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Gonçalves R et al.
484 Rev Assoc M ed Bras 2017; 63(6):484-487
IMAGE IN MEDICINE
Gastric cancer with lesion extending to spleen and perforation into
free peritoneum
Roberto Gonçalves1*, Roberto Saad Jr2, Carlos Alberto Malheiros2, Paulo Kassab2, Nathália L ins Pontes Vieira3
1MD, MSc. Department of Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil
2MD, PhD. Department of Surgery, FCMSCSP, São Paulo, SP, Brazil
3MD. General Surgery Resident, Department of Surgery, FCMSCSP, São Paulo, SP, Brazil
Summary
Study conducted at the Department of
Surgery, Faculdade de Ciências Médicas
da Santa Casa de São Paulo (FCMSCSP),
São Paulo, SP, Brazil
Article received: 11/8/2016
Accepted for publication: 12/4/2016
*Correspondence:
Address: Rua Dr. Cesário Mota Júnior, 61
São Paulo, SP – Brazil
Postal code: 01221-020
Perforated gastric carcinoma is a rare condition that is hard to diagnose preop-
eratively. It is associated with advanced cancer stages and has a high mortality,
particularly in cases presenting preoperative shock. Few studies have investi-
gated the presentation and adequate management of these carcinomas. In ad-
dition, there are no reports in the literature on perforations extending to the
spleen, as described in this case, making the management of these lesions chal-
lenging. Our article reports a case of gastric tumor perforation extending to the
spleen, which presented as a perforated acute abdomen. The patient was treated
with total gastrectomy and D2 lymph node resection with splenectomy and
progressed well with current survival of one year at disease stage IV.
Keywords: acute abdomen, hemoperitoneum, stomach neoplasms.
Introduction
Perforation of gastric cancer is a rare condition occurring
in only 1% of gastric tumors and accounting for 10 to 16%
of all perforations to this organ, with a mortality rate of
up to 82%. Cancer is generally not suspected in these cases
because the majority of patients seeking emergency ser-
vices have a picture consistent with acute perforated abdo-
men and diffuse peritoneal irritation. Intraoperative diag-
nosis remains challenging especially in services without
freezing techniques for anatomopathological analysis.1-3
Given the low incidence of cases and consequent scant
studies, the optimal surgical treatment in these situations
is not yet well defined. Full oncological resection can be
hampered by the absence of pre or intraoperative diag-
nosis of the tumor.
Case report
A 54-year-old male patient with history of significant
weight loss of 10 kg over the past two months presented
to emergency services with intense abdominal pain and
fainting 1 hour before. Physical examination revealed the
patient to be thin, pale (++/+++) and dehydrated (++/+++).
The abdomen was flat, painful on palpitation, tympanic
on percussion in the right hypochondrium (Jobert’s Sign)
and there were signs of peritoneal irritation (abdominal
muscular rigidity). This patient was diagnosed with a
suspected acute perforated abdomen, and exploratory
laparotomy was indicated.
The intraoperative finding was a tumor of the gastric
floor with blockage and perforation of the spleen, and this
also perforated the free peritoneum (Figures 1-3). A total
gastrectomy including the spleen, large omentum and
regional lymph nodes was performed. Reconstruction was
achieved by Roux-en-Y jejunoesophageal anastomosis.
The anatomopathological exams revealed a moder-
ately differentiated gastric adenocarcinoma contiguous
to the hilar face of the spleen, affecting 7 of the 13 lymph
nodes studied. Since no distal metastases were found, the
patient was classified as stage IV. He was discharged on
day 15 of the hospital stay and has been undergoing out-
patient follow-up for one year.
Discussion
Perforation of gastric adenocarcinomas is rare. The patient
in this case, akin to the majority of other cases described
in the literature, presented at our emergency service with
signs of perforated acute abdomen and no prior diagno-
sis of gastric neoplasia. The most commonly described
signs and symptoms include abdominal pain and perito-
neal irritation, which was the case of our patient. Recent
studies have shown that only 15 to 30% of patients are
diagnosed with neoplasia at a preoperative stage.1,2 The