Rare Case of Adenocarcinoma of Stomach with Disseminated Bone Marrow Metastasis

A 50-year-old man diagnosed with intestinal-type gastric adenocarcinoma, with no other associated comorbidities. On laboratory workup, bicytopenia (severe anemia and thrombocytopenia) was found; the peripheral blood smear was consistent with leukoerythroblastosis. The patient was also found to have elevated lactate dehydrogenase and alkaline phosphatase levels and hyponatremia. In view of suspected bone marrow metastasis, positron emission tomography/computed tomography (PET/CT) was performed. The Maximal Intensity Projection (MIP) image of ¹⁸F-fluorodeoxyglucose (FDG) PET/CT showed FDG uptake in the hypochondriac region in primary stomach lesion (red arrow) with diffuse increased FDG uptake involving the axial and appendicular skeleton [Figure 1a]. There is diffuse FDG-avid bone marrow metastasis involving the entire vertebral column and sternum without structural changes on the CT image [Figure 1b: sagittal CT image; Figure 1c: fused image]. FDG-avid wall thickening at antropyloric region of the stomach with maximum thickness ~ 20mm with few FDG-avid abdominal lymph nodes [Figure 1d: fused; Figure 1e: axial CT image]. Diffuse FDG-avid bone marrow deposits were noted in the pelvic bones including bilateral iliac bone and sacrum [Figure 1f: fused; Figure 1g: axial CT image]. The primary lesion involving the distal part of the stomach extends 6 cm in length [Figure 1h: fused coronal image]. Unfortunately, the patient died in 2 months of diagnosis in spite of the best supportive care. The prognosis of metastatic stomach cancer is quite poor despite the developments in diagnosis and treatment modalities.[1234] Bone marrow metastasis in gastric cancer is extremely rare, and it usually occurs in younger patients with aggressive histopathological subtype.[567] Marrow metastasis most commonly presents with hematological manifestations such as anemia and thrombocytopenia.[8910] Our case highlights an unusual case of gastric adenocarcinoma with extensive bone marrow metastasis without any other visceral or peritoneal involvement at presentation. As the patient was found with hematological manifestations of bicytopenia and leukoerythroblastosis which has a broad differential diagnosis, our case established PET/CT as a noninvasive method in evaluating bone marrow involvement when suspicion is high.

Close

Figure 1 (a) MIP image showing FDG uptake in the primary gastric lesion and skeletal system; (b) sagittal CT showing no structural vertebral changes; (c) fused PET/CT of vertebral marrow involvement; (d) fused PET/CT showing antropyloric wall thickening and lymphadenopathy; (e) axial CT image of the same region; (f) axial CT image of pelvis; (g) fused PET/CT showing pelvic bone marrow involvement; (h) fused coronal PET/CT image showing FDG avid distal stomach lesion

Export to PPT