Presentation of signet ring cell type at carcinoma ventriculi of the patient aged 20 years old

doi:10.4236/crcm.2013.26096

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Vol.2, No.6, 358-362 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.26096

Presentation of signet ring cell type at carcinoma

ventriculi of the patient aged 20 years old*

Afrim A vdaj1, Ugur Gozalan2, Nexhmi Hyseni3#, Hatim Baxhaku1, Sherif Krasniqi1,

Shpejtim Rramanaj1

1Division of Surgery, Regional Hospital “Primarius Daut Mustafa”, Prizren, Kosova;

[email protected], [email protected], [email protected], [email protected]

2American Hospital, Pristina, Kosovo; [email protected]

3Department of Pediatric Surgery, University Clinical Center, Prishtina, Kosovo; #Corresponding Author: [email protected]

Received 1 July 2013; revised 4 August 2013; accepted 11 August 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Diffuse variant of GC is composed

of gastric-type mucou s cells, which generally do

not form glands, but rather permit the mucosa

and wall as scattered individual cells or small

clusters in an “infiltrative” gro wth p attern. These

cells appear to arise from the middle layer of the

mucosa, and the presence of intestinal meta-

plasia is not a prerequisite. In this version,

mucin formation expands the malignant cells

and pushes the nucleus to the periphery, creat-

ing a “signet ring” conformation. If the signetr-

ing cells are more than 50% of the tumor, the

tumor is classified as signetring cell carcinoma

[1]. This case is important for reporting because

we encountered for the first time such a carci-

noma type, due to the new age and its atypical

presentation. Case Presentation: We report a

case of a 20 years Albanian old patient with

Signet Ring Cell Type of Gastric CA. The patient

was brought at the urgency with severe ab-

dominal pain, nausea and peritoneal irritation.

Clinical examination has been made in emer-

gency, where we conclude the signs of perito-

neal irritation, from native Ro no signs of pneu-

moperitoneum, while laboratory tests found a

slight anemia (erythrocytes 3.36, HCT 25, HGB

8.6). Two hours later we repeated the native RTG

and there were present the signs of pneumop-

eritoneum. It was indicated urgent surgical in-

tervention. Intraoperatively, we found Ulcer duo-

denal perforation and undertook the operation

procedures by Roscoe Graham technique. Con-

clusions: At this age, it is rare, and it is difficult

to detect in its early stages, because the signs

and symptoms are often non-existent, non-spe-

cific, or mimic as an ulcer. The most common

symptoms are early heartburn indigestion, ab-

dominal pain or discomfort, vomiting, constipa-

tion, diarrhea or to feel of filling after a small

meal, loss of appetite, weakness and fatigue.

Less common symptoms are anemia and weight

loss.

Keywords: Signet Ring Cell Type; Gastric

Adenenocarcinoma; Diffuse Variant of GC

1. INTRODUCTION

Gastric Aden carcinoma is rare at young people, while

the risk increases significantly after age 50, and gastric

biopsies ambulatory ring cell carcinoma is rarely found

due to atypical clinical presentation [2]. GCs are pre-

sented in different histological characteristics, with a

positive family history, while genes regulate the sensi-

tivity of Helicobacter Pylori at different types of CG [3].

Histological confirmation is very important for deter-

mining the method of treatment [4]. Signet ring cell car-

cinoma is characterized by sub-mucosal infiltration of

different sizes and with distribution in distant lymph

node, and metastasis in the skin [5,6]. Here we report the

rare case of a 20-year-old girl presented with acute ab-

domen, because of the perforated duodenal ulcer, with

positive family history for GC and with Helicobacter

Pylori positive.

*Competing interests: The authors declare that they have no compet-

ing interests.

Contributions of authors: Our patient was admitted under the care o

SHK, with the contribution of HB, was treated. The main contributors

to this manuscript are all authors who have approved the final manu-

script.

A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362 359

2. PRESENTATION OF CASE

We report one case of 20 years old patient (Kosovo,

Albanian) with Signet Ring Cell Type of gastric CA. The

patient was brought in emergency with severe abdominal

pain, nausea, vomiting, pallor, and fatigue. The patient

had a position with curved knees towards the stomach,

hypertensive (TA: 100/60 mmHg), pulse speed (110/min)

and with superficial breathing. The clinical examination

took place in emergency centre, which concludes: diffuse

abdominal pain, irritation peritoneal signs. In X-ray na-

tive of abdomen are concluded signs of pneumoperito-

neumit while in laboratory analysis are concluded the

following values: RBC = 3.69; RDW% = 15.1; RDWA =

32.1; HCT = L 25.2; PLT = H 458; MPV = L 7.2; PDW =

9.7; PCT = 0.33; LPCR = 9.7; WBC = H 18.4; HGB = L

88HL; MCH = L 23.8; MCHC = 349; LYM = 0.9;

GRAN = H 16.4; MID = 1.1; LYM% = L 5.3; GRA% =

H 89.2; MID% = 5.5; Fe2+ = 4.31 µmol/L. Glucose = 8.2

µmol/L; Urea = 6.8 µmol/L; Creatinine 8.5 µmol/L; To-

tal Bilirubin = 7.5 µmol/L; Direct Bilirubin = 2.4 µmol/L;

Na+ = 134 µmol/L; K+ = 4.45 µmol/L; Cl− = 103 µmol/L;

Ca++ = 1.23 µmol/L; Albumins = 43 g/L; CRP = 5.7

mg/L. Helicobacter Pylori IgG = positive (3.42) Blood

type = A − RhD(+)poz. The patient was hospitalized

from emergency to the surgery department with diagno-

sis: acute abdomen, ulcer perforation. In the department

we placed the wide nasogastric probe, and the compen-

sation of the fluids parenteral were provided, blockers

H2 histaminic and antibiotics. It is indicated the Surgical

intervention, where the abdomen has been opened in lay-

ers through the median upper and middle laparotomy. In-

tra operative concludes: Serofibrinous fluid content and a

hole that has penetrated to the wall of the front duode-

num. It has been taken excision from the part of perfo-

rated duodenum for biopsy, and operation has been con-

ducted by Roscoe Graham with omentoplasty. Washers

of peritoneal space and drainage of the Douglas space.

Postoperative, the patient stays in intensive care.

Treated with intensive therapy: compensation of fluids,

antibiotics, analgesic blockers, H2 Histaminic. Nasogas-

tric tube and abdominal drain are removed in the fifth

day after operation. Wound with no leaks. The patient

has been recommended home care, in general stable

condition. With therapy: oral antibiotics and oral protein

pump inhibitors. The result of the biopsy of the excision

of perforated place in the duodenum results as chronic

peptic ulcer of the duodenum Figur e 1.

10 days after discharge from the hospital, patient came

back to Hospital In, while the patient continues to suffer

the pain in the epigastria region, fatigue, and anorexia.

The patient returns at home with therapy—analgesic as

needed and protein pump inhibitors. After two weeks, the

patient visited the surgeon again with the same symp-

toms (abdominal pain in the epigastria, nausea, vomiting,

anorexia, fatigue). The surgeon suggested the patient to

make the esophago gastro duodenoscopy, which resulted:

hyperemia and non confluent longitudinal erosion of the

bottom of stomach. In pre pyloric area of the stomach

mucosa is edematous, infiltrated, and vulnerable. Infil-

trate includes the pyloric canal which is narrow and is

inaccessible by the instrument. From the infiltrated pre

pyloric part is taken the biopsy in six parts for histopa-

thological examination. Biopsy results: gastric carcinoma

(Signet ring cell type)—infiltration into the pylorus with

evident stenosis and Reflux esophagitis gr. A. (Figure 2).

Six days after verification of the diagnosis with histo-

pathology, the patient was hospitalized at the American

hospital in Prishtina. In the day of admission is done the

CT of the abdomen and pelvic with application of in-

strument of the oral contrast and intravenous which re-

sulted: expansive process in the rear wall of the small

curvatures of the stomach and also pylorus have been

affected, with characteristics of mucinous carcinoma,

Figure 1. Histological report: ulcer peptic chronic duodenum (tissue granulation and peptic necrosis).

A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362

360

Figure 2. Histological report: ventricular carcinoma (signet ring cell type)—(fragments of gastric mucosa with solid islands malign-

nant stromal cells, polymorphous eccentric nuclei).

with gangrene of the gallblader.

On date: 23. 03. 2013 took place: op. Subtotal Gas-

trectomy D1 Lymph node disection, Gastroenterostomy,

where more than 2/3 of the stomach (pylorus, duodenum

initial part) was removed and was established gastroin-

testinal continuity by direct anastomosis between the rest

of the resected stomach and proximal anse of jejunum.

Where initially gastro colic ligament is cut within gas-

troepiploic arcade, curvature ventricle major is released

as long as the lower pole of the spleen is seen. Then re-

section duodenum is conducted about two cm. from py-

lorus after resection of duodenum and the mobilization

of the stomach. Stomach pulled above and now sinister

gastric artery and vein are released which present resec-

tion line of curvature ventricle minor. It is set Gastroin-

testinal continuity in two layers, then occurs entero-en-

tero-anastomosis according to Brown about 20 cm dis-

tally from gastrointestinal anastomosis with one layer.

During surgical intervention in gastric tissues were iden-

tified lymph nodes as following (according to the classi-

fication of the Japanese Research Association for the

classification of gastric cancer): Zone 1. (Right pericar-

dial): 0 lymph nodes, Zone 2. (left pericardial): 0 lym-

ph’s nodes, Zone 3. (Curvature minor): 0 lymph’s nodes,

Zone 4. (Curvature major): 4 lymph nodes’ measuring

0.2 - 0.6 cm in greatest diameter, Zone 5. (Supra pyloric):

0 lymph’s nodes, Zone 6. (Infra pyloric): 9 lymph nodes

measuring 0.2 - 1.2 cm in greatest diameter. Histological

report resulted: Adenocarcinoma type Diffuse. Zone 4

(curvature major): Metastatic tumor tissue is identified in

1 lymph node (1/4). Zone 6 (infra pyloric) Metastatic

tumor tissues is identified in 5 lymph nodes (5/9). Histo-

logical type: Adenocarcinoma-diffuse type. TNM patho-

logical classification: pT4b, pN2, pM1.

The postoperative is treated with antibiotic, analgesic,

4 doses blood and 3 plasma. On date 03. 04. 2013 rec-

ommended going home, and visit the oncologist for fur-

ther treatment. The patient has taken the therapy with

chemotherapeutic.

3. DISCUSSION

Gastric carcinoma (GC) is more common in develop-

ing countries, among black peoples and in countries with

poor socio-economic condition. Dietary factors and in-

fection with Helicobacter pylori (H. pylo ri) are main risk

factors for the development of such tumors [7]. H. py-

lori-stimulates cell polarity disorder that can be associ-

ated with the pathogenesis of carcinoma, at least in the

layers of the population infected with HP [8]. Recently

GC shows an EBV (+), in vitro EBV infection induces

extensive mutation of the (ADN) DNA gene repression

within 18 weeks, which can be considered another risk

factor for the emergence of GC [9]. Gastric carcinoma of

type (SRC) is known to have different characteristics and

biological microscopic compared to non-(SRC) [5]. Our

case has unusual clinical and histopathological manifes-

tation that responds to data from the literature. On the

basis of data protocol of our hospital was not evidenced

so far any case with such type of CG under the age of 30

years. GC is one of the most common causes of can-

cer-related deaths worldwide. The success of surgery

depends on the depth of penetration in layers, the extent

of lymph node and distant metastases, and it is possible

through diagnostic methods: MDCT (multi detector com-

puted tomography) and PET (positron emission tomo-

graphy). Multi detector computed tomography (MDCT)

has the ability to assess the depth of the tumor, the main

disease and metastasis so that preferred technique for

managing GC. Endoscopic ultrasound is the most accu-

rate assessment of the depth of wall invasion in early

cancers, but is limited in the evaluation of stenosis or

local advanced cancer and detection of distant metas-

A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362 361

tases. Magnetic resonance imaging (MRI) has not proved

to be effective. Positron emission tomography (PET) is

useful for detection and characterization of distant me-

tastases. Both MDCT and PET methods are useful for

evaluating the response to treatment after chemotherapy,

preoperative and detection of recurrence after surgical

removal [10]. in our case was not possible to use diag-

nostic methods mentioned above, and because of the

atypical clinical presentation, our case was diagnosed in

the late stages of distant metastases, which represents an

unfavorable prognostic factor. Rapid development of the

tumor in our case, atypical clinical presentation and the

increasing number of cancer in general, the experts sup-

pose the risk factor comes from the high level of de-

pleted uranium due to the recent war. SRC Ca, do not

have good prognosis and can be neglected during routine

pathological examination [11]. For patient survival is

important tumor localization, histopathological stages

and treatment [12]. The following factors are also im-

portant for the patient survival: the extent of tumor in

lymph nodes, depth of infiltration in layers and distant

metastases [13]. SRC Ca survival depends on tumor size,

histological cell differentiation level, the degree of pene-

tration in layers and metastasis. 5-year survival after ap-

plication of chemotherapy at patients with GC resectable

is less than 20% and therefore the effectiveness of che-

motherapy is disputed [14]. 5-year survival of the four

groups classified by differentiation and depth of penetra-

tion in layers is [T2/3 (differentiated type), T2/3 (undif-

ferentiated type), T4a (differentiated type), and T4a (un-

differentiated type)] were 98%, 92%, 80%, and 72%,

respectively (P < 0.01) [15]. Inhibitory effects on cell Ca

growth of the stomach have antioxidant substances like:

CFPS-2 containing: Glucosamin, glucose, Galactose, Fruc-

tose, protein and sulfate groups [16]. Our case is sent for

chemotherapy treatment after consular decision and con-

sultation with oncologist. Since about four months past

after the first surgery and about three months after the

second surgery, the general condition of the patient is

stable.

4. CONCLUSION

Gastric Aden carcinoma in such age is rare, and it is

difficult to detect it in its early stages, because the signs

and symptoms are often non-existent, non-specific, or

mimic as ulcer, therefore we recommends taking into

consideration all patients complaints regardless of age

and non-specific clinical data for malignant disease. The

most common symptoms at the beginning are indigestion

heartburn, abdominal pain or discomfort, vomiting, con-

stipation, diarrhea, or a feeling of fullness after a small

meal, loss of appetite, weakness and fatigue. Less com-

mon symptoms are anemia and weight loss. This case is

presented because it is very rare at this age, and clinic

atypical manifestation is in the form of perforated ulcers.

It is the first reported case of this type of tumor for us,

because of the very young age of the patient.

Patient Perspective: In order to provide data on the

case, I report my concerns about the disease.

I am a second year student, living in the village, I have

never been sick before. It has been about 3 months since

I started to feel occasional pain in the stomach but no

other concerns. At this time I used tablets to ease my

pain, and I visited a general practitioner. I have thought

the pain was coming from studies stress, but pain day by

day hardened, when at hospital admission day at a time I

felt severe abdominal unbearable pain, associated with

nausea which forced me to go to the hospital. It was the

first time that I had lay in the hospital, where I was un-

dergoing urgent surgical intervention. After the operation

I began to feel improvement and get sucked, even though

after a week I continued to feel pain. A week after leav-

ing the hospital I started the same concerns as before

surgery such as stomach pain, loss of appetite and lassi-

tude and I asked again for medical help from my surgeon

who suggested me doing endoscopy of the stomach. Af-

ter endoscopy my situation got worse and I have been

hospitalized, where after a few days by the suggestion of

doctors I have been transferred to American Hospital for

second surgical intervention. It has been about 5 days

since I left the hospital and I am waiting for further

treatment. With the help of God and the support of fam-

ily members, I want to fight for the life that I love it so

much.

5. CONSENT

Written consent was obtained from our patient for the

presentation of this case. A copy of the written consent is

available for review by the editor of this magazine.

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