A Rare Presentation of Hereditary Diffuse Gastric Cancer Masquerading As Cancer of Cervix

4 Jun

A Rare Presentation of Hereditary Diffuse Gastric Cancer Masquerading As Cancer of Cervix

Unusual presentations of cancer are well recognized by oncologists world over and at DHRC we get to see a fair number of them. This 45 years old, Nepalese lady presented to the Gynae Oncology clinic of DHRC with complaints of bleeding per vagina and severe pain in the left lower limb and lumbo-sacral region for the last 6 weeks. She was carrying reports from one of the prestigious medical institutes ofIndia, suggesting an adenocarcinoma of the cervix, FIGO clinical stage IIA. She had the following investigation reports.

1 USG (Abdomen and Pelvis) Cervix replaced by 4-5cms growth with a left adenexal mass and left parametrial thickening in its medial portion.

2 MRI (Abdomen and Pelvis) 4- 5 cms growth of cervix with a left adenexal mass.

3 CA 125 within normal limits (56 u/ml)

4 Guided FNAC of left adenexal mass- inconclusive for cancer.

5 Punch biopsy of cervical growth was reported as an adenocarcinoma.

Since, there was a long waiting period and the lady was having severe bleeding p/v episodes, her son, a medical student inBangladesh, brought her to our hospital for second opinion and further management. On her detailed clinical examination following findings were found –

1 Systemic examination showed a 5 cms X 6cms, irregular, hard lump with restricted mobility and suspicious in nature in the right breast. The left breast had features of fibroadenosis

2 Per speculum, per vaginum and per rectal examination revealed the cervix was replaced by a 4 cms by 5cms growth involving all fornices and upper 1cm of left vagina. A 3 cms hard irregular left adenexal mass was felt in the left fornix.

3 Rest of clinical examination was unremarkable.

Further investigation of the suspicious right breast lump

Since FNAC was reported as inconclusive for cancer and mammography showed highly suspicious findings with Bio-rad III/IV a trucut biopsy of the breast lump was done, this was reported as a metastatic carcinoma to the breast with no expression of estrogen or progesterone receptors (ER/PR negative). Probability of primary in the gastro intestinal tract was considered, PET-CT (whole body) was done, which showed a FDG avid lesions at multiple sites in stomach, ascending colon, left breast, cervix, lower uterus and left adenexa..

When reports were discussed with patient’s relatives, they further reported that the patient’s sister and brother had died of gastric carcinoma in past. They were counseled for genetic study of close family members.

After the final discussion in the Tumor Board at DHRC, with all investigation reports, it was decided that a palliative treatment plan, with haemostatic radiotherapy and palliative chemotherapy should be imparted rather than a Wertheim Hysterectomy as it was thought at provisional diagnosis of clinical stage IIA adenocarcinoma of cervix.

Discussion

Metastases to the uterine cervix are rare. The commonest primary tumors metastasizing to cervix are primary endometrial carcinoma followed by breast. It is very rare to find a gastric carcinoma metastasizing to the cervix, with rarest of rare situation, where there is a strong suggestion that it has a distinct familial proclivity. Retrograde lymphatic spread is the probable mode of spread to the cervix from the stomach. Metastases to cervix are generally associated with Kruckenberg tumors of the ovaries, as presented in this case.

Cancer of cervix, is commonly a squamous cell carcinoma but recent trends show an increasing incidence of adenocarcinomas of the uterine cervix and currently 10-25 percent of primary uterine cervical malignancies .

If Patients with cervical carcinoma on histopathology are reported as adenocarcinomas, one can not over-emphasize the importance of a thorough clinical examination and supportive investigations, to rule out the presence of a primary tumor at a distant site. In the present case, this appraisal included thorough systemic examination, sonography, MRI of the abdomen, pelvis, X-ray chest, mammography, relevant tumor markers, FNAC, trucut biopsy from adenexal mass and breast lump and PET -CT.

The detailed family history of cancer in blood relatives was a pointer in this direction although genetic studies could not be done in this patient. It most likely is a case of Hereditary Diffuse Gastric Cancer (HDGCs), which represents 1 to 3percent of all gastric cancers. About 53percent of these are associated with CDH1 gene mutation. These familial cancers demonstrate autosomal dominant inheritance and a high penetrance. The 5-year survival is just 20%, if the diagnosis is made after the patient is symptomatic.

Conclusion By careful examination, detailed investigations and planning, the inadvertent surgery could be avoided and correct prognostication was offered in this rare case of a Hereditary Diffuse Gastric Cancer with metastatic adenocarcinoma to the cervix. The importance of metastatic work up and thorough clinical examination and history can not be overemphasized in any cancer patient before definitive treatment planning.

4 May

Changing Lifestyles Responsible For Vast Increase in Breast Cancer Cases

Changing Lifestyles responsible for vast increase in Breast Cancer Cases

Breast cancer, the urban malaise is spreading fast and the doctors say the main reason is lifestyle. In the last 20 years, women have their first child later, don’t breast-feed children for long and are overweight compared to their mothers. Breast cancer, which has genetic component as well, is now mainly lifestyle disease, said experts.

Besides, a study published in Lancet last month showed younger women were dying in larger numbers in developing countries India was no exception, said the study of 187 nations by the Washington University’ Institute of Health Metrics And Evaluation

While the age profile of a breast cancer patient from the West would be 55 to 70 years, the patient could be in the 40-55 age group. However, This is because the developing countries in Asia and Africa have more young than old people. Another study, published in August in the British Journal of Cancer, showed college-educated Mumbai women had a 90% increased risk for being overweight, compared to illiterate women It showed in 30 years, rates of breast cancer among women aged 30-64 rose significantly

A recent Breast Cancer Foundation sample survey of 1,000 women found a worrisome socio – economic trend. Nannies appointed by urban working women are mimicking employers. They leave their children in slums on packaged milk, forgetting breast-feeding. Patients from the lower socio-economic strata were hence increasing.

Late marriages, delayed child-bearing and fewer children, leading to reduced breastfeeding, are behind the increased risk of breast cancer. Sedentary lifestyle, increased consumption of fat and less of fruits and vegetables is one of the main reasons for the increased rates of breast cancer among women in urban India.

Africa and Asian country’s worst statisticis that though the country’s cancer incidence was one-third of the US, death rate due to the disease was almost same. This is because women, whether old or young, come to a specialized Cancer hospital at a very late stage.

THE ORIGINS

Breast cancer arises from cells lining the milk ducts and slowly grows into a lump. A tumour is believed to take about 10 years to become 1 cm in size, starting from a single cell. A malignant tumour has the ability to spread beyond the breast to other parts of the body via the lymphatics or the blood stream

THE FACTORS

Lifestyle choices or biological characteristics contribute to developing breast cancer

Biological characteristics encoded in DNA are factors that cannot be controlled

Other factors, however, can be controlled to prevent an increased risk for breast cancer

Preventable Factors

BODY WEIGHT Obese or overweight women are at increased risk of developing breast cancer. A woman who exercises four hours per week reduces her risk of breast cancer. Exercise pumps up the immune system and cuts estrogen levels

SMOKING

Smoking not only increases risk of lung cancer, but breast cancer as well. A recent study indicated there may be a link between breast cancer and cigarette smoking and second-hand cigarette smoke, though the relationship is still under investigation. However, smoking decreases survival rate once you have been diagnosed with breast cancer

DRINKING ALCOHOL

The more alcohol you drink, beyond a drink a day, the higher your risk. Studies show that breast cells are exposed to higher levels of estrogen when consuming alcohol, which may trigger them to become cancerous

DIET

Eat a low-fat, nutritious diet. Fat triggers the hormone estrogen, that fuels tumour growth. Fill your diet with plenty of fruits and vegetables

Non-Preventable Factors

FAMILY PRE-DISPOSITION |

If a person has developed breast cancer in the past, or currently has breast cancer, women in the immediate family are at greater risk for breast cancer than those without family history. If you have a grandmother, mother, sister, or daughter who has been diagnosed with breast cancer, this puts you in a higher risk group. See your doctor at any sign of unusual symptoms

AGE

The risk increases with age. Most cases are found in women over 40, though the number of younger women developing breast cancer is currently on the rise

RACE

Breast cancer is diagnosed more often in white women than Asian or African women. Reason for this is yet to be defined, but women of all races should still be concerned

REPRODUCTIVE AND MENSTRUAL HISTORY |

Women who experienced their first menstrual cycle before age 12, had menopause after age 55, and/or never had children are at increased risk.

For More Information. Please Visit us on