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<Chief
complaints>
Post-prandial vomiting for three weeks.
<Present
illness>
A 45 y/o man had been healthy before until 6 months prior
to admission, when he began to suffer from retrosternal chest
dull pain shortly after a large meal, which could be relieved
through increased water intake initially. However, the
symptoms aggravated in the past 3 weeks and could only be
alleviated by self-induced vomiting. He also complained of
dysphagia and spontaneous post-prandial vomiting during this
period, and he had a weight loss of 8 kg in 3 months. He
visited our OPD for help, where esophagogram revealed a large
submucosal tumor at the cardiac portion of the stomach. He was
then admitted for further evaluation and management.
Physical examination revealed an acute ill-looking man with
clear consciousness. The blood pressure was 110/70 mmHg, body
temperature 36.2 oC, pulse rate 80 0/min, and the respiratory
rate was 18/min. The conjunctiva was not pale, and the sclera
was anicteric. The cardiac and pulmonary auscultations were
unremarkable.
The abdominal examination revealed a distended abdomen with
hypoactive bowel sounds on auscultation, and tenderness and
rebound tenderness on palpation in the lower abdomen. Muscle
guarding was also noted. The liver and spleen were both
impalpable.
<Laboratory
data>
| WBC |
RBC |
Hb |
MCV |
Plat |
Seg |
Eos |
Baso |
Mono |
Lym |
| /ul |
106/ul |
G/dl |
fl |
103/ul |
% |
% |
% |
% |
% |
| 6000 |
4.95 |
12.4 |
78.4 |
231 |
92.0 |
0.3 |
0.1 |
3.4 |
4.2 |
| Alb |
Bil-T |
AST |
ALT |
ALP |
r-GT |
BUN |
Cre |
CEA |
LDH |
Na |
K |
Ca |
| g/L/g/L |
mg/dl |
U/L |
U/L |
U/L |
U/L |
mg/dl |
mg/dl |
U/L |
U/L |
mM |
mM |
mM |
| 4.2 |
0.56 |
39 |
28 |
187 |
19 |
19 |
1.0 |
1.1 |
472 |
141 |
3.8 |
2.3 |
| PT |
PTT |
Glu.AC |
| sec |
sec |
mg/dl |
| 11.1/11.2 |
32.7/33.9 |
115 |
<Image
study>
CT of Abdomen (圖1):
Abdominal CT with/without contrast enhancement showed :
- A large (12x6.5cm) lobulated
homogeneous submucosal mass was found at the gastric body
with a satellite lesion at the gastric fundus. The gastric
cardia was also involved with dilatation of the lower
esophagus.
- There were multiple LNs around the
mesenteric root and the foramen of Winslow.
- The left adrenal gland was
hypertrophic.
- Atelectasis at RLL. There were
multiple adjacent nodules (at least 6 in number) found at
LLL.
- A left renal cyst.
Splenomegaly.
Panendoscopy
(圖2)&
EUS (圖3)
Gastric submucosal tumor with ulceration, fundus, upper
body, PW, favoring gastrointestinal stromal tumor
A 8.7x9.6cm lobulated heterogeneously hyperechoic tumor,
originating in the fourth layer of gastric wall was
identified. Surface ulceration was noted. Cystic change with
septa at the periphery of the tumor was also observed.
Op Findings and
method
- A 12*12*6 cm cardiac tumor, with
posterior invasion to the preaortic fascia, adrenal gland
and pancreas. Fowl smell(+).
- On incision, the character of the
tumor: a submucosal elevation with central necrosis
- The tumor was not resected completely because of
invasion to nearby organs and the aorta.
Op Method
:
- Total gastrectomy with
esophagojejunostomy (retrocolic)
- Jejunostomy
Pathology
Gastric malignant lymphoma, esophageal involvement.
<Course and
treatment>
After admission, endoscopic ultrasound revealed a gastric
submucosal tumor with ulceration and abdominal CT scan
revealed a large gastric submucosal tumor. Therefore, general
surgeon was consulted for surgical resection of the tumor.
Total gastrectomy with esophago-jejunostomy, retrocolic
(Roux-en Y anastomosis) and jejunostomy were performed
smoothly on 2004/07/21. The postoperative period was
uneventful and he restarted intake smoothly. The final
pathology report showed malignant lymphoma and an oncologist
was consulted for further treatment. He was discharged 2 weeks
after operation in stable condition.
<Discussion>
胃淋巴瘤（gastric
lymphoma）是一少見的胃惡性腫瘤，約占胃原發惡性腫瘤的2%。從另一方面來看消化道是非何杰金氏淋巴瘤（Non-Hodgkin’s
Lymphoma）淋巴結外最常侵犯的器官，其中又以胃為最常見。有研究報告高達75%的原發消化道淋巴瘤都是來自胃。其中最好犯的年齡是50歲以上，性別是男性。
胃淋巴瘤被認為是從黏膜和黏膜下層起源的，大部份的淋巴瘤常常擴散性地生長在黏膜層，黏膜下層及肌肉層。胃淋巴瘤幾乎都是非何杰金氏淋巴瘤（Non-Hodgkin’s
Lymphoma），根據Working Formulation的分類最常見的是Diffuse large B-cell
type。
臨床上的症狀不容易與胃炎、消化性潰瘍，或其他的胃腫瘤來做區分。一開始都是腹痛、噁心、嘔吐、厭食、體重下降、或出血。等到出現全身無力、出血、幽門狹窄、或穿孔的症狀時，都已是進行性癌的變化了。
理學檢查通常並不容易有所發現，約35%會有腹部壓痛，20-30%會摸到腫塊，14%會肝腫大。診斷主要是要靠胃鏡檢查，它可同時做診斷及切片確認。如果是黏膜下腫瘤來表現的胃淋巴瘤可能與胃間質瘤不易區別，須靠內視鏡超音波和細針抽吸才可能確定診斷。
治療方面包括傳統手術、化療及電療，目前以化療為主要，電療效果較不確定。手術則主要對侷限性腫瘤，有治癒效果及對進行性癌有姑息性目的（Palliative
surgery）。
<REFERENCES>
- Frazee RC, Roberts J. Gastric
lymphoma treatment: medical versus surgical. Surg Clin North
Am 1992;72:423-31.
- Coulson WF. The Stomach. In:
Coulson WF, ed. Surgical Pathology, Philadelphia:J.B.
Lippincott Company, 1988:123-5.
- Dworkin B, Lightdale CJ, Weingrad
DN, et al. Primary gastric lymphoma: a review of 50 cases.
Dig Dis Sci 1982;27:986-92.
- Azab MB, Henry-Amar M, Rougier P,
et al. Prognostic factors in primary gastrointestinal
non-Hodgkin's lymphoma. Cancer 1989;64:1208-17.
- Shiu MH, Nisce LZ, Pinna A, et al.
Recent results of multimodal therapy of gastric lymphoma.
Cancer 1986;58:1389-99.
- Weingrad DN, Sherlock P, Straus D, et al. Primary
gastrointestinal lymphoma: A 30 year review. Cancer
1982;49:1258-65.
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Case Discussion
繼續教育考題