Stage IV Signet Ring Gastric Cancer Presenting With DIC and Severe Anemia

What happened, in summary

A 71-year-old man was brought to hospital after fainting. He had a fever, confusion, black stools and profound anemia, with a hemoglobin of 4.2 g/dL and a platelet count of 44,000/µL. Testing supported disseminated intravascular coagulation, a serious clotting and bleeding disorder. When asked about earlier symptoms, he described 4 months of early fullness, difficulty swallowing and unintentional weight loss. An initial stomach biopsy did not show cancer even though endoscopy found diffusely thickened gastric folds. A bone marrow biopsy then showed metastatic adenocarcinoma. Further imaging demonstrated marked thickening of the stomach and gastroesophageal junction, and deeper submucosal biopsies confirmed high-grade invasive gastric adenocarcinoma with signet ring features. MRI also showed multiple suspicious bone lesions in the spine and right ilium. The cancer was classified as Stage IV. He received blood products and cryoprecipitate for the anemia and clotting disorder, then began palliative chemotherapy with 5-FU and leucovorin. His need for blood products fell, his coagulation results improved and his hemoglobin stabilized. He was discharged in stable condition to continue chemotherapy. Oxaliplatin was subsequently added to the 5-FU regimen. The case illustrates a gastric cancer that was difficult to detect on superficial biopsy and first became apparent through metastatic disease and a severe systemic complication.