Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Dec 6, 2018; 6(15): 1024-1028
Published online Dec 6, 2018. doi: 10.12998/wjcc.v6.i15.1024
Gastric cancer with severe immune thrombocytopenia: A case report
Zhe-Wei Zhao, Wei-Ming Kang, Zhi-Qiang Ma, Xin Ye, Jian-Chun Yu
Zhe-Wei Zhao, Wei-Ming Kang, Zhi-Qiang Ma, Xin Ye, Jian-Chun Yu, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
Author contributions: Zhao ZW and Yu JC drafted this manuscript; Kang WM and Yu JC performed the operation for this patient; Ma ZQ and Ye X analyzed the patient data and prepared the figures; all authors read and approved the final manuscript.
Informed consent statement: Consent was obtained from relatives of the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jian-Chun Yu, MD, Chief Doctor, Professor, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing 100730, China. yjcpumch@126.com
Telephone: +86-10-69155067 Fax: +86-10-69155068
Received: August 16, 2018
Peer-review started: August 17, 2018
First decision: October 8, 2018
Revised: October 31, 2018
Accepted: November 7, 2018
Article in press: November 7, 2018
Published online: December 6, 2018
Processing time: 113 Days and 1.5 Hours
ARTICLE HIGHLIGHTS
Case characteristics

The patient suffered from decreased appetite, nausea, vomiting, and weight loss for 2 mo with a past medical history of thrombocytopenia, which progressed to difficulty in feeding and gastrointestinal hemorrhage.

Clinical diagnosis

The patient was diagnosed with gastric cancer accompanied with severe and medically refractory immune thrombocytopenia.

Differential diagnosis

Mucosal biopsy from endoscopy was useful for differential diagnosis and histological analysis revealed a gastric adenocarcinoma.

Laboratory diagnosis

Laboratory findings revealed elevated tumor markers (CA19-9 and CA242), low platelet count, and decreased hemoglobin.

Imaging diagnosis

Abdominal contrast-enhanced computed tomography revealed a thickening wall of the gastric antrum with significantly enhanced, multiple small lymph nodes around the stomach but no obvious retroperitoneal lymph nodes and a normal spleen.

Pathological diagnosis

The histopathological examination after the subtotal gastrectomy revealed a poorly differentiated gastric adenocarcinoma which had reached the serosal layer and the cancer had also metastasized to 3/30 lymph nodes.

Treatment

The patient underwent a splenectomy and a distal subtotal gastrectomy (D2 radical resection) with a Roux-en-Y reconstruction simultaneously.

Related reports

Five cases of immune thrombocytopenia (ITP) patients suffering with gastric malignant tumors have been reported in English in MEDLINE. Patients in these cases suffered mild ITP with a platelet (PLT) level larger than 25000/μL. The commonest pathologies are gastric cancer and gastric mucosa associated lymphoid tissue (MALT) lymphoma. Helicobacter pylori (H. pylori) may play a key role in the pathogenesis of both gastric malignant tumors and ITP. Noda et al[7] reported a case of regression of ITP after resection of gastric MALT lymphoma and eradicating treatment of H. pylori. In terms of treatment, endoscopic resection could be performed only when the tumor is restricted to the mucosa during eradication therapy. Subtotal/total gastrectomy combined with splenectomy is the most appropriate treatment when tumors invade the submucosa.

Experiences and lessons

For patients with cancer and medical refractory ITP, surgical treatment may be the only option for therapy despite a high risk of bleeding. Simultaneous splenectomy, preoperative PLT transfusion, and early enteral nutrition are important treatment methods for postoperative recovery.