Missed Diagnosis of Gastric Cancer Leads to Linitis Plastica

This case involves a forty-nine-year-old male patient who presented to a new family physician complaining of severe indigestion after eating. The doctor counseled the patient in his office and prescribed Nexium, a PPI heartburn medication that would prevent excessive acid reflux. The patient had a significant family history of gastric cancer but the doctor neglected to extract a detailed medical history or perform a full physical exam during the initial visit. Several months later, the reflux became worse and was associated with nausea, vomiting, and weight loss. The physician became alarmed and sent the patient for imaging of the upper digestive tract. A biopsy taken during the investigation was sent to pathology and showed diffuse Linitis plastica.

Question(s) For Expert Witness

1. What treatment is required for this disorder and what is the likely prognosis for gastric cancer that has progressed to this point?

Expert Witness Response E-000052

In general, most surgeons in the United States perform a total gastrectomy (if required for negative margins), an esophagogastrectomy for tumors of the cardia and gastroesophageal junction, and a subtotal gastrectomy for tumors of the distal stomach. A randomized trial comparing subtotal with total gastrectomy for distal gastric cancer revealed similar morbidity, mortality, and five-year survival rates. Because of the extensive lymphatic network around the stomach and the propensity for this tumor to extend microscopically, traditional teaching is to attempt to maintain a five centimeter surgical margin proximally and distally to the primary lesion. The five-year survival rate for a curative surgical resection ranges from 60-90% for patients with stage I, 30-50% for patients with stage II disease, and 10-25% for patients with stage III disease.