A 70-year-old man comes to the office due to persistent epigastric discomfort and nausea for the past several months. He has also noticed black-colored stools on several occasions. Medical history is notable for hypertension and osteoarthritis. The patient emigrated from rural China 5 years ago to live with his daughter. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows a thin male with pale mucous membranes, an enlarged left supraclavicular lymph node, and epigastric tenderness on deep palpation. Stool testing for occult blood is positive. Upper gastrointestinal endoscopy reveals a 3-cm ulceration at the gastric antrum, with a heaped-up irregular border. Biopsy from the edge of the ulcer reveals glandular structures containing intestinal-like columnar cells. Which of the following most likely predisposed this patient to his current condition?
Gastric adenocarcinoma | |
Risk factors |
|
Clinical features |
|
Gross appearance/ | Intestinal type:
Diffuse:
|
This patient with epigastric pain, occasional melena, and left supraclavicular lymphadenopathy (ie, Virchow node) has intestinal-type gastric adenocarcinoma, the most common primary gastric malignancy. It is typically visualized endoscopically as an ulcerated mass with irregular folded or heaped-up edges. Histologically, intestinal-type gastric cancer resembles colon adenocarcinoma and is characterized by glandular structures containing intestinal-like columnar (or cuboidal) cells.
Gastric cancer occurs with the highest incidence in patients from Eastern Asia, Eastern Europe, and South America, possibly due to the increased consumption of salt-preserved foods (eg, salt-cured fish), which directly damage the gastric epithelium and potentiate the effects of carcinogens. Common carcinogens associated with gastric cancer include n-nitroso–containing compounds (eg, tobacco, processed meat) and chronic Helicobacter pylori infection, both of which may also be present at increased levels in these populations. Other risk factors include obesity and autoimmune atrophic gastritis.
(Choices A and E) Chronic nonsteroidal anti-inflammatory drug use and gastrin-producing tumors (ie, Zollinger-Ellison syndrome) are associated with benign peptic ulcer disease, not gastric adenocarcinoma. Benign ulcers are typically clean-based with regular borders (as opposed to this patient's ulcerated lesion with irregular, heaped-up borders); in addition, intestinal metaplasia is unexpected.
(Choice C) Excessive consumption of hot beverages is associated with esophageal squamous cell carcinoma, not gastric adenocarcinoma.
(Choice D) Disruption of the lower esophageal sphincter enables gastric acid to reflux into the esophagus, which predisposes patients to esophageal intestinal metaplasia (eg, Barrett esophagus) and ultimately esophageal adenocarcinoma. However, this is not a risk factor for gastric adenocarcinoma.
Educational objective:
Intestinal-type gastric adenocarcinoma is visualized endoscopically as an ulcerated mass with irregular folded or heaped-up edges. Histologically, it resembles colon adenocarcinoma and is characterized by glandular structures containing intestinal-like columnar (or cuboidal) cells. Risk factors include Helicobacter pylori infection, a high-salt diet, n-nitroso–containing compounds, and autoimmune atrophic gastritis.