Clinical Case Summary

Background: Malignant peripheral Nerve Sheath tumour is an extremely rare condition, arising from peripheral nerve and extraneural soft tissue. In this report, we describe a malignant peripheral nerve sheath tumour of the duodenum with liver metastasis.
Case presentation: A 54 years old female presented with gastric outlet obstruction associated with significant weight loss (5 kg) for 2 months. On arrival, blood tests showed Hb 7.4g/dl, with normal kidney function, electrolyte, and liver function tests. The serum tumour markers were unremarkable. Initially abdominal CT scan showed an asymmetrical circumferential, irregular wall thickening involving 2nd part duodenum, and two liver nodules, size up to 0.7 cm. Subsequently upper endoscopy was performed, which showed a large circumferential, obstructing mass, malignant appearing, at the second part of the duodenum. The gastroscope was unable to traverse. Tissue biopsies were taken, and histopathology showed high-grade spindle cell neoplasm. The immunohistochemistry showed positive S-100 (diffuse), positive SOX-10 (diffuse), positive CD34 (few), positive SMA (few), negative AE1/AE3, negative Desmin, negative h-caldesmon, negative CD117, negative DOG-1, negative HMB45, negative Melan A, and positive Ki-67 (30-50%); suggestive of malignant peripheral nerve sheath tumour. Liver biopsy was performed targeting at the liver lesion, and histopathology also confirmed spindle cell tumor consistent with liver metastasis, therefore deemed to be unresectable. Subsequently duodenal stent was placed for palliative measure, she was then able to tolerate soft diet, and underwent palliative chemotherapy.
​Conclusion: Malignant Nerve Sheath tumour is extremely rare disease, there is no clear guideline of management and the prognosis remain unclear. In this case, we reported the malignant peripheral nerve sheath tumour of the duodenum with liver metastasis. Multidisciplinary approach, and immunohistochemistry remains crucial.

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

Clinical Case Summary

The stomach is not a common secondary location of breast cancer. It is more frequent in lobular carcinomas than ductal ones. The diagnosis can be challenging since some gastric metastases present as primitive tumors and appear several years after primary tumor treatment.
A 54 years-old woman was diagnosed with left lobular breast cancer in January 2018. The patient had a tumorectomy and lymph nodes dissection. Histology was in favor of grade II invasive adenocarcinoma. Then, she received adjuvant radiotherapy and chemotherapy until August 2019. Initial computed tomography (CT) didn’t show any other lesion. Five years later, while she was asymptomatic, monitoring CT-scan showed a diffuse thickening of the gastric wall associated with a retroperitoneal infiltration. No other abnormalities were described. Physical examination found a performance status (PS) at 0. It showed a retraction of the left breast which had a smaller size compared to the right one. The patient reported a gastric cancer history in her sister, and a death by uterine cancer in her mother. FDG-PET showed no abnormal uptake. Ultrasound and mammography didn’t show any suspicious breast lesion. Upper endoscopy was performed: It showed multiple antral elevations of different sizes, with an ulcerated surface for some of them. A prominent nodule was observed on the greater curvature. Angular mucosa was nodular, with multiple irregular lesions. Anatomopathology showed gastric location of grade II breast lobular carcinoma. Labtests revealed a high rate of CA 15-3 antigen which was superior to 400 UI/l ; CA 19-9 antigen was subnormal, at 48 UI/l. A pluridisciplinary meeting was held and the decision was to initiate systemic therapy.
Even several years after initial diagnosis, gastric location of breast cancer can occur. It may be a challenge for the clinicians, especially when the patient is asymptomatic. Good monitoring through imagery, is useful to get an early screening and better treatment options.

Clinical Case Summary

We present the case of a 67-year-old man with a history of arterial hypertension who consulted for frontal headache, vomiting and unsteady gait for a week. Cranial CT scan on admission showed no alterations. Lumbar puncture was performed with findings suggestive of leptomeningeal carcinomatosis: 190 red blood cells/mcL, 10 leukocytes/mcL, glucose 45 mg/dL, protein 29 mg/dL; cytology suspicious for malignancy. A thoracoabdominal-pelvic CT scan was completed in search of an occult tumour with no evidence of lesions. In addition, colonoscopy was performed in which 6 0-IIa Paris polyps of 7-10 mm were observed in the left colon (photo 1A), and gastroduodenoscopy showed a poorly distensible and hard stomach on biopsy, together with the presence in the duodenum of 3 raised lesions of about 5 mm, excavated in the centre (photo 1B), also biopsied. Histology results reported mucosal and submucosal infiltration by poorly differentiated carcinoma, with positive immunohistochemistry for CK19 and CK7 and negative for inhibin, synaptophysin, chromogramin and S-100, all suggestive of infiltration by poorly differentiated carcinoma of probable gastric origin. Unfortunately, the patient presented a progressive clinical deterioration and died 2 weeks later.
Leptomeningeal carcinomatosis is the diffuse seeding of malignant cells in the cerebrospinal fluid. Its association with gastric cancer is extremely rare, with a prevalence of 0.14-0.24% of patients, mostly described in undifferentiated and signet ring tumours. Similarly, gastric metastases in the colon, and even more so in the duodenum, have been poorly described, being mainly associated with seeding and extension of implants through the gastrointestinal lumen. The benefits of intrathecal chemotherapy are currently controversial. In light of this case, the clinician should consider in the differential diagnosis of leptomeningeal carcinomatosis, the possibility of an occult gastric tumour, even in early stages.

References

Park, Kwang-Kug et al. "A case of metastatic leptomeningeal carcinomatosis from early gastric carcinoma". World J Surg Onc 10, 74 (2012).
Sonoda, Hirofumi et al. “Lymphogenous metastasis to the transverse colon that originated from signet-ring cell gastric cancer: A case report and review of the literature.” Clinics and research in hepatology and gastroenterology vol. 41,6 (2017): e81-e86.

Clinical Case Summary

A 66-year-old patient underwent cephalic pancreaticoduodenectomy on 05/2021 for moderately differentiated adenocarcinoma of the distal bile duct (R1 pT3 pN1). He underwent 8 cycles of adjuvant chemoradiotherapy with Capecitabine, which ended on 12/2021. On 09/2022, locoregional recurrence was detected and the disease was considered unresectable. At this time, he started systemic therapy with Cisplatin+Gemcitabine+Durvalumab (TOAZ trial 1). Prior to the beginning of the third cycle, the patient began to suffer from food intolerance with vomiting. A CT scan showed locoregional progression of the disease with extension to the stomach and infiltration of the gastro-jejunal anastomosis. In the endoscopic comparison, the anastomotic stenosis was confirmed, only transposable with the pediatric gastroscope, leaving the efferent loop permeable. Given the unequivocal progression of the disease, an assumed palliative strategy and, in line with this decision, a minimally invasive – endoscopic – approach was chosen to protect the gastric outlet tract. Once the efferent loop has been isolated, a nitinol guidewire was advanced under direct vision through which a metal prosthesis with luminal apposition (Spaxus®) 16x20 mm was submitted by backload, released simultaneously under control under fluoroscopic control and endoscopic vision. At the end of the procedure, luminal patency was confirmed with contrast injection. One week after stent placement, the patient continues to tolerate the oral diet, was discharged and will be reassessed in a Medical Oncology consultation with the aim of starting second-line chemotherapy (FOLFOX).
Locoregional recurrence after Whipple’s procedure is high.Lumen-apposing metal stents, originally designed for the management of pancreatic fluid collections, have been shown to be option for gastrointestinal strictures due to their anti-migratory design. This report shows its application in cases of short strictures requiring preventive migration measures.

Clinical Case Summary

Introduction: On a global scale, carcinoma of the stomach ranks within the four most common causes of oncological death in men, and within the fifth in women. Based on the level of tumor staging, there exist differing strategies for therapy.
The most well-known metastatic sites associated with gastric primary cancer are the peritoneum and the liver
Medullary invasion is generally discussed in the context of gastric lymphomas, while it is exceptionally rare in gastric adenocarcinoma. There are limited published data about gastric cancer with bone marrow involvement, its treatment and its prognosis, which remains unfavorable to date.
Objective of the study: The aim of this case report is to detail its clinical presentation, diagnostic workup, treatment approach, and outcomes to contribute to the understanding and management of this rare variant of gastric cancer.
Observation: A 43-year-old man with no medical history, presented to the emergency department with one-month history of a hemorrhagic syndrome characterized by melena, gingival bleeding, and retinal hemorrhage.
A biological assessment was performed upon admission, revealing normochromic normocytic anemia with hemoglobin levels at 3.4 g/dL and platelet count at 11,000/mm^3. Due to the lack of improvement in platelet count even after transfusion, an osteomedullary biopsy was performed for diagnostic purposes revealing a Spinal infiltration by a poorly differentiated and infiltrating gastric adenocarcinoma. After a platelet transfusion that brought the count up to 31000, we performed a fibroscopy to investigate the primary cause. This fibroscopy revealed a moderately differentiated and infiltrating adenocarcinoma with a signet ring component, ulcerated on the surface and the presence of neoplastic vascular emboli.
The case was discussed in a multidisciplinary consultation meeting, and the decision was made to start chemotherapy based initially on the LVFU5 protocol then the folfox protocol after a significant improvement.
Conclusion: Gastric cancer is known for its frequency, but the uniqueness of our patient lies in its rare medullary localization.
Gastric cancer can have an atypical presentation revealing its secondary localization.
Despite its poor prognosis, treatment can improve survival duration and quality of life in patients with medullary metastatic disease.

References

1. Zaanan A, Bouché O, Benhaim L, Buecher B, Chapelle N, Dubreuil O, et al. Gastric cancer: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Digestive and Liver Disease. août 2018;50(8):768‑79.
2. Ekinci AŞ, Bal Ö, Özatlı T, Türker İ, Eşbah O, Demirci A, et al. Gastric Carcinoma with Bone Marrow Metastasis: A Case Series. J Gastric Cancer. mars 2014;14(1):54‑7.
3. Zhang L, Chen F, Xu L, Li N, Zhuo Q, Guo Y, et al. Comprehensive review of solid tumor bone marrow metastasis. Critical Reviews in Oncology/Hematology. 1 févr 2024;194:104248.

Clinical Case Summary

Introduction: Among gastric malignancies, lymphomas rank as the second most common type, following gastric adenocarcinoma.
Primary gastric Burkitt lymphoma, is a subtype of non-Hodgkin's lymphoma, represents an exceptionally rare and aggressive malignancy, with only a limited number of reported cases globally.
A case: An 81-year-old man, smoker and chronic alcoholic, who presented to the emergency unit for epigastralgia evolving for a month with intermittent vomiting complicated on the same day of his hospitalization by the occurrence of hematemesis and melena evolving in a context of altered general condition.
Physical examination revealed pallor and epigastric tenderness.
The upper gastrointestinal endoscopy revealed an antral pre-pyloric ulcerative process, bleeding easily on contact, as well as two fundic ulcerations with raised edges.
Histological examination of the endoscopic gastric biopsy revealed diffuse infiltration of the gastric mucosa by a lymphomatous tumoral process, the immune histochemical evaluation revealed that lymphoid cells were positive for CD20, CD10, and Bcl6, negative for CD23, CD5 and Bcl2. All of the neoplastic cells were positive for Ki-67. These findings pointed toward a diagnosis of gastric Burkitt's lymphoma.
A CT scan of the abdomen showed diffuse and irregular endoluminal thickening of the antropyloric wall. Lymph nodes measuring 1 to 2 cm were present around the stomach, with no secondary location.
Considering all the clinical, radiological, and pathological findings, a final diagnosis of Burkitt's lymphoma arising from the stomach was made. The case was discussed in the multidisciplinary clinic, it was decided to go ahead with intensive systemic chemotherapy with cyclophosphamide and rituximab.

Disclosure

no conflict of interest