CASE BASED
PRESENTATION
DR. SADIA ARSHAD
➢ A 50 Years old male smoker presented to OPD with
complaint of
• Epigastric discomfort - 6 months
• Anorexia – 6 months
• Early satiety – 2 months
• What other question will you ask in history?
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➢ History of presenting complaint?
➢ History of associated signs and symptoms?
• Altered bowel habits
• Weight loss
• Melena
• Dyspepsia
➢ History of differential diagnosis?
➢ History of Risk factors?
• Family history
• H. Pylori infection
• History of polyps
• Smoking
• Dietary habits ( Salt and smoked meat, low intake of fruits and vegetables)
• Prior radiation exposure
• Prior history of gastric surgery 2/28/2025 3
➢ On detailed history, he has epigastric pain and discomfort for the last 6
months, pain is dull in nature, mild in intensity but persistent, it
aggravates after meal and is not relieved by anything, associated with on
and off indigestion and recent onset early satiety.
➢ He recalls passing dark colored stools once or twice during this period.
➢ He has lost 15kgs in the last 2 months.
➢ He is fond of eating processed and smoked meat.
➢ There is no family history of malignancy or polyposis syndromes.
➢ There is no significant past surgical history.
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➢ Differential diagnosis?
• Stomach Carcinoma
• Duodenal Carcinoma
• Gastric Lymphoma
• GERD
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➢ Examination :
➢ General Physical examination
➢ Abdominal examination
➢ Lymph node examination
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➢ On Examination :
• Old aged pale looking male with thin lean built and
average height.
• On abdominal exam, abdomen soft, non tender, with
vaguely palpable epigastric fullness.
• There is no ascites, no palpable lymph nodes , no
hepatosplenomegaly.
• DRE unremarkable.
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➢ How will you proceed?
• Admit the patient.
• Get biochemical workup done including
➢ CBC
➢ Electrolytes
➢ Creatinine
➢ LFTs
➢ Coagulation profile
• Ultrasound Abdomen
• CXR
• Endoscopy and biopsy
• CT scan abdomen with contrast.
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➢ Biochemical Workup
• Hb – 6.8mg/dl
Rest unremarkable.
➢ Endoscopy was done
which showed
ulcerated and
hypertrophic growth
at pyloric antrum, 6-8
biopsy samples were
taken.
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➢ Histopathology showed :
• Moderately differentiating invasive adenocarcinoma.
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➢ CT Abdomen with Contrast was done ;
• Increased wall thickness of around 1cm as tumor
infiltration present at gastric antrum, No local invasion to
adjacent structures and no regional lymphadenopathy
noted.
• No distant metastasis.
➢ How will you proceed further?
➢ Counsel the patient regarding his/her diagnosis and
available treatment options and proceed for staging
workup
• Endoscopic ultrasound - to determine the depth of
tumor invasion
• PET CT – To rule out occult metastasis, should be done
in patients with greater than T1 disease on initial CT
scan.
• Staging Laparoscopy – Should be done to rule out
peritoneal metastasis, since the lesions are iso dense and
cannot present on CT.
INTERNATIONAL UNION AGAINST CANCER (UICC) STAGING SYSTEM :
➢ Staging
• Stage 0 – Tis , N0, M0
• Stage 1 – T1/T2, N0, M0
• Stage 2A – T1/T2, N1/N2/N3, M0
• Stage 2B – T3/T4a, N0, M0
• Stage 3 – T3/T4a, N1/N2/N3, M0
• Stage 4A – T4b , Any N, M0
• Stage 4B – Any T, Any N, M1
➢ Definitive Management
• Neoadjuvant
Chemotherapy (4 cycles)
• Subtotal Gastrectomy with
Roux-en-Y
Gastrojejunostomy and
locoregional
lymphadenectomy.
• Adjuvant Chemotherapy
(4 cycles)
➢ Pathology Report
• Histology type : Adenocarcinoma
• Histological grade : Grade 2, moderately differentiating
• Tumor bed focality ; Unifocal
• Tumor configuration ; Ulcerating
• Tumor bed extent ; Invades muscularis propria
• Size ; 4 x 2.7 x 1cm
• Macroscopic tumor bed perforation : not identified
• Resection margins :
➢ Proximal 4.5cm away, tumor free
➢ Distal 5cm away, tumor free
• Lymphatic/vascular invasion ; not identified.
• Perineural invasion ; not identified.
• Lymph nodes ; total 16 recovered, all tumor free.
• Treatment effect : Present , with residual cancer showing evident tumor regression but
more than single cells are identified ( Partial response )
• Pathological Stage : ypT2, N0.
➢ Chemotherapy Regimen :
• FLOT ( 5- Fluorouracil, leucovorin,
Oxaliplatin, Docetaxel)
• 4 cycles Pre Op, 4 cycles Post Op.
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➢ Post Surgical Complications :
• Anastomotic leak
▪ Gastrojejunostomy leak
▪ Duodenal stump leak ( usually due to a degree of distal obstruction
and care must be taken to avoid kinking when performing a Roux
en y anastomosis).
• Paraduodenal collection
• Hemorrhage
• Nutritional deficiency – Occur in 30% patients, iron, folate, vitamin
B12 deficiency requiring replacement.
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• Dumping Syndromes
▪ Early Dumping : Occurs within 30 minutes of eating ,
characterized by nausea , epigastric discomfort,
explosive diarrhea. It is caused by rapid shift of
extracellular fluid into the bowel lumen in response
to a hyperosmolar load entering the small bowel
from the stomach.
▪ Late Dumping : Occurs 2-3 hours after eating,
hormonal response to eating leading to
hyperinsulinemia and reactive hypoglycemia,
leading to catecholamine release, it is relieved by
carbohydrate ingestion.
➢ Surveillance :
• History and Examination every 3 t6 monthly for 1-2 years, then 6-12
monthly for the next 3-5 years.
• Annual endoscopy upto 5 years.
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THANKYOU.
