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: Since the covid-19 pandemic, there has been a significant resurgence of tuberculosis in endemic countries. As a result, extremely rare localizations of tuberculosis have appeared. Stomach involvement is rarely seen in gastrointestinal tuberculosis. The clinical presentation can be either alarming symptoms (anorexia, weight loss...), or a complication (digestive hemorrhage, perforation). In front of the weight loss and the alteration of the general state, the diagnosis is often directed towards a neoplastic pathology, which represents a diagnostic challenge.

Clinical case: We received in our institution a 77-year-old woman, referred from the emergency room for hematemesis with epigastric pain. She had experienced important weight loss during the last month. The clinical examination was unremarkable, and blood tests was normal, despite an hemoglobin of 8,7 g/dl. An upper endoscopy was performed, which showed the existence of 3 ulcerations localized on the greater curvature of the stomach, the largest measuring 4 centimeters. Biopsies of the ulceration borders were performed. Histology revealed the presence of an epithelio-giganto-cellular granuloma with caseous necrosis.
The final diagnosis was gastric tuberculosis. We started an antituberculosis therapy, with a proton pump inhibitor, with significant improvement within one month.

Conclusion: In conclusion, gastric tuberculosis, even if it is a rare entity, should be considered when gastric signs are associated with signs of tuberculosis impregnation, especially in endemic countries. The endoscopic signs are not specific, only histology can establish a reassuring diagnosis. Our patient was successfully treated by Antitubercular drug despite the severity of his bleeding.

References

Endoscopic images showing tow small gastric ulcers and a large gastric ulcer of the greater curve of the stomach
Histological image showing epithelio-giganto-cellular granuloma with caseous necrosis

Clinical Case Summary

A 72 years old caucasian women with no relevant medical history presented to the emergency department with two weeks history of abdominal pain in the upper quadrants associated with fullness, vomiting and a significant weight loss and nighttime hypersweating. On physical examination, abdomen was painful on epigastric and periumbilical region. Analytically, hemoglobin 11.1g/dL, leukocytes 9200/mm3, platelet count 315000/μL, CRP 8.22mg/dL. Tests for HIV and EBV were negative. Computed Tomography (CT) of the abdomen and pelvis revealed stomach with thickened walls, densification of adjacent fat and heterogeneous adenopathies. She was admitted to the department of Gastroenterology for investigation. The upper gastrointestinal endoscopy revealed extensive neoplasia of the body and gastric antrum. Biopsies revealed gastric mucosa with infiltration by atypical lymphoid proliferation with a "starry sky" pattern suggestive of high-grade B-cell non-Hodgkin's lymphoma (NHL). FISH analysis revealed t(8;14) c-myc positive. Once morphological and immunohistochemistry feature favors Burkitt’s lymphoma, she was transferred to the department of Hematology. Patient was treated with a full dose CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone) and 3 cycles of dose adjusted EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab). Complete remission was documented on positron emission tomography (PET).
Sporadic Burkitt's lymphoma is rare (1-2% of all lymphomas in adults), being one of the most aggressive forms of B-cell NHL. Primary gastric involvement is extremely rare. With the advancement of medicine and greater survival, we must consider this diagnosis, even in the absence of risk factors, atypical location and age group. This case emphasizes the importance of clinicopathological correlation and the importance of early diagnosis for immediate and aggressive intervention, fundamental in reducing morbidity and mortality.

References

1. Zhimin Bai, Yong Zhou. A systematic review of primary gastric diffuse large B-cell lymphoma: Clinical diagnosis, staging, treatment and prognostic factors, Leukemia Research,
Volume 111, 2021, 106716, ISSN 0145-2126, https://doi.org/10.1016/j.leukres.2021.106716.
2. Čubranić A, Golčić M, Fučkar-Čupić D, Brozović B, Gajski D, Brumini I. BURKITT LYMPHOMA IN GASTROINTESTINAL TRACT: A REPORT OF TWO CASES. Acta Clin Croat. 2019 Jun;58(2):386-390. doi: 10.20471/acc.2019.58.02.25. PMID: 31819338; PMCID: PMC6884372.
3. Usman A. Pirzada, Kishore Kumar, Hassan Tariq, Masooma Niazi, Jasbir Makker; Case of Gastric Diffuse Large B-Cell Lymphoma. Case Rep Oncol 6 May 2019; 12 (1): 39–46. https://doi.org/10.1159/000496332
4. Khan A, Khan S, Arshad U. Primary Gastric Burkitt's lymphoma. Pak J Med Sci. 2017 Sep-Oct;33(5):1294-1297. doi: 10.12669/pjms.335.13002. PMID: 29142583; PMCID: PMC5673752.

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: 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

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.