Clinical Case Summary

Introduction: Myeloid sarcoma (MS) is a rare neoplasm composed of immature myeloid cells, which can occur de novo or in association with hematologic malignancies such as acute myeloid leukemia (AML). Gastric involvement is rare.
Case Report: A 56-year-old woman with a medical history of acute myeloid leukemia (AML) with inv(16). Following two unsuccessful induction therapy cycles, she underwent two unrelated allogeneic hematopoietic stem cell transplantations (HSCT). During the second post-HSCT period, she developed grade I gastrointestinal graft-versus-host disease (GI GVHD), confirmed by biopsy and managed with budesonide.
Five months post-HSCT, the patient was admitted due to upper gastrointestinal bleeding (melena) and worsening anemia (Hb: 5,6 g/dL). Gastroscopy revealed multiple hemorrhagic suffusions, petechial areas, nodular formations with erythematous borders, and eroded centers that bled upon contact and were not amenable to endoscopic treatment (Figure 1). Biopsies were performed to exclude GI GVHD and viral superinfection. Histological examination revealed acute myeloid leukemia (myeloid sarcoma) infiltration in the gastric mucosa (Figure 2). Six months post-HSCT, the patient succumbed to AML progression.
Discussion:
- Myeloid Sarcoma (MS) typically affects the skin, lymph nodes, and brain, making its occurrence in the gastrointestinal tract uncommon.
- Endoscopic imaging may mimic other conditions therefore biopsies are required to confirm the diagnosis.
- In hematologic patients post-HSCT, endoscopic evaluations are essential for diagnosing gastrointestinal complications such as opportunistic infections, GI graft-versus-host disease (GI GVHD), and progression of their underlying disease. Our case highlights the rarity of gastric MS.

References

Figure 1: Gastroscopic images (A and B) depicting multiple hemorrhagic suffusions, petechial areas, nodular formations with erythematous borders, and eroded centers.

Figure 2: Histological examination of gastric and oxyntic mucosa biopsies revealing lamina propria occupation by small to medium immature blast cells, consistent with acute myeloid leukemia infiltration of the gastric mucosa (previously identified).

Clinical Case Summary

Introduction: Kaposi's Sarcoma is a neoplasia in blood and lymphatic vessels, often linked to HHV-8, affecting 40% of HIV-positive patients. Upper gastrointestinal endoscopy reveals thickened folds with rounded nodular violaceus lesions or hemorrhagic macules, hence it represents an unusual cause of digestive bleeding in HIV patients.
Case Report: A 67-year-old male, previously healthy, was admitted to the gastroenterology department for symptoms including progressive dysphagia, weight loss of 6 kg over 2 months, and intermittent episodes of melena. Laboratory tests revealed iron deficiency anemia (Hb 11.5g/dL). Gastroscopy showed a diffuse distribution of multiple prominent whitish plaques throughout the esophagus, indicative of candidiasis (Figure 1). In the stomach, several elevated erythematous-violaceous vascular-like lesions were observed in the greater curvature of the gastric body (7-8) (likely related to KS) (Figures 2 and 3). Histological analysis confirmed the presence of KS, showing vascular spindle-shaped cells, with immunohistochemical tests positive for CD34 and HHV-8 (Figure 4) leading to a HIV testing, turning positive with a high viral load and critically low CD4+ count. The patient is now receiving antiretroviral therapy and is monitored by infectious disease specialists. KS was also found in the skin and palate but not in the lungs.
Discussion: Improved access to antiretroviral therapy has led to a reduction in the incidence of AIDS-related illnesses among individuals with HIV. However, it is imperative not to disregard the presence of certain endoscopic lesions that may indicate this diagnostic probability, such as esophageal candidiasis or gastric/duodenal vascular lesions. Gastric KS, as a cause of digestive bleeding is rare; nevertheless, it merits consideration in the differential diagnosis of HIV-positive patients.

References

Figure 1: Endoscopic image showing a diffuse distribution of multiple prominent whitish plaques throughout the entire length of the esophagus, indicative of candidiasis.

Figures 2 and 3: Endoscopic images displaying elevated erythematous-violaceous vascular-like lesions in the greater curvature of the gastric body, likely related to Kaposi's sarcoma (KS).

Figure 4: Displays histopathological examination results, showing the proliferation of vascular spindle-shaped cells consistent with KS, with positive immunohistochemistry for CD34 and HHV8.

Clinical Case Summary

Case: We present a case of parietal cell carcinoma presenting with melena and pain abdomen. A 57-year-old Indian male, known diabetic and reformed smoker/alcoholic presented with upper abdominal pain and generalised weakness for three months. He also reported passage of black tarry stools for 3–4 days, about 15 days back, following which he started having general weakness and easy fatigability. Physical examination showed pallor with normal abdominal examination. Investigations revealed haemoglobin to be 10 g/dl and peripheral blood film showed microcytic hypochromic anaemia. Liver and renal function test were normal. Contrast enhanced CT scan of abdomen revealed arterial phase enhancing polypoidal lesion on greater curvature of the stomach. Esophagogastroduodenoscopy showed a six cm size ulcerated, friable mass in proximal body of stomach. Biopsies showed evidence of parietal cell carcinoma. The cells showed glandular arrangement, abundant granular eosinophilic cytoplasm, along with positive immunohistochemistry for Pan-Cytokeratin. Patient underwent exploratory laparotomy with total gastrectomy, distal pancreatectomy, splenectomy, roux-en-y esophagojejunostomy. He received adjuvant chemoradiotherapy. Patient recovered well and became asymptomatic.
Discussion: Parietal Cell Carcinoma is a rare malignant tumor of stomach with a strikingly male (9:1) preponderance. It generally occurs in older males and runs a relatively indolent course. These well to moderately differentiated tumors are usually diagnosed by pathology. Lymph node and distant metastasis occur rarely, hence prognosis is generally favourable.
Conclusion: Parietal cell carcinoma is rare cause of gastric mass and upper gastrointestinal bleeding. It is rarely considered in differential diagnosis clinically and diagnosis invariable emerges on histopathology.

References

Motta, M., Athanazio, D., Motta, A., Studart, E. and Athanazio, P., 2008. Parietal Cell (Oncocytic) Adenocarcinoma of the Stomach in a Female Patient: Superficial Spreading and Extensive Nodal Involvement. International Journal of Surgical Pathology, 16(4), pp.447-449.
Byrne, D., Holley, M. and Cuschieri, A., 1988. Parietal cell carcinoma of the stomach: association with long-term survival after curative resection. British Journal of Cancer, 58(1), pp.85-87.
Takubo, K., Honma, N., Sawabe, M., Arai, T., Izumiyama-Shimomura, N., Kammori, M., Sasajima, K. and Esaki, Y., 2002.

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

Clinical Case Summary

Introduction: Nonvariceal upper gastrointestinal bleeding is mostly due to peptic ulcer disease [1]. Occasionally, gastric malignancy may be implicated in these situations [2]. Here, we report a case of nonvariceal upper gastrointestinal bleeding as the only manifestation of gastric bladder carcinoma metastasis.
Discussion: A 81 years old caucasian man performed a bladder endoscopic resection for a non metastatic bladder carcinoma in January 2022 with a negative follow up since October 2023 when the patient was hospitalized for a melena episode.
During the hospitalization, an esophagogastroduodenoscopy (EGD) was performed and showed a large gastric fundic lesion covered with flat pigmented clots, that was sampled: at the histological evaluation a gastric metastasis of bladder carcinoma was found. The patient, then, performed a thorax and abdomen computed tomography (CT) scan that didn’t show bladder neoplastic recurrence or other metastasis sites. The patient, so, performed a wedge gastric resection and then started chemotherapy that is now ongoing with good response.
Conclusion: We describe, as we know, the first case of a nonvariceal upper gastrointestinal bleeding as the only manifestation of bladder cancer recurrence. Indeed, in our clinical practice, neoplastic lesions aren’t routinely taken into account, in the differential diagnosis of nonvariceal upper gastrointestinal bleeding.

References

1. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332. doi: 10.1055/a-1369-5274. Epub 2021 Feb 10. PMID: 33567467.

2. Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg. 2022 Apr;26(4):932-949. doi: 10.1007/s11605-022-05258-4. Epub 2022 Jan 26. PMID: 35083723.

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 62-year-old woman with hypothyroidism and multiple sclerosis presented to our care to underwent outpatient esophagogastroduodenoscopy (EGD) after one episode of hematemesis, which had occurred 20 days earlier following the use of Naproxen (440 mg/day) for low back pain. Proton pump inhibitor (PPI) therapy had been initiated afterward. EGD revealed a 20 mm ulcer in the gastric body with an adherent clot. Upon gastric distension, oozing bleeding from the ulcer was observed and treated with adrenaline injection and endoscopic clips. Diffuse oozing from the gastric mucosa and multiple suction-related hematomas were also noted. The patient was hospitalized and started on high-dose intravenous PPI therapy and fasting. H. pylori serology was negative. Physical exam showed hepatomegaly and lower limb edema. Lab tests revealed elevated cholestatic enzymes, proteinuria, leukocytosis, hypoalbuminemia, mild anemia, and a monoclonal spike on serum protein electrophoresis. Abdominal ultrasound confirmed hepatomegaly. Autoimmune, viral, and metabolic liver diseases were excluded. Liver magnetic resonance raised suspicion of a storage disorder. Liver biopsy confirmed AL-type amyloid deposits. A follow-up EGD was performed, in absence of further GI bleeding, to obtain gastric biopsies. It showed a 1 cm ulcer with an adherent clot in the fundus. Again, insufflation triggered diffuse oozing from the ulcer and gastric mucosa with suction-related hematomas. Histology confirmed amyloid deposits. Suspecting multiple myeloma, immunofixation identified Bence-Jones proteinuria and hypergammaglobulinemia. Spinal MRI showed vertebral collapse at D12–L1; cardiac MRI excluded cardiac involvement. MM with secondary AL amyloidosis was diagnosed. Treatment with targeted therapy led to symptom resolution.This case highlights the importance of considering rare systemic diseases in atypical GI bleeding, especially when triggered by minimal stimuli such as gastric distension.

References

1. Histological images of liver and stomach with amyloid deposits.
2. Endoscopic images of gastrointestinal bleeding manifestations in patients with gastric amyloidosis