Gastric outlet obstruction due to adenocarcinoma in a patient with Ataxia-Telangiectasia syndrome: a case report and review of the literature
© Otabor et al; licensee BioMed Central Ltd. 2009
Received: 11 December 2008
Accepted: 12 March 2009
Published: 12 March 2009
Ataxia-Telangiectasia syndrome is characterized by progressive cerebellar dysfunction, conjuctival and cutaneous telangiectasias, severe immune deficiencies, premature aging and predisposition to cancer. Clinical and radiographic evaluation for malignancy in ataxia-telangiectasia patients is usually atypical, leading to delays in diagnosis.
We report the case of a 20 year old ataxia-telangiectasia patient with gastric adenocarcinoma that presented as complete gastric outlet obstruction.
A literature search of adenocarcinoma associated with ataxia-telangiectasia revealed 6 cases. All patients presented with non-specific gastrointestinal complaints suggestive of ulcer disease. Although there was no correlation between immunoglobulin levels and development of gastric adenocarcinoma, the presence of chronic gastritis and intestinal metaplasia seem to lead to the development of gastric adenocarcinoma. One should consider adenocarcinoma in any patient with ataxia-telangiectasia who presents with non-specific gastrointestinal complaints, since this can lead to earlier diagnosis.
Ataxia-Telangiectasia (A-T) was first reported in 1926 in three patients that presented with progressive choreoathetosis and ocular telangiectasias . By 1958, it was recognized as a distinct disease process and named ataxia-telangiectasia . The most common initial abnormalities noted are balance and gait problems . Unsteadiness and truncal ataxia typically appear before 3 years of age, with slurred speech by 5 years of age. Patients are usually wheel-chair bound by 10 years of age due to excessive falling coupled with slow reflexes that cause serious bodily injuries. About a third of the patients present with severe immunodeficiencies accompanied by severe sino-pulmonary infections with non-opportunistic organisms, a third have moderate immunodeficiencies, and a third have no signs of immunodeficiency . Serum levels of alpha fetoprotein (AFP) are usually increased in A-T patients [4–6]. There appears to be a direct correlation between serum AFP levels and age .
While there have been significant improvements in diagnostic modalities for A-T, there is still no cure and treatment is mainly symptomatic. Patients with A-T have a 70–250 fold increased risk for developing a lymphoreticular malignancy [8, 9]. However, clinical and radiographic diagnosis of malignancy in these patients can be difficult because the presentation is usually atypical and may be confused with the infectious processes commonly associated with immunodeficiency syndromes. Six cases of gastric cancer associated with A-T have been reported in the literature in patients ages 14–26 years; of these, four cases were reported in the English literature with the last case reported in 1979 . We present the case of a 20 year old female with ataxia-telangiectasia who was transferred to our institution with a diagnosis of pancreatic abnormality. Further diagnostic evaluation revealed gastric adenocarcinoma that was resected.
Postoperatively, the patient initially did well, but then developed increased output from her abdominal drain containing high amylase and lipase levels. An UGI series revealed no evidence of anastamotic leak. On post operative day 7 she developed bloody emesis which resolved spontaneously. However, she developed increasing abdominal pain and a CT scan of the abdomen showed ascites with small bowel obstruction. She was therefore returned to the operating room for exploratory laparotomy which revealed diffuse ascites, an intact gastrojejunostomy, and an obstruction in the afferent limb of the gastrojejunostomy due to large blood clots. The clots were removed via an enterotomy in the afferent limb, and the pancreatic ascites was widely drained. She had a prolonged hospital course but recovered from surgery and was discharged to home on hospital day 48. Two months after surgery she was on continuous jejunostomy tube feeds and eating small amounts by mouth. However, three months after surgery she was refusing to eat, appeared uncomfortable although without complaints, and subsequently declined clinically thereafter. She expired 100 days from initial diagnosis while under hospice care, presumably due to wasting secondary to metastatic adenocarcinoma.
Our patient was the last of three children born at term to a healthy 23 year old mother. Her birth weight was 2.45 kg; there is no family history of congenital immunodeficiency disorder; her two older siblings are healthy and living. The patient was initially seen at age 18 months due to loss of previous ability to walk, poor head control and tendency to walk and fall to the right. By age 3 years, she had progressively worsening ataxia, choreoathetosis, prominent ocular telangiectasias and an elevated alpha fetoprotein of 205.4 ng/mL (normal 0–6 ng/mL) consistent with ataxia-telangiectasia. All immunoglobulin levels were within normal limits except IgM and IgE, which were slightly depressed. The patient did not receive routine immunoglobulin administration since her disorder was mostly neurologic.
Ataxia-Telangiectasia, an autosomal recessive disorder, is characterized by early onset progressive cerebellar ataxia, oculocutaneous telangiectasia, immune deficiency, and cancer. The causative gene, A-T mutated (ATM) on chromosome 11q22-23, codes for a 350 kDa Ser/Thr protein kinase that belongs to the phosphoinositide 3-kinase (PI3K)-related protein kinase (PIKK) family. ATM with associated proteins function primarily as phosphorylating agents in controlling genomic stability and regulating lymphocyte maturation. Although rare, A-T is the most common primary immunodeficiency syndrome listed in the Immunodeficiency Cancer Registry (ICR), and approximately one-third of A-T patients develop a malignancy during their lifetime. These patients most commonly develop lymphoreticular neoplasms. ATM has also been implicated in breast, lung, head and neck carcinoma, and is associated with a poor prognosis in adult patients with advanced gastric cancer .
Previous cases of gastric adenocarcinoma associated with Ataxia-Telangiectasia Syndrome.
Symptoms on presentation
Age at diagnosis (years)/Sex
Time to death (days)
Haerer A et al. (1969)
Nausea, intractable vomiting and weight loss
Abdominal pain, nausea, vomiting and weight loss
Kondo K and Horikawa Y (1975)
Severe mental retardation, gait and speech disturbances, nystagmus
Gastric cancer confirmed at autopsy
Watanabe A et al. (1977)
Abdominal pain, vomiting, postive fecal occult blood test
Frais MA (1979)
Weight loss, anorexia and dyspepsia
The A-T patients with gastric carcinoma reported to date presented with non-specific signs of abdominal pain, nausea, vomiting and weight loss. Three patients including ours had initial clinical findings suggestive of ulcer disease. On endoscopy, our patient was noted to have diffuse gastritis, which may have contributed to the development of her adenocarcinoma. All cases reported in the literature had metastatic disease at the time of exploratory laparotomy. Although depressed immunoglobulin levels are associated with increased risk of malignancy, there was no significant correlation between abnormal immunoglobulin levels and the development of gastric cancer in those patients in whom levels were checked, suggesting that injury to the gastrointestinal mucosa in the form of chronic gastritis may predispose these patients to the formation of gastric adenocarcinoma in light of their poor immunologic defense systems. Our patient further demonstrates the challenges associated with diagnosing and caring for these complex patients.
Although rare, one should consider adenocarcinoma in any patient with ataxia-telangiectasia greater than 10 years of age who presents with non-specific gastrointestinal complaints, since this can lead to earlier diagnosis. Given the poor survival outcome, palliative rather than curative measures may be necessary for unresectable disease. The role of chemo-radiation therapy in A-T patients is limited as it may further predispose the patient to the risk of developing new malignancies . Continuous research efforts will increase our understanding of this disease process and the role of the ATM gene in carcinogenesis.
Written informed consent was obtained from the legal guardian for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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