Signet Ring Cell Carcinoma of the Stomach Presenting With Painless Obstructive Jaundice: Do We Need to Think out of the Box? 2603

• Published in: The American journal of gastroenterology Vol. 113; no. Supplement; p. S1446
• Main Authors: Inayat, Faisal, Amjad, Waseem, Hussain, Qulsoom, Zafar, Fahad, Khan, Ali T., Lodhi, Hanan T., Munir, Ahmed, Ullah, Waqas
• Format: Journal Article
• Language: English
• Published: New York Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01.10.2018
• Subjects: Cancer; Cervical cancer; Gastric cancer; Gastroenterology; Medical prognosis; Metastasis
• ISSN: 0002-9270; 1572-0241
• DOI: 10.14309/00000434-201810001-02602

PA Signet-ring cell carcinoma (SRCC) of the stomach with initial presentation related to painless obstructive jaundice is an extremely rare clinicopathologic entity. A 65-year-old female with medical history of hypertension, diabetes mellitus, non-ischemic cardiomyopathy, stroke, and cervical cancer admitted for painless jaundice, and unintentional weight loss (40 lbs. within the past year). Liver function test showed alkaline phosphatase of 308 IU/L, total bilirubin 21 mg/dl and direct bilirubin of 18.1 mg/dl. CT abdomen and pelvis showed intrahepatic and extrahepatic biliary ductal dilatation. Endoscopic ultrasound (EUS) was significant for gastric wall thickening, measuring 14mm in the antrum and 19 mm in the body. It was consistent with Linitis plastica or infiltrating gastric cancer. EUS-guided fine needle aspiration showed SRCC with local metastasis to ampulla of Vater (Image 1). ERCP could not be performed due to the edematous mucosa. Therein, interventional radiology placed a percutaneous biliary drain. Bilirubin levels trended downward after placement of drain. She had surveillance contrast-enhanced CT for staging, which was negative for any metastasis or lymphadenopathy. Patient was not a candidate for chemotherapy, radiation therapy or surgery. SRCC of stomach is a well-established clinical entity. However, gastric SRCC presenting with obstructive jaundice is an unusual and unique occurrence. Prognosis in early stages is better in SRCC compared to non SRCC gastric carcinomas while prognosis is less clear between SRCC and non-SRCC gastric cancers in advanced stage. Prognosis with SRCC in the ampulla is even less clear, with >5 year survival reported in only 4 out of 26 cases. Our patient had advanced gastric SRCC and given her local metastasis and poor functional status, she was not a candidate for further therapeutic measures. Clinicians should include gastric Signet-ring cell carcinoma among differentials in patients presenting with obstructive jaundice even in absence of gastric symptoms due to associated vital clinical