Curative resection following conservative treatment for perforated early gastric cancer: A case report

Background: Gastric perforation is a relatively rare complication of gastric cancer. Malignant gastric perforation is often a manifestation of advanced cancer with serosal invasion and lymph node metastasis; thus, gastric cancer rarely perforates at an early stage. Herein, we describe a case of gastric perforation, which was treated conservatively; later, the patient was diagnosed with an extremely rare early-stage gastric cancer and underwent radical surgery in two stages. Case presentation: An 81-year-old woman was referred to our hospital for breathlessness. Abdominal contrast-enhanced computed tomography (CT) revealed gastric perforation and perforated peritonitis. She was hospitalized, and conservative treatment was initiated; upper gastrointestinal endoscopy was performed on the 14th day after admission. Gastric ulcer scars were observed in the anterior wall of the stomach; biopsy from around the ulcer showed group V (moderately-well differentiated adenocarcinoma). She was diagnosed with gastric perforation due to early gastric cancer. Abdominal CT revealed no findings suggestive of liver, lung, or para-aortic lymph node metastasis, and a radical gastrectomy with lymph node dissection was performed 32 days after onset. Microscopic findings revealed that the cancer cells proliferated to the regenerated mucosa of ulcer scars and infiltrated into scar tissue equivalent to submucosal tissue (T1b). The gastric cancer was staged as T1bN0M0, stage IA. The patient has been reported healthy without any evidence of gastric cancer recurrence for the past 48 months. Conclusions: : Treatment of gastric cancer perforation includes first-stage surgery and second-stage surgery after conservative therapy and closure of the omental patch or perforation site. Ensuring a balance between lifesaving and curability, while selecting surgical methods is necessary. Depending on the patient's general condition and degree of peritonitis, curatively resectable perforated gastric cancer, including early-stage gastric cancer, should be treated conservatively as in our case, or minimally invasively with an omental patch or perforation closure as surgery for gastric perforation. After evaluation of the patient's general condition and adequate assessment of the extent and progression of the gastric cancer, a two-stage gastrectomy with lymph node dissection was suitable and achieved an improved general condition, which may lead to a highly curative surgery and improve prognosis.