Perforated Early Gastric Cancer: Uncommon and Easily Missed a Case Report and Review of Literature
A 56-year-old Chinese gentleman with history of hypertension and gastritis over the past two months presented at our emergency department with an acute onset of epigastric pain. An erect chest X-ray followed by computed tomography of the abdomen and pelvis (CTAP) revealed pneumoperitoneum secondary to a perforated gastric ulcer along the lesser curve ().\nThe patient underwent an uneventful emergency open omental patch repair. Intra-operatively, there were no features to suggest malignancy. Frozen sections were not available after office hours. Intra-operatively, tissue biopsies were obtained from the edge of perforation. These were inconclusive with ulcer bed debris and granulation tissue with no malignant cells seen.\nThe patient had an uneventful postoperative recovery. Six weeks post omental patch repair, we performed an oesophagogastroduodenoscopy (OGD) for routine evaluation. An incisura ulcer was seen with no surrounding gastric wall thickening (). The ulcer edge was biopsied, which revealed moderately differentiated adenocarcinoma. This corresponded to macroscopic Type 0~III appearance of early gastric cancer ().\nStaging CTAP performed showed neither lymphadenopathy nor distant metastases. We hence proceeded to perform an open distal subtotal gastrectomy with formal D2 lymphadenectomy and Bilroth II reconstruction (gastrojejunostomy). No peritoneal metastasis was noted during the surgery. Peritoneal washing cytology was not performed at second operation due to extensive adhesions. The patient had an uneventful post-operative recovery, and was discharged well 5 days after surgery. Outpatient follow-up at 1 week and 3 months were unremarkable. At 6 months post-operation, the patient had recovered back to his pre-morbid status and was taking well orally. He remains asymptomatic with no sign suggestive of a recurrence.\nHistological examination of the resection specimen were taken from various sites (). The entire ulcer was submitted in five sections (), each 3 mm thick.\nMicroscopic examination of the resection specimen revealed a T1bN0M0 moderately differentiated adenocarcinoma of tubular/intestinal type (). The majority of the tumour was confined to the mucosa, with focal invasion of the submucosa () but no involvement of the muscularis propria (). There was also attenuation and focal loss of the muscularis propria underlying the tumour site, with replacement by fibrosis that extended into the submucosa and subserosa, in keeping with a previous perforation. The serosal surface at this site showed adherent connective tissue with a focal foreign-body reaction to suture material, consistent with the previously applied omental patch. The proximal and distal resection margins, as well as the serosal surface, were free of tumour. A total of 48 lymph nodes were sampled from different stations. All lymph nodes showed no evidence of malignancy. The presence of such a rare diagnosis mandated a review of the sampling methods. The histological methods were reviewed and the diagnosis confirmed at a multi-disciplinary meeting, before making the diagnosis of a perforated early gastric cancer (EGC), TNM stage pT1b N0, Type 0~III (also known as EGC Type III).