Abstract
Introduction and importance
Gastric cancer is the fifth most common malignant tumor in the world. It is considered to be the second most common cause of cancer-related death. It is still described as the preserve of people aged over 50. However, it is rarely described in young people. In this study, we report three cases of gastric cancer for subjects under 35 years of age.
Methods
The study was a retrospective single-center non-consecutive case series.
Results
We report three cases of gastric cancer for young people under 35 years old. The consultation reason was chronic pain with a mean evolution of 2.1 years associated with post prandial vomiting. Clinical, biological and prognostic aspects were evaluated. Biopsies in all these patients were consistent with a moderately differentiated adenocarcinoma. The mean age was 28.3 years, with males predominating.
Conclusion
Gastric cancer is generally considered to be a pathology of the elderly, but it can also occur in younger patients. Late consultation for treatment leads to late-stage diagnosis and a poorer prognosis.
Keywords: Gastric cancer, Endoscopic biopsy, Adenocarcinoma, Young people, Democratic Republic of Congo
Highlights
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Gastric cancer is considered to be a cancer of the elderly. Its occurrence in young people is rare and its prognosis is poor.
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The contribution of endoscopy with biopsy is crucial in the diagnosis.
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This report invites clinicians to consider the problem on a case-by-case basis, as prognosis depends on time of discovery.
1. Introduction
Gastric cancer is the fifth most common malignancy in the world [1,2]. It is considered to be the second most common cause of cancer-related death, with a higher incidence in the elderly [3,4]. In the literature, gastric cancer occurs in subjects over the age of 50, although there is an increase in the relative proportion of gastric cancers in young people compared with adults [2,4]. Data on the clinical, biological and prognostic characteristics of gastric cancer in young patients are still controversial. Approximately 2–15 % of gastric cancers occur in patients under 45 years of age [4,5]. Although the relationship between the prognosis and age of patients with gastric cancer is controversial, some authors report that gastric cancer in young people is more aggressive than in adults [2,5]. In fact, other authors report that young patients with gastric cancer have a tumor stage and survival comparable to other patients [2,4,6]. In young people, Helicobacter pylori infection is associated with advanced stage poorly differentiated carcinoma [4,6]. The majority of young patients present at an advanced stage, which has an impact on five-year survival, which is very poor [6]. In this study, we report three cases of gastric cancer in young people under 35 years of age treated surgically during the period from 1 January 2022 to 31 July 2022 in whom the clinical, biological and prognostic aspects were analyzed.
2. Methods
The study was a retrospective single-center non-consecutive case series, which was carried out at the Panzi general referral hospital.
We report three cases of gastric cancer for young people under 35 years old. The consultation reason was chronic pain with a mean evolution of 2.1 years associated with post prandial vomiting. Clinical, biological and prognostic aspects were evaluated. Biopsies in all these patients were consistent with a moderately differentiated adenocarcinoma. The mean age was 28.3 years, with males predominating.
The work has been reported in line with the PROCESS criteria [7].
3. Results
3.1. Observation 1
The patient was 21 years old, male, with history of occasional consumption of locally produced alcohol, and had been suffering for two years from epigastric pain treated with unidentified medicinal plants. The persistence of the pain, combined with post-prandial vomiting and hematemesis, prompted him to consult our department for investigation and improved management. A physical examination revealed 40 % weight loss. The abdomen was slightly enlarged, supple and tender, with no epigastric mass palpated and no hepatosplenomegaly. The hemogram showed anemia with a hemoglobin level of 7.2 g/100 ml. Œsogastroduodenoscopy showed a submucosal budding process 10 cm for diameter opposite the lesser curvature of the stomach and extending into the antropyloric region and the duodenum, with central ulcerated areas and blood clots. Image 1 shows the Œsogastroduodenoscopy image showing a submucosal budding process. Helicobacter pylori testing was positive. Abdominal CT showed the antrum tumefaction region extending over approximately 130 mm with ulcerative lesions and liver metastases. Image 2, Image 3 show the results of the abdominal CT scan, demonstrating an antrum tumefaction and hepatic metastasis, respectively. The biopsy showed a moderately differentiated adenocarcinoma. Given the advanced stage of the cancer, the patient was discharged from hospital on palliative supportive care consisting of Tramadol and Omeprazol. No chemotherapy was started due to lack of funds.
Image 1.
This image illustrates a submucosal budding process.
Image 2.
This CT scan image shows a swelling of the antrum.
Image 3.
This CT scan image shows liver metastases.
3.2. Observation 2
A 35-year-old patient from a rural area, with history of occasional alcohol consumption, non-steroidal anti-inflammatory drugs and traditional products made of unidentified plants, came to the clinic with chronic epigastric pain that had been present for a year, vomiting and hematemesis for more than two months. Physical examination revealed hypovolemic shock, with blood pressure of 80/40 mm Hg (mm Hg), weight loss and an epigastric mass palpated and adherent to the deep abdominal wall. The blood count showed a microcytic hypochromic anemia of 6 g/100 ml. The emergency fibroscopy showed the existence of a budding gastric tumor with active bleeding. Image 4 shows an image of a budding gastric tumor with active hemorrhage. The Helicobacter pylori test came back positive. Biopsy revealed a poorly differentiated adenocarcinoma. After intensive care, an exploratory laparotomy was performed, revealing a stenosing antropyloric tumor with hepatic nodules and mesenteric invasion. An emergency partial hemostasis gastrectomy was performed to control the cataclysmic gastric hemorrhage. The patient was referred to a specialized center for chemotherapy.
Image 4.
Image illustrating a budding gastric tumor with active hemorrhage.
3.3. Observation 3
29 year old female with no previous history. She came for epigastralgia and vomiting for 4 months. Physical examination revealed weight loss and epigastric tenderness with no palpable abdominal mass. Fibroscopy revealed an antropyloric ulcer-burgeoning tumor. Image 5 shows an ulcerating-bourging tumor seen on oesogastroduodenoscopy. The abdominal CT scan did not reveal any signs of extension. Helicobacter pylori serology came back positive. Pathological examination concluded that the tumor was a moderately differentiated adenocarcinoma. A subtotal gastrectomy was performed with adjuvant chemotherapy.
Image 5.
Image of an esogastroduodenal fibroscopy illustrating an ulcerating and budding tumor.
4. Discussion
We report three cases of gastric cancer for young people under 35 years old. The consultation reason was chronic pain with a mean evolution of 2.1 years associated with post prandial vomiting. Clinical, biological and prognostic aspects were evaluated. Biopsies in all these patients were consistent with a moderately differentiated adenocarcinoma. The mean age was 28.3 years, with males predominating.
GLOBOCAN 2020 data shows that gastric cancer is the fifth most common cancer worldwide, after breast, lung, colorectal and prostate cancer. There are more than one million new cases each year, with men more affected than women. [1]. This is usually a cancer of the elderly, aged over 60 [3]. Few studies have reported this type of cancer in people under 50 [4,8]. Some authors have taken the view that the reasons for the appearance of gastric cancer in young people remain unexplained [2,4]. In our study, the mean age of the patients was 28.3 years, the youngest being 21 years, which is rarely described in the literature, which defines gastric cancer in young people as a gastric tumor occurring in subjects under 50 years of age [2,6]. There were two men, all of them had consumption alcohol history, and one woman. It is recognized that, regardless of age, gastric cancer affects men more than women [2,5]. This can be explained by lifestyle factors such as smoking and alcohol consumption, which are much more common among men than women in our countries [9,10]. A history of consumption traditional products was found for all our patients. We are not aware of any studies demonstrating a correlation between the use of traditional products and the development of gastric cancer. For our cases, the traditional products used had not been clearly identified by the patients. We found that our three patients presented with a history of vomiting associated with severe weight loss, indicating late recourse to hospital; the patients were seen at an advanced stage of the disease. This is consistent with the findings of Horacio et al. [2] who found that there is link between for late diagnosis of disease in young people and a higher frequency of stage IV of gastric cancer at diagnosis [2]. Other authors have described similar results [6,10]. Other authors have investigated the relationship between symptoms and disease state of gastric cancer in young patients, finding that the proportion of cases presenting with alarming symptoms was significantly higher in the advanced stage than in the early stage [5,6,10,11]. Symptoms are often overlooked in young patients were and there is general and indiscriminate use of proton pump inhibitors which can alter the clinicopathological features of gastric cancer [6,11]. All our patients tested positive for Helicobacter pylori. Helicobacter pylori infection is strongly associated with the development of gastric cancer for young patients [11,12]. Some epidemiological data have demonstrated an association between Helicobacter pylori infection and an increased risk of gastric cancer in young people [[10], [11], [12]]. The advent of microscopy in several countries with limited resources is a step forward in diagnosis [2,10]. It is used not only to take samples for Helicobacter pylori testing but also, and above all, to take samples for pathological examinations [13,14]. Our series reports moderately differentiated adenocarcinomas on pathological examination. Other authors who have studied gastric cancer in young people report a histological type of poorly differentiated adenocarcinoma [2,4,13]. We report hepatic metastases in the form of hepatic nodules for two patients, one on abdominal CT scan and the other during emergency gastrectomy indicated for cataclysmic gastric hemorrhage (2nd observation). López-Basave et al. and Smith & Stabie have found a higher incidence of invasion of adjacent organs and distant metastases in patients under 35 years of age [2,15] and Other authors have found that because this cancer is diagnosed at an advanced stage, there is usually involvement of neighboring or distant organs [3,16]. Early diagnosis of gastric cancer in young subjects may contribute to long-term survival [2,4]. However, younger populations are not interested in mass screening, particularly for Helicobacter pylori, and endoscopic screening for gastric cancer for at-risk patients, which may delay investigation and diagnosis and result in a more advanced stage at detection [10,16]. In this study, the patients reported had delayed consultations which would explain the alarming clinical state in which the patients found themselves, which is proportional to the advanced stage of the cancer, resulting in the poor prognosis observed in our patients.
This case study was carried out in a context of limited resources, which would explain the limitations in some investigations and the quality of some images taken not by appropriate equipment but by available equipment.
5. Conclusion
Gastric cancer is generally considered to be a disease of the elderly population, but it can also occur in younger patients. We observed a mean age of 28.3 years with a lower range of 21 years with male predominance. The clinical and anatomopathological characteristics were no different in the younger patients than in the older patients, although there was a late need for care and the disease was diagnosed at an advanced stage. There should be a high index of suspicion of gastric cancer, even in young patients, so that it can be detected at an early stage and curative treatment can be instituted.
Patient consents
Consent to publish the case report was not obtained from patient. This report does not contain any personal information that could lead to the identification of the patient. Publication has been authorized by the deanery of the faculty of medicine and the administration of our hospital.
Provenance and peer review
Not commissioned, externally peer reviewed.
Ethical approval
This report does not contain any personal information that could lead to the identification of the patient. Publication has been authorized by the deanery of the faculty of medicine of Evangelical University in Africa and the administration of Panzi hospital.
Funding
This research did not receive any specific grant from funding a commercial, or not for profit sectors.
Author contribution
Conception: Amisi Mangaza; Design: Amisi Mangaza and Balagizi Ganywamulume; Administrative support: Alumeti Munyali Désiré; Litterature search: Amisi Mangaza, Bwemere Mungwete Josué, Byabene Gloire, Mongwa Justin and Balagizi Ganywamulume; Manuscript preparation: Amisi Mangaza and Balagizi Ganywamulume; Manuscript editing: Alumeti Munyali Désiré and Amisi Mangaza; Manuscript review: All authors; Supervision: Alumeti Munyali Désiré; Final approval of manuscript: All authors.
Guarantor
Amisi Mangaza is the guarantor of the work and accept full responsibility of the work.
Research registration number
N/A.
Declaration of competing interest
The authors declare no conflicts of interest.
Acknowledgements
Our special acknowledgements go to the anaesthetic nurses in the operating room at the Panzi General Referral Hospital and the nurses in the surgery department for their collaboration and facilitation.
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