Locally advanced synchronous hemorrhagic gastric cancer – from the first symptom to therapy – case reportAuthors:Szabolcs Attila Gabor¹, Botond Istvan Kiss¹, Moriczi Renata¹, Siklodi Evelyn3 , Daniela Tatiana Sala¹˒², Radu Mircea Neagoe¹˒²Affiliation¹ 2nd Department of Surgery, County Emergency Clinical Hospital of Targu Mures² George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures3 Institute for Cardiovascular Diseases and Heart Transplantation of Targu MuresCorresponding author:Tatiana Daniela SalaAffiliation: 2nd Department of Surgery, County Emergency Clinical Hospital of Targu Mures, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu MuresTargu Mures, Gheorghe Marinescu 50, 540136, Mures, RomaniaE-mail address: salatatiana@yahoo.comPhone: 0265-212.111Key Clinical Message(KCM):Synchronous gastric cancers present unique therapeutic challenges, and in carefully selected patients, extended resections such as pancreaticoduodenectomy can enable R0 resection and potentially improve survival, despite the increased risk of postoperative complications.Abstract:Gastric cancer is one of the most common malignancies worldwide, and it’s occurrence is becoming increasingly frequent due to the ageing population and growth of high-risk groups. It is most often recognized in advanced stages due to the few symthoms and the low rate of regular screening.We present a case of a male patient treated in our department for synchronous hemorrhagic gastric cancer(T4b), with preoperative chemotherapy. A total gastrectomy, cephalic pancreaticoduodenotomy and transvers colon resection was performed, due to invadation of the transvers colon and the head of the pancreas.The treatment of advanced gastric cancer is multidisciplinary, including preoperative chemotherapy, surgical treatment and adjuvant oncotherapy. In order to achive an R0 resection, in some selected cases, it is necessary to perform extended resections. These extended resections increase the rate of early postoperative complications, but they have a positive impact on long-term survival.Performing a cephalic pancreaticoduodenotomy simultaneously with gastric resection in advanced gastric cancers to achive an R0 resection remains controversial, as the benefits of radical intervention are sometimes outweighed by its morbidity, but they can have a positive impact on long-term survival.Keywords: Synchronous gastric cancer, cephalic pancreaticoduodenotomy, segmental colectomy, chemotherapy, R0 resection, T4b gastric cancerIntroduction:Gastric cancer is one of the most common malignant tumor, it’s prevalence is increasing due to higher life expectancy and changes in environmental and lifestyle factors. Early detection of gastric cancer is challenging as it is often asymptomatic. The most common symptoms include nausea, vomiting, weight loss, dysphagia, a feeling of fullness, upper gastrointestinal bleeding, and loss of appetite. When these symptoms are present, the cancer is usually already in an advanced stage. (1)(2)It is typically detected in the early stage only through screening or during a gastroscopy conducted for other reasons. The treatment of gastric cancer is multidisciplinary, involving a gastroenterologist, radiologist, oncologist, surgeon, and dietitian.(3)In advanced cases, treatment begins with neoadjuvant chemotherapy, which improves increases the chances of curative treatment. The primary chemotherapy agents used are platinum-based compounds and fluoropyrimidine combinations. If the cancer is HER2-positive, the addition of trastuzumab is recommended, and immunotherapy may also be used after testing for immunohistochemical characteristics. This is followed by restaging of the tumor. (4)(5)(6)Tumor regression or the occurrence of complications (bleeding, gastrointestinal obstruction) requires surgical treatment. Synchronous gastric cancers represent a rare group, typically diagnosed at later stages. In advanced cases (T4/b), the tumor is also attached to surrounding organs, one of the most common is the pancreas. Pancreatoduodenectomy for advanced gastric cancer is rarely performed because of the high morbidity and mortality rates and low survival rate.(7)(8)Case history and Examination:We present the case of a 62-year-old male patient, a chronic smoker, with a history of mitral and tricuspid valve insufficiency. The patient presented to a county emergency clinic 3 months prior to surgery with epigastric and left hypochondriac pain, along with hematemesis.Investigations and treatment:An abdominal ultrasound was performed, which described a tumor mass (77 mm in diameter) at the level of the stomach, extending beyond the gastric wall and contacting the transverse colon, with the presence of locoregional lymphadenopathy.This was followed by a pelvic-abdominal CT scan, which described the following: a heterogeneous, heterocaptant tumor mass with central necrosis in the antral part of the stomach, exophytic growth, but predominantly directed toward the interior of the stomach, with circumferential extension at the level of the antrum, infiltrating the mesocolon transversum; several enlarged locoregional lymph nodes with central necrosis, up to 33 mm in diameter; suspicious mass at the right adrenal gland level; the liver was homogeneous, and the pancreas has normal size, with no dilatation of the Wirsung duct.(Figure 1 )