A case of carcinoma of the stomach

TUMOR

BOARD

CONFERENCE

A Case of Carcinoma

of the Stomach

T Assistant

of the Georgetown Tumor Board, edited by John F. Potter, M.D., Professor of Surgery and Head of the Division of OncoIogic Surgery, arc published in each issue of the Journal. The participants of the following conference are: Willy E. Baensch, M.D., Professor of Radiology; Charles F. Geschickter, M.D., Professor of Pathology; Robert J. Coffey, M.D., Professor of Surgery; Murray M. Copeland, M.D., Assistant Director and Visiting OncoIogist, The M. D. Anderson Hospital, Houston, Texas; and Modestino G. CriscitieIIo, M.D., Assistant Professor of Medicine. HE

A

PROCEEDINGS

year old white man was admitted to this institution with a diagnosis of carcinoma of the stomach. The present ilIness began ten months previously with anorexia and vague epigastric discomfort for which an upper gastrointestinaI series was performed. This reveaIed a 6 cm. intralumina1 mass arising from the greater curvature of the stomach (Fig. I), and a diagnosis of carcinoma of the stomach was made. The patient refused surgery and was discharged. The epigastric pain increased in severity, and intermittent nausea and vomiting ensued. A forty-three pound weight loss occurred during the following seven months. On the day of admission the patient had two bouts of massive hematemesis, and was referred to this hospital. The only significant feature in the past medical history was hypertension. Physical examination revealed an emaciated white man. A mass measuring 2 by 3 cm. was paIpated in the left epigastrium. There was a grade II systolic murmur over the precordium, and the blood pressure on admission was Q/65 mm. Hg. Laboratory data incIuded a hematocrit of I 6 per cent and a white blood ceII count of IS,OOO per cu. mm. with a shift to the Ieft. The urinalysis was within normal Iimits. Blood urea nitrogen was 40 mg. per cent; carbon dioxide, 17.5 ; sodium, 134 mEq. per L.; potassium, 4.9 mEq. per L. and chlorides, IOO mEq. per L. Total protein was 4.4 gm. per cent; albumin, 1.6 gm. per IOO ml. and globuIin, 2.8 gm. per 100 ml. SEVENTY-EIGHT

After multiple transfusions, surgical exploratory operation was undertaken as a palliative resection. The carcinoma involved the distal half of the stomach, but no distant metastases were found. The tumor was fixed to the subadjacent pancreas at one point. A radical subtotal gastrectomy with gastroduodenostomy was performed, and in addition, a local resection of the involved pancreas was carried out. The procedure was Iisted as a “curative resection.” Initially, the patient did well until the fifth postoperative day when a pleural effusion developed with some dyspnea and orthopnea, and became oIiguric. A Iow grade temperature developed at the same time. The bIood urea nitrogen increased to 70 mg. per cent. Therap) consisted of intravenous albumin and invert sugar, and the patient was rapidly digitalized with digoxin. An electrocardiogram revealed changes compatible with a myocardial infarction. Vasopressor agents were necessary to maintain the blood pressure. The patient’s condition deteriorated, and he died in shock. This patient is presented to the Board for a review of case management. DISCUSSION

DR. W’ILLY E. BAENSCH: The stomach shows an irreguIarity along the greater curvature with narrowing of the distal portion of the corpus and the prepyloric area. This fiIling defect indicates the presence of a tumor in the stomach. Diagnostic possibilities include a

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.4mericanJournal

OJ Surgery.

Volume rod, July 1962

Tumor

Board Conference

FIG. I. Upper gastrointestinat series reveals irreguIarity along the greater curvature of the stomach with a definite HIing defect, indicative of tumor.

of adenocarcinoma of the stomach. Note the acinar FIG. 2. Microphotograph structures, sheets and cords of hyperchromatic, pIeomorphic tumor ceIIs. OriginaI magnification X 98.

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benign tumor, a sarcoma or a carcinoma. Benign tumors of the stomach are rare, accounting for onIy z per cent of a11gastric Iesions; they are usually seen in the pyIorus, and present as a sharply demarcated, symmetrica mass. The possihiIity that this lesion is a sarcoma is unIikeIy from a statistical basis, and sarcomas are usually more diffuse and infiItrative. Carcinoma of the stomach presents, radiographicaIIy, either as an ulcerative, an infiItrative or an exophytic pattern. With the features of disruption of the mucosa1 folds, rigidity 01 the stomach waI1 and the presence of a fiIling defect, the diagnosis of stomach cancer is exceedingly probable. DR. CHARLES F. GESCHICKTER: The gross specimen removed at the time of surgery reveaIed an infiItrating carcinoma of the stomach. On the microscopic sIides (Fig. 2) you can see smaI1 acinar structures which the tumor presents and an uIcerated area of the mucosa. Thickening of the muscIe apparentry beneath this area of ulceration is evident. Islands of tumor ceIIs with a tendency to form acini and to infiltrate in cords and sheets were observed. There is great proliferation of the connective tissue around the tumor. The Iymph nodes reveal the same structures, microscopicaIIy, and the Iymphoid tissue is almost fuIIy repIaced by tumor acini. A great degree of connective tissue in the lymph nodes aIso was observed. At, the time of the postmortem examination coronary atheroscIerosis and a recent septal myocardia1 infarction were noted. Chronic passive congestion of the liver, hemothorax and the kidney of lower nephron nephrosis were present. No evidence of residual stomach cancer was noted. DR. ROBERT J. COFFEY: An ironic feature of this case is that after a delay of six months before surgica1 treatment was accepted, the tumor was still atnenable to a “curative resection.” If the patient had survived the immediate postoperative course, his prognosis for a proIonged survival wouId have been reasonably good. This type of favorabIe lesion is certainIy not typica of gastric cancer which in 75 per cent of patients is too advanced for curative surgery. If an improvement in the present 6 to 8 per cent five year surviva1 rate is to be obtained, both improved methods of diagnosis of early cancer and prompt operation on a11 suspicious lesions and most precursor Iesions are necessary.

of the Stomach Patients with Iesions, which are known to be precursors to gastric cancer, must be carefully followed. AI1 patients with anacidity must have a follow-up examination at least once annualIy. Since patients with a pernicious anemia have an increased susceptibihtv to gastric cancer, they too should have a periodic x-ray examination. The relationship of gastric polyps to carcinoma is so clearly established that remova of al1 such polyps is desirable. The fact that gastric carcinoma may masquerade as a benign uIcer needs to be re-emphasized. If any improvement in the saIvage rate of gastric cancer is possibIe with our present modalities, it will probably stem from a more aggressive attitude toward the gastric uIcer. The differentia1 diagnosis between benign and malignant gastric ulcers is extremeI> difficult. Even on gross examination of the resected stomach the pathoIogist may confuse the two Iesions. The difficulty of distinguishing these ulcers on the basis of clinical features and x-ray studies is well known to all doctors. It is true that certain x-ray criteria are helpful in distinguishing between the benign and maIignant uIcer, but there are so many exceptions to these rules that they cannot be relied upon. Neither the size of the ulcer nor the position in the stomach are compIetely reliable distinguishing characteristics. Because of these many difficulties in distinguishing the benign from malignant gastric ulcer, the demonstration of a clinically benign gastric ulcer is an indication for an immediate, intensive and vigorous course of medical therapy, preferably in a hospitaI, to be promptIy followed by surgical intervention in those patients who fail to respond to conservative measures. Some authors beIieve that there is an increased incidence of carcinoma in the gastric remnant after subtota1 gastric resection or gastroenterostomy performed for gastric ulcer. It is hypothesized that this increased incidence may be caused by either the achlorhydria which resuIts from gastric resection or the regurgitation of alkaline intestinal juice through the gastric stoma. A STUDENT: What do you consider the operative treatment for gastric cancer? DR. COFFEY: This depends somewhat upon the situation and extent of the tumor. If the tumor is situated in the dista1 portion of the stomach, and no distant metastases are present, I beIieve that a radica1 subtotal gastric resec-

Tumor

Board Conference

tion with removal of the spleen, the greater omentum, and if necessary, the distal portion of the pancreas is warranted. I believe that a small gastric pouch should be Ieft along the greater curvature to which the small bowel may be anastomosed. This gastric pouch will prevent some of the metabolic sequellae such as dumping syndrome or a severe anemia which develop after the total gastrectomy. If the lesion is of the infiltrative type, total gastrectomy may be necessary. For palhative purposes a conventional subtotal gastrectomy is often desirable to remove an uIcerating and bleeding tumor. If this cannot be done, a gastroenterostomy may allow bypass of an obstructing stomach tumor. A STUDENT: What is the prognosis for the patient with cancer of the stomach? DR. COFFEY: Unfortunately, the outlook is quite bleak. Of all patients with gastric cancer onIy 6 to 8 per cent will survive five years. Of these patients who are suitable for a curative resection, however, the survival figure is about 25 to 30 per cent. Although the outlook for a cure in the patient with stomach cancer is poor, I do not believe that any patient should be denied Iaparotomy unless there is unequivocal evidence of distant spread as evidenced by a palpable Blumer’s shelf implant, paIpabIe metastasis to the umbilicus, a palpably enlarged noduIar Iiver or the demonstration of metastases by roentgenogram. The elderly patient with symptoms of long duration often has an easiIy resected lesion associated with a reasonabIy good prospect of salvage. This is probably related to the fact that these Iesions are bioIogicaIIy less active than the tumors which present more dramaticahy. In summary, a survey of today’s case would indicate to me that the patient was adequately prepared for surgery by replacement of blood volume deficit, and that as thorough an evaluation of his systemic status as possible was carried out preoperatively. It is regrettable that earlier surgery was not performed. DR. MURRAYM. COPELAND: An interesting feature of gastric cancer is the decreasing incidence of this disease in the United States. In rg3o the incidence of gastric cancer deaths in the United States was 28.8 per IOO,OOO persons, and amounted to 25 to 30 per cent of all cancer deaths. At the present time, the incidence is 12.6 per IOO,OOO persons and accounts for only 15 per cent of a11 cancer mortality. This de-

crease of gastric cancer is predominantIy because of a decreased incidence in the Caucasian race. Negro women have shown a slight decline, but Negro men have shown apparently the same incidence of this disease. Similar decreases have also been reported in Canada, the Netherlands, Australia and Switzerland. However, this is not a universal trend as England and Wales showed no change in mortahty from stomach cancer, and Japan has a high incidence rate. Fifty-three and eight-tenths per cent of a11 cancers in Japanese men were in the stomach according to death certificates in 1959. Interestingly the incidence of carcinoma of the stomach among Japanese is highest among those Iiving in Japan; whereas, the incidence falls progressively among Japanese living in Hawaii, and stilI further with those residing in California. Apparently both race and environment have something to do with the production of this condition. Iceland also has a high incidence of gastric cancer and 45 per cent of all cancer deaths in men are of this type. Dungal has recently investigated this situation in Iceland, and he believes that the frequent ingestion of smoked meat and fish which has a measurable amount of 3,4-benzpyrene may be responsible. These food stuffs, when fed to laboratory animals, produced an apparently elevated incidence of tumors; although, these neoplasms were not confined to the stomach. Dungal also believed that the geographic distribution of the disease in his country favored the etioIogic significance of the ingestion of smoked trout and saImon. DR. COFFEY: I would be interested to hear what our medical coIIeagues think about operative risk in patients with heart disease, and their opinion of this patient’s death. DR. MODESTINO G. CRISCITIELLO: This elderly man was presumed to have had heart disease in the past. His systolic blood pressure had been elevated presumably as a result of atherosclerosis of the Iarge vessels. He had experienced no dyspnea or orthopnea, and no evidence of congestive heart failure on admission was noted. An electrocardiogram taken preoperatively was suggestive of an old anterosepta1 infarction, but there was no evidence of electroany acute process. A postoperative cardiogram, taken approximately twenty-four hours after surgery, was unchanged. In a tracing taken on the sixth postoperative day, however, inverted T waves were seen in leads Vg and Ve, and suggested myocardial ischemia. 92

A Case

of Carcinoma

of the

Stomach

following, ;t surgical procedure may provoke suspicion of a myocardial infarction. Of course an infarction may occur without producing such evidence, and since the anesthetized patient is unable to report pain, the detection of such an infarction may be diff’cult. Dr. Proger and his group ha\.e also analyzed this problem by taking routinely pre- and postoperative electrocardiograms in nonselected patients. In a group 12 proved to have myoof 496 such patients, cardial infarction postoperatively as detected by an electrocardiogram. In sis of these patients the infarctions could have been cletected clinically either because of chest pain or a drop in blood pressure, but it is interesting that in the other six patients the diagnosis could not have been made without the electrocarcliogram. All of these twelve patients were over fifty years of age, and all had had one or more of the following: (I ) Chronic coronary artery disease, (3) diabetes melhtus, (4) (2) hypertension, peripheral vascular disease or (3) an abnormal electrocardiogram preoperatively. From this data it xvould appear wise to take an electrocardiogram postoperatively on all patients over the age of 50 years with such a backgrouncl. This recommendation was followed in the case under discussion, but no change in the electrocardiogram was noted until the fifth or sixth dav. Although his infarction was cletected, digitalis therapy and pressor agents failed to reverse the ensuing failure and shock. STUDEKT: Would you advocate preoperative digitalization of patients not in failure who have a history of coronary artery disease? DR. CRISCITIELLO: No, I believe that digitalization is not routinely indicated in all such patients. If a patient, particularly an elderly one, has been in failure in the past, one could argue for preoperative digitalization even in the absence of current signs of decompensation. Certainly the patient with atrial fibrillation or flutter should receive digitalis in amounts adequate to provide a slow ventricular rate prior to surgery. However, I would not give cligitalis as a routine preoperative measure to a patient with coronarv disease, who has no history of congestive failure and whose rhythm is stable.

They persisted to the seventh postoperative clay. During this interval, the patient developed respiratory distress, orthopnea and pleural effusion, and it was postulated that he had sustained a myocardial infarction. I should like to ask if the patient reported any chest pain in the postoperative period. ANSWER: No chest pain was noted, but he dicl have some cyanosis and dyspnea in the final two days. DR. CRISCITIELLO: Was the patient alert enough to recognize and report pain? ANSWER: Yes, he was. DR. CRISCITIELLO: It would be my impression, then, that there had been no electrocardiographic or clinica evidence of a myocardial infarction until about the sixth day. It is likely that the dyspnea and cyanosis, which occurred terminally, were the consequences of this infarction. In answer to Dr. Coffey’s question about operative risk in patients with heart disease, I should like to refer to the work of Drs. Etsten and Proger, at the New England Hospital Center. They assessed the risk of surgery in patients with coronary disease. In their control group of over 4,000 persons with no history of heart disease of any sort, the mortality rate, related to heart disease, was 0.1 per cent. Among patients with heart disease, it was discovered that there was no increase in mortaIity related to hypertensive, vaIvular or noncyanotic congenital heart disease unless congestive failure was present. However, in the group of over 300 patients with a history of coronary artery disease, a mortality rate, related to the heart. disease, was 1.2 per cent. This indicates that there is a definite, but not prohibitive, increase in the risk of surgery for patients with coronary disease. The conclusion of these investigators was that necessary surgery should not be withheld because of a history of coronary disease. It is emphasized that this statement does not apply to recent myocardial infarction. In retrospect, despite the severe anemia present on admission, no evidence of congestive failure appeared in the patient under discussion. He tolerated multiple transfusions well, and approached surgery with a stable cardiac status. STUDENT : How do you detect myocardia1 infarction in the operative or postoperative patient? DR. CRISCITIELLO: An otherwise unexplained fall in bIood pressure, or the deveIopment of an arrhythmia during, or immediateIy

CONCLUSION OF THE BOARD Cause of death classified as nonpreventable. Al1 reasonable methods of assessing the patient and preparing for surgery had been taken. Deficiencies in treatment were not noted. 93