Case 40-2000

Abstract

A 38-year-old woman was admitted to the hospital because of a tumor at the gastroesophageal junction.The patient had been in excellent health until six and a half weeks earlier, when she began to have a fever with a cough productive of green sputum. At about the same time, she also felt a "sticking" sensation on swallowing solid foods, even after thorough chewing; liquids were swallowed adequately. Lansoprazole was prescribed, without improvement. Two and a half weeks before admission, esophagogastroduodenoscopic examination at another hospital revealed a tumor, 7 by 4 cm, in the proximal portion of the stomach, with extension into the distal portion of the esophagus. Bougienage was performed, and on further endoscopic examination, the distal portion of the stomach and the duodenum had a normal appearance. Biopsy of the tumor disclosed a grade 3 adenocarcinoma. Computed tomographic (CT) scans of the thorax and abdomen, both obtained after the oral and intravenous administration of contrast material, and radiographs of the chest were normal.Two weeks before admission, the urine was normal. The prothrombin and partial-thromboplastin times were normal, as were the glucose, creatinine, conjugated and total bilirubin, and aspartate aminotransferase concentrations. The results of other laboratory tests are shown in Table 1. An electrocardiogram was normal.Ten days before admission, the patient was examined at this hospital. Her cough had persisted but had become nonproductive, and the bouts of fever had continued despite antibiotic therapy. The dysphagia had worsened recently, and she had lost 1.5 kg of weight. The patient had no known exposure to car-cinogens and maintained an active lifestyle. There was no history of early satiety, hematochezia, or melena. She did not drink alcohol or smoke. Her medications comprised an oral contraceptive, a sleeping medication, a multivitamin supplement, and occasionally, loratadine for "allergy." Her maternal grandmother had had breast cancer, but there was no other family history of cancer.The temperature was 37.8°C, the pulse was 84, and the respirations were 16. The blood pressure was 115/70 mm Hg.On examination the patient appeared well. No lymphadenopathy was detected. The anterior portion of the tongue appeared denuded in several areas. The lungs were clear, and the heart sounds were normal. Rectal examination showed only a hemorrhoid. A stool specimen was negative for occult blood. Neurologic examination revealed no abnormalities.The patient was admitted to the hospital, and a diagnostic procedure was performed. DIFFERENTIAL DIAGNOSISD R . C HRISTOPHER L. C ARPENTER *: How do we explain an adenocarcinoma of the stomach in a 38year-old woman? The first steps are to make certain that the diagnosis was correct and determine whether the tumor was primary or metastatic. Adenocarcinomas comprise 95 percent of gastric cancers, but occasionally, they are confused with other cancers. Lymphomas, squamous-cell carcinomas, carcinoids, and sarcomas also occur in the stomach. A gastric ly...