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<Case
report>
A 42-year-old housewife had no history of dyspepsia,
nausea, vomiting, easily fatigue or weight loss in the past
few years. Ten days before coming to our hospital, she
suffered from episodes of tarry stool passage and dizziness.
The symptoms persisted, even after treatment by local medical
doctors. She was then transferred to our ER. Physical exam
revealed that she had significant tachycardia and general
pallor. The laboratory data showed that she had severe anemia
(Hb 6.2%, Hct 20.1%) with mild PT prolongation (PT 14.3 sec,
control 11.9 sec, InR 1.3). She received blood transfusion
with Packed-RBC 4 units. Upper gastrointestinal endoscopy
revealed an active bleeder in the high body of the stomach on
the lesser curvature. Diluted Bosmine (1:10000) 8ml was
locally injected for injection hemostasis. However, due to too
much blood, the lesion visualization was poor. The initial
impression of endoscopy examination was bleeding from the LC
side high body, r/o Mallory-Weiss syndrome, ulcer or
lymphoma.
After admission, NPO, intravenous
injection of LosecR , fluid
and nutrition supply were given. Two days later, the repeated
endoscopy revealed a tumor lesion on the lesser curvature in
the high body to middle body of the stomach. The tumor had
abnormal friable mucosa, erosive surface, nodular structure
and was easily bleeding on touch. Biopsy confirmed a poorly
differentiated adenocarcinoma (see picture
1). Abdominal CT showed an enlarged lymph node near the
gastric lesion without evidence of liver metastasis. The bone
scan asserted multiple bone metastases, which conformed to her
complaints of generalized soreness and pain (see picture
2
).
However, tarry stool persisted during
the hospitalization. The following data of PT, APTT and
platelet were shown on table 1. Packed RBC, FFP, and platelet
were prescribed with only partial response. An episode of
fever (39.3℃) developed and the blood culture, urine analysis
and culture were all negative. At the same time, empiric
antibiotics was prescribed until a negative blood culture was
yielded. The disseminated intravascular coagulopathy (DIC)
profile was abnormal (see table 2) and cancer related acute
DIC was diagnosed by the oncologist. On the 24th
day after admission, she died of acute
hemorrhagic complication after receiving the first course of
chemotherapy.
【Table 1】Coagulopathy and thrombocytopenia happened during
admission and poor response to transfusion therapy
| |
Day 1 |
Day 18 |
Day 21 |
Day 24 |
| PT InR |
1.3 |
4.2 |
2.5 |
|
| APTT (sec[control]) |
32.3 [34.9] |
61.9 [35.3] |
48.0 [33.5] |
|
| Platelet (/uL) |
210000 |
92000 |
|
27000 | 【Table
2】DIC profile on the 23rd day
| Fibrinogen 199.5 mg/dl |
(N: 200-400) |
| FDP 178.0 g/ml |
(N: <5) |
| D-dimer: 7351 g/L |
(N: <250) |
<Discussion:>
Many paraneoplastic conditions are infrequently found in
gastric carcinoma, such as: microangiopathic hemolytic anemia,
membranous nephropathy, the sudden appearance of seborrhcic
keratosis (the Leser-Trelat sign), filiform and popular
pigmented lesion in skin folds and mucous membranes
(acanthosis nigricans), chronic intravascular coagulation
leading to arterial and venous thrombi (Trousseau's syndrome),
and in rare cases, dermatomyositis. It is also rare to find
acute disseminated intravascular coagulopathy (DIC) as the
first manifestation of gastric cancer.
Most metastasis region of gastric adenocarcinoma was
intra-abdominal lymph node, liver spread, and peripheral organ
invasion. The computed tomography (CT) scans of the abdomen
can delineate the extent of the primary tumor, the presence of
nodal or distant metastasis. Patient, who has diffuse bone
metastasis and hematologic disorders while gastric cancer
diagnosed, was very rare also. The clinic-pathological
features and prognosis in these patients was poor. They have
several characters, including rapid clinical course, relative
younger age, significantly related to undifferentiated
adenocarcinoma, and elevated levels of serum LDH and ALP-bone
isoenzyme.
The onset of acute DIC can be the first manifestation of
gastric malignant tumor and the sudden appearance of the
hemorrhagic syndrome. It is associated with thrombocytopenia,
hypofibrinogenemia and elevated fibrin/fibrinogen degradation
products (FDP), without infectious disease or bone marrow
impairment. Bleeding is one of the most common complications
in these patients. Severe hemorrhage can happen suddenly and
may be rapidly fatal. However, these patients were always
failure of treatment by heparin, FFP and platelet
transfusion.
Yeh (et al.) of NTUH reported his experience about
successful initial treatment with HDFL in gastric cancer
associated acute DIC. HDFL means“high dose 5-fluorouracil and
leucovorin”. It is composed with 5-fluorouracil
2600mg/m2 and leucovorin 300mg/m2, and
prescribes 24-hour infusion weekly. The regimen is used for
treatment advanced gastric cancer before, and it is an
effective and low-toxic regimen for patients with poor general
condition.
The toxicity of HDFL, including myelosupression and
mucositis, was minimal. However, some patients treated with
high dose 5-fluorouracil infusion therapy may lead to
hyperammonaemia, lactic acidosis and encephalopathy. Yeh (et
al.) recommended that (1) encephalopathy is an important
complication of HDFL treatment; (2) HDFL-related
encephalopathy is associated with unique biochemical changes
of hyperammonaemia, lactic acidosis and hypocapnia; and (3)
patient with hypotriglyceridaemia are relatively
contraindicated for HDFL treatment.
There was the other effective regiment, employed in VGHTPE,
called “Weekly EEPFL” for treatment advanced gastric cancer
with tolerable toxicities. It is consisted of weekly etoposide
40 mg/m2 intravenous (i.v.) infusion over 30 min;
weekly epirubicin 10 mg/m2 i.v. over 5 min; and
cisplatin 25, 5-fluorouracil 2200 and leucovorin 120
mg/m2 given simultaneously by weekly 24-h i.v.
infusion. Chao (et al.) applied weekly EEPFL for advanced
gastric cancer with acute DIC. Successful initial treatment of
patients with acute DIC was found. However, DIC symptoms
eventually recurred in all patients in association with tumor
progression. Once DIC recurs after initial control, prognosis
is grave.
In conclusion, acute DIC can be the first manifestation of
gastric cancer. These cases were rare and relative younger in
age. The clinical course was rapid and fetal. The prognosis
was poor. Most patients died from hemorrhagic complication.
Chemotherapy is the only way to alert the rapid clinical
course. There were 2 effective regiments published. The
toxicity of these regiments was minimal and tolerable. While
we meet the patient, early diagnosis and immediately
chemotherapy could rescue the
patient.
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Case Discussion
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