Gastric carcinoma in the young (review of 14 cases).
A retrospective study of 14 cases of gastric carcinoma in the age group of 19 to 35 years is presented. The relevant literature has been reviewed.
While gastric cancer is much more common in the second half of life, it does occur in the younger individuals with a much higher rate of morbidity and mortality. We had recently under our care, a case of gastric cancer in a young man of 20 years, which prompted us for this presentation.
During a period of five years, from 1983 to 1987, 107 patients of gastric carcinoma were recorded at the King Edward Memorial Hospital, Mumbai; of these 14 were less than 36 years of age (13.06%). The case records of these patients were analysed in detail, greater emphasis being laid on the pathological aspects. Available histological material of all the patients (excised primary tumour and lymph nodes) was studied with the help of special stains; lymphomas and carcinoids were ruled out.
The incidence of gastric carcinoma in young patients was found to be 13.06%. The average age of the patients was 28.57 + 5.9 years; the youngest being 19 years old [Table - 1]. The male : female ratio was 1.33 : 1.
Abdominal pain was the dominant symptom (in 12 of 14 patients), duration of which varied from 15 days to 2 years (average 5.8 months). Bleeding was the presenting symptom for 7 cases. Other symptoms were nausea, vomiting (7 patients), dyspepsia (6 patients) and wasting (6 patients).
Examination findings were as follows: intra-abdominal lump and distension of upper abdomen in 7 patients each, hepatomegaly in 6, jaundice in 4 and lymphadenopathy (supraclavicular) in 2 patients.
In 3 patients barium meal study and in 8 gastroscopy were found to be the only diagnostic investigations. In remaining 2, barium study with gastroscopy and biopsy aided the diagnosis. Other investigations were liver scan (in four patients, of whom one showed presence of metastasis) and ultrasonography (in 3 patients).
The operative procedures and findings are listed in Table 1 and the histological findings in [Table - 2].
The complications observed in these patients were, aggravation of pulmonary tuberculosis, thrombophlebitis, massive wound sepsis and lobar pneumonia. Intestinal obstruction was observed in one patient (case no. 11) after 6 months of gastrectomy and at re-exploration he was found to develop jejunal metastasis causing complete luminal block.
Four patients died while in hospital; the causes of death were: acute renal failure (case no. 2), malignant cachexia (case no. 3), gastric perforative peritonitis (case no. 4) and hepato-renal failure following obstructive jaundice (case no. 14).
Amongst the rest, case no. 13 received a course of post-operative chemotherapy and was found to be symptom-free at a follow-up 15 months later. No follow-up records of other patients were found.
The lympho-reticuloendothelial activity in the primary tumour and regional lymph-node is presented in Table 2. This activity was found to be poor in case nos. 1, 2, 3 and 4. No reaction was observed in patient nos. 7, 8, 9, 12 and 14. Of these patients, 4 expired in the hospital as mentioned above. Lymphoid aggregates were found in primary tumour and regional lymph-nodes of 5 patients (see [Figure - 1] and [Figure - 2]); in two of them extensive lymph-node metastases were detected (case nos. 6 and 13).
Though incidence of gastric carcinoma increases with age, 0.7-6% of young population (less than 40 years) has found to be affected in various studies,,,,. The male : female ratio has been reported to be 1 : 2 in these patients, as against the predominance of males observed in adult studies (M:F=3:1-2:1) ,
Though the diagnosis of gastric neoplasm is often overlooked in young patients, symptoms observed in this age group did not differ from those in adult,,,. This was our experience too. In our series intra-abdominal mass was the commonest findings. In previous studies upper abdominal mass has been noted in 71% of patients. It was also the commonest sign in the series reported by Bellegie and Dahlin.
In our study gastroscopy aided by biopsy was found to be the most useful investigation. Though barium meal study alone was carried out in 3 patients and was found to be diagnostic, false negative findings have been reported in the literature,. Some investigators report achlorhydria as one of the diagnostic parameter, but value of this investigation has been doubted by Bellegie and Dahlin.
The prognosis of cancer depends on the degree of nuclear differentiation. However, a study by Black et al has demonstrated that lympho-reticuloendothelial (L-RE) reactivity, as evidenced in form of lymphoid infiltrations in primary tumour, follicular hyperplasia (FH) and histiocytosis (SH) in the regional lymphnode, is of prognostic significance. It has also been shown that the survival of cancer patients with SH is more than the survival of patients with comparable nuclear differentiation but without SH.
Furthermore, this prognostic indicator is independent of regional lymph node metastasis, lethality of primary tumour (as judged by nuclear differentiation) and surgical eradication.
We studied L-RE activity of the available histopathological specimens of our patients. The patients who died in the hospital showed poor or no immunological reaction; similarly a patient (case no. 13) who had good lymphoid aggregates, was found to be symptom-free even after 15 months of surgical procedure in spite of extensive lymphnode metastasis However, follow up records were found to be missing for the remaining cases and therefore value of this prognostic parameter cannot be fully evaluated in our series.
We thank the Dean, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, for permitting us to utilize hospital records.