Mr J, 67 years old gentleman, presented with symptoms of post cibal abdominal bloating and burning discomfort along with feeling of heaviness in retrosternal region for past 3 weeks. His past history was significant for left orchidectomy for Seminoma testis (35 years), Systemic hypertension, CKD, Hypothyroidism, Sinus node dysfunction-S/P PPI (2019).

Clinical examination revealed normal vitals, mild pallor, no significant adenopathy/icterus, normal systemic examination including abdomen.

Specifically, no mass /organomegaly/ free fluid noted in abdomen.

Initial cardiac evaluation was done and ECG revealed Pacing rhythm, Echo revealed concentric LVH, Pacemaker lead in situ, Mild LV dysfunction (LVEF-50%).

Baseline blood tests revealed mild anemia (Hb 11.6g%), raised Serum Creatinine(1.6mg%) and normal LFT/TFT.

CT Abdomen plain was done and revealed mild OGJ thickening.

Image 1-OGJ WALL THICKENING ON CT

In view of late onset dyspepsia and CT evidence of OGJ thickening, he was planned for UGI Endoscopy after cardiac clearance and informed consent.

UGI Endoscopy revealed ulcerating unhealthy mucosa in gastric side of OGJ with mild luminal narrowing and hence multiple biopsies were taken from the lesion. Rest of study up to D2 was normal.

IMAGE 2- ENDOSCOPIC LESION

HPE of the biopsy material revealed poorly differentiated adenocarcinoma.

IMAGE 3 – HPE PHOTOMICROGRAPH

Fig 1 – H&E 100x – tumour composed of cords and nests of malignant epithelial cells forming vague glandular pattern

Fig 2 – H&E 400x – the cells show moderate eosinophilic to clear cytoplasm and pleomorphic hyperchromatic nuclei.

IMAGE 4 – PET CT

PET CT whole body was proceeded with and revealed disease localized to OGJ and no metabolically active lesions anywhere else in the body.

Gastrosurgical consult was obtained and patient/attenders were well explained about nature of disease, need for surgery and prognosis.

He is being planned for partial gastrectomy and esophagogastric anastomosis.

DISCUSSION

Late onset dyspepsia refers to new onset dyspeptic symptoms after age of 55 years. Upper GI Endoscopy is mandatory in these cases due to need for ruling out malignancy.

OGJ Tumors are special group of tumors that occur at the transition zone between esophageal squamous and gastric columnar epithelium.

They are classified using SIEWERT STEIN CLASSIFICATION SYSTEM which helps decide type of surgery required for individual lesion in a given patient.

Image 5 -SIEWERT STEIN CLASSIFICATION

Type II /III lesions are managed as gastric cancers whilst Type I Lesions are classified as esophageal lesions, managed appropriately.

Thus this case shows need for early endoscopic evaluation in all patients with late onset dyspepsia. Early detection of malignancy results in improved patient survival.

Dr. M. A. Arvind
Consultant Medical Gastroenterologist
Kauvery Hospital Chennai

Dr. Ramya Natarajan,
MD DNB Pathology
Consultant Pathologist
Neuberg Diagnostics Pvt Ltd