1 kg, a woman of Japanese–Brazilian ancestry and had and the oxygen saturation was 97% while the lived with his wife and children until 4 months patient was breathing ambient air. The abdominal before admission, when his family returned to scar was well healed, and there was moderate Brazil after he left his job in a factory because of clubbing of the fingers; the remainder of the poor health. He ate cooked, but not raw, shell- examination was normal. CT of the chest revealed fish. His father had died at 39 years of age from multiple, small centrilobular nodules and small gastric cancer, and his mother had died at 65 cysts, each less than 3 mm in diameter. The years of age from bronchitis. His children and patient was advised to have a follow-up CT scan siblings were healthy. He had smoked cigarettes 3 months later. for 25 years but had stopped 3 months before A follow-up CT scan obtained 5.5 months later admission. (4.5 months before admission) revealed persistent The vital signs were normal, and the physical centrilobular ground-glass nodules and scattered, examination was unchanged. An electrocardio- 1240 n engl j med 357;12 www.nejm.org september 20, 2007 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2007 Massachusetts Medical Society. All rights reserved. case records of the massachusetts general hospital gram was normal, and pulmonary-function tests for gastric adenocarcinoma.2,4 The risk of gastric showed a low diffusion capacity of the lung for adenocarcinoma varies even among geographic carbon monoxide, after correction for alveolar areas in which H. pylori infection is highly preva- volume. The complete blood count, serum electro- lent, suggesting that additional factors lead to lyte levels, liver function, and renal function were H. pylori–associated gastric cancer. For instance, normal. certain polymorphisms in genes coding for pro- A diagnostic procedure was performed. inflammatory cytokines have been associated with gastric cancer, suggesting that differences First Differential Diagnosis in host inflammatory responses to H. pylori infec- tion may affect the development of gastric carci- Dr.
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