Case report on Signet ring cell carcinoma in the distal stomach with a history of CABG and a known case of diabetes mellitus (DM) and hypertension (HTN)

Case report on Signet ring cell carcinoma in the distal stomach with a history of CABG and a known case of diabetes mellitus (DM) and hypertension (HTN) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case report on Signet ring cell carcinoma in the distal stomach with a history of CABG and a known case of diabetes mellitus (DM) and hypertension (HTN) Dr. Kavita Gomase, Dr. Pooja Kasturkar, Ms. Achal Gulghane This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6159490/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A 70-year-old male patient who presented with complaints of nausea, vomiting, and black-colored stools. The patient is a known case of diabetes mellitus (DM), hypertension (HTN), and ischemic heart disease (IHD), with a history of coronary artery bypass grafting (CABG) performed in 2018. All investigations are done, including a digital PET scan, shows asymmetric hypermetabolic thickening in the distal stomach and pyloric region, shows of malignancy. A gastric biopsy confirmed moderately differentiated signet ring cell carcinoma. The patient underwent radical distal gastrectomy with gastrojejunostomy, under preoperative treatment. Signet ring cell carcinoma distal stomach cancer radical distal gastrectomy gastric malignancy coronary artery bypass grafting (CABG) gastrointestinal oncology surgical management Figures Figure 1 Figure 2 Figure 3 Introduction Signet ring cell carcinoma (SRCC) is a rare and aggressive form of gastric cancer, often found in the distal stomach. It is characterized by the presence of signet ring cells, which are tumor cells that have a distinctive appearance with a large mucin-filled vacuole pushing the nucleus to the periphery, resembling a signet ring. SRCC is typically diagnosed at an advanced stage, as it tends to grow in a diffuse manner, making it harder to detect early. Gastric cancer (GC) is a significant global health issue. In 2012, there were 951,000 new cases, making up 6.8% of all new cancer diagnoses. That same year, 723,000 people died from gastric cancer, which accounted for 8.8% of all cancer-related deaths.( 1 ) Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer deaths worldwide. While overall gastric cancer rates have decreased in recent years, the incidence of signet-ring cell carcinoma (SRCC) is rising. In recent studies, SRCC accounts for 35–45% of gastric adenocarcinoma cases in regions like Asia, the United States, and Europe.( 2 ) Signet-ring cell carcinoma (SRCC) is a type of adenocarcinoma, defined by the World Health Organization (WHO) as a cancer where more than 50% of the tumor cells are signet-ring cells. These cells contain a large amount of mucin that pushes the nucleus to the edge of the cell, giving them a distinctive ring-like appearance.( 3 ) Signet-ring cell carcinoma (SRCC) is characterized by cells with abundant intracellular mucin production, leading to distinguishing cellular morphology resembling that of a signet ring.( 4 ) Signet-ring cell carcinoma (SRCC) is a rare and aggressive type of gastric cancer, characterized by tumor cells with a large mucin-filled vacuole pushing the nucleus to the edge. It often presents at an advanced stage, has a poor prognosis, and is resistant to treatment. SRCC is increasing in incidence worldwide and is typically treated with surgery and chemotherapy. However, survival rates remain low due to its aggressive nature and early metastasis. Case Presentation A 70-year-old male patient presented with complaints of nausea, vomiting, and black-colored stools, raising suspicion of an upper gastrointestinal pathology. The patient had a known medical history of diabetes mellitus, hypertension, and ischemic heart disease, for which he underwent coronary artery bypass grafting (CABG) in 2018. On clinical examination and evaluation, the findings were suggestive of a potential gastrointestinal malignancy. Further diagnostic investigations, including a digital PET scan(Fig. 1.1), revealed asymmetric hypermetabolic malignant wall thickening localized to the mid and distal body, as well as the pyloric region of the stomach. Subcentimeter regional lymph nodes were noted with insignificant metabolic activity, and no evidence of distant metastasis was identified. A gastric growth biopsy was performed for histopathological examination, which confirmed the presence of moderately differentiated signet ring cell carcinoma. Microscopic evaluation showed tumor infiltration into the gastric mucosa, with sections demonstrating extracellular mucin production, a hallmark feature of this type of malignancy. These findings corroborated the diagnosis of gastric cancer with signet ring cell morphology. On evaluation, the patient was found to have symptoms suggestive of gastrointestinal malignancy. Investigations, including a digital PET scan, revealed asymmetric hypermetabolic malignant wall thickening in the mid and distal body as well as the pyloric region of the stomach. Subcentimeter regional lymph nodes were noted, but with insignificant metabolic activity. There was no definite evidence of distant metastasis. Subsequent histopathological examination of a gastric growth biopsy confirmed the diagnosis of moderately differentiated signet ring cell carcinoma. Microscopic examination revealed tumor infiltration into the gastric mucosa, with sections showing extracellular mucin. Treatment Following the confirmation of moderately differentiated signet ring cell carcinoma through histopathological examination, the patient was planned for surgical intervention as the primary treatment modality. Preoperative optimization was conducted to manage the patient's comorbid conditions, including diabetes mellitus, hypertension, and ischemic heart disease, to reduce perioperative risks. The patient underwent an exploratory laparotomy to assess the extent of the tumor and surrounding tissue involvement. Based on intraoperative findings, a radical distal gastrectomy was performed. This procedure involved the surgical removal of the distal part of the stomach, including the tumor, with an adequate margin of normal tissue to ensure complete resection of the malignancy. Additionally, lymphadenectomy was performed to remove potentially affected regional lymph nodes and to prevent disease progression. Reconstruction of the gastrointestinal tract was achieved via gastrojejunostomy to restore digestive continuity. Postoperatively, the patient was closely monitored in the surgical unit for any complications. Pain management, nutritional support, and early mobilization were prioritized to promote recovery. Laboratory tests and imaging were conducted to ensure there were no signs of infection, anastomotic leakage, or residual disease. The patient was started on a soft diet as tolerated and gradually transitioned to a regular diet. The histopathological examination of the resected specimen confirmed complete tumor removal with clear margins. The patient showed a good postoperative recovery and was discharged in stable condition. Follow-up plans were established, including regular clinical examinations, imaging studies, and, if necessary, adjuvant therapy to monitor for recurrence or metastasis. Overall, the surgical intervention proved successful, and the patient is currently in remission, with no immediate postoperative complications or signs of residual disease. Postoperative Outcome The patient underwent successful exploratory laparotomy with radical distal gastrectomy and gastrojejunostomy. Postoperative recovery has been smooth, with no immediate complications such as infection, bleeding, or anastomotic leakage. The surgical wound is healing well, as observed during follow-up assessments. The patient has resumed a soft diet and is tolerating oral intake without nausea, vomiting, or dysphagia. Pain management has been effectively controlled, and mobility is progressively improving. Regular physiotherapy and nutritional counseling have been initiated to optimize recovery. Histopathological analysis of the excised specimen confirmed the complete removal of the tumor with negative margins, suggesting a favorable oncological outcome. Subcentimeter regional lymph nodes with insignificant metabolic activity on the preoperative PET scan correlate with the absence of nodal metastasis. Discussion Signet ring cell carcinoma is a rare and aggressive form of gastric cancer, often presenting with nonspecific gastrointestinal symptoms. Early detection and intervention, as seen in this case, are critical for improving outcomes. The patient's management involved a multidisciplinary approach, including oncologists, surgeons, and physicians, to address his complex comorbid conditions alongside the malignancy. Signet-ring cell carcinoma (SRCC) is a rare tumor, most commonly found in the stomach, compared to other parts of the digestive tract. Recent studies show that SRCC makes up 35–45% of all gastric adenocarcinoma cases.( 5 ) Most cases of signet-ring cell carcinoma (SRCC) in the duodenum arise in the ampulla. Only four cases have been reported in other parts of the duodenum in English literature.( 6 ) Intestinal-type adenocarcinomas in the duodenum are similar to colorectal adenocarcinomas and are often linked to adenomas. Studies suggest that duodenal adenocarcinomas may develop from these preexisting adenomas, following a sequence similar to colorectal cancer. Intestinal-type histology is associated with a better prognosis in both ampullary and non-ampullary adenocarcinomas.( 7 ) The exact origin of signet-ring cells is still unclear. One theory suggests they come from ectopic gastric mucosa in the duodenum, while another proposes they arise from gastric-type metaplastic cells. These metaplastic changes are seen as a protective response to acid production and are often found in the duodenal bulb.( 8 ) Signet-ring cell carcinoma (SRCC) is a rare and highly aggressive form of gastric cancer, known for its distinct histological appearance, where tumor cells contain large mucin-filled vacuoles that displace the nucleus to the periphery, resembling a signet ring. The exact origin of SRCC is still not fully understood, though two primary theories have been proposed. One suggests that SRCC may originate from ectopic gastric mucosa found in the duodenum, while the other theory posits that it arises from gastric-type metaplastic epithelia, typically seen in the duodenal bulb as a protective response to acid production. Conclusion This case underscores the critical importance of early detection and timely intervention in managing gastric malignancies, particularly in patients with comorbidities that may complicate treatment and recovery. Gastric cancer, including signet-ring cell carcinoma (SRCC), often presents at advanced stages, making effective surgical management essential for improving prognosis. The patient's positive outcome following radical distal gastrectomy highlights the potential for recovery when appropriate surgical intervention is combined with careful postoperative care. However, it also emphasizes the need for continuous monitoring, as SRCC has a tendency to recur and metastasize. The case further reinforces the need for individualized treatment strategies, taking into account the patient's overall health, stage of the cancer, and response to therapy. Additionally, it serves as a reminder of the necessity for ongoing research into better diagnostic techniques, novel therapeutic options, and preventive measures to improve survival rates and quality of life for gastric cancer patients. Declarations Conflict of Interest: Nil Funding: No financial support was indicated for this case report Ethical Considerations: This case report was conducted in accordance with ethical guidelines and principles, ensuring respect for patient confidentiality and autonomy. The patient’s identity has been protected, and all personal information has been anonymized to maintain confidentiality. Consent to Participate: Informed consent was obtained from the patient for participation in this case report. The patient was fully informed about the nature of the report, the voluntary nature of participation, and the use of their medical information for educational and research purposes. Consent to Publish: The patient has provided written consent for the publication of this case report, including any anonymized images and medical information. The patient understands that the case details may be published in a medical journal and used for educational purposes. I, the corresponding Author declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere. Data Availability : All the data relevant to this case is already incorporated References Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015 Mar 1;136(5):E359-386. Bamboat ZM, Tang LH, Vinuela E, Kuk D, Gonen M, Shah MA, et al. Stage-stratified prognosis of signet ring cell histology in patients undergoing curative resection for gastric adenocarcinoma. Ann Surg Oncol. 2014 May;21(5):1678–85. Fléjou JF. [WHO Classification of digestive tumors: the fourth edition]. Ann Pathol. 2011 Nov;31(5 Suppl):S27-31. Nguyen MD, Plasil B, Wen P, Frankel WL. Mucin profiles in signet-ring cell carcinoma. Arch Pathol Lab Med. 2006 Jun;130(6):799–804. Taghavi S, Jayarajan SN, Davey A, Willis AI. Prognostic significance of signet ring gastric cancer. J Clin Oncol. 2012 Oct 1;30(28):3493–8. Mochizuki K, Kondo T, Tahara I, Inoue T, Kasai K, Oishi N, et al. Signet ring cell carcinoma of the non-ampullary duodenum: A case report. Pathol Res Pract. 2015 Oct;211(10):801–4. Westgaard A, Tafjord S, Farstad IN, Cvancarova M, Eide TJ, Mathisen O, et al. Pancreatobiliary versus intestinal histologic type of differentiation is an independent prognostic factor in resected periampullary adenocarcinoma. BMC Cancer. 2008 Jun 11;8:170. Hoedemaeker PJ. Heterotopic gastric mucosa in the duodenum. Digestion. 1970;3(3):165–73. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6159490","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":456333650,"identity":"3c5f9a8e-090b-42f6-8bb0-6e0afc660f43","order_by":0,"name":"Dr. Kavita Gomase","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBACCSA+AGIYMDAwPuBhkEgAC/OAER4tByBamA2I1sIA1cImAVQG14ITSLafMTz8oYZBzpx/jVnF2xyLPH7pA4wP3rYxyJjj0CLNk2Nw4MAxBmPLGW/Mbs7dJlEs2ZfAbDi3jYHHsgG7FjmGtIQDB9gYEjfcOGN2m3ebROKGMwxs0rxALQYHcGjhfwbU8g+ipRikZf8ZBvbf+LRISyQfOHCwDajlfI8ZM9gWHgY2ZnxaJGc8PnDgbJ8E0C9sxZJAvyTOOMPYLDnnnAROLRLnE5s/VHyzAYbY4Y0f3m6rS+zvYT744U2ZjT0uLTCdQJRhAOUwNjBAI4wA4D/+gAhVo2AUjIJRMBIBAB36XHmHxpsXAAAAAElFTkSuQmCC","orcid":"","institution":"Datta Meghe Institute of Higher Education \u0026 Research(Deemed to be University) Maharashtra India.","correspondingAuthor":true,"prefix":"Dr.","firstName":"Kavita","middleName":"","lastName":"Gomase","suffix":""},{"id":456333651,"identity":"b901b06a-eae1-4645-b0a7-29aaed66fe2d","order_by":1,"name":"Dr. Pooja Kasturkar","email":"","orcid":"","institution":"Datta Meghe Institute of Higher Education \u0026 Research(Deemed to be University) Maharashtra India.","correspondingAuthor":false,"prefix":"Dr.","firstName":"Pooja","middleName":"","lastName":"Kasturkar","suffix":""},{"id":456333653,"identity":"fc900ff8-b322-470e-891f-aac8d42fd5b7","order_by":2,"name":"Ms. Achal Gulghane","email":"","orcid":"","institution":"Datta Meghe Institute of Higher Education \u0026 Research(Deemed to be University) Maharashtra India.","correspondingAuthor":false,"prefix":"Ms.","firstName":"Achal","middleName":"","lastName":"Gulghane","suffix":""}],"badges":[],"createdAt":"2025-03-05 06:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6159490/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6159490/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82890944,"identity":"18b08988-0958-49ae-8ec4-bc85c01d1249","added_by":"auto","created_at":"2025-05-16 12:10:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58997,"visible":true,"origin":"","legend":"\u003cp\u003eFig 1.1: PET-CT Imaging Showing Stomach Wall Thickening and Associated Findings\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6159490/v1/91062dda0aef6199b39b5cea.png"},{"id":82888480,"identity":"7f14fdc2-945d-4713-bb73-fdaa9e97b02c","added_by":"auto","created_at":"2025-05-16 12:02:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":153419,"visible":true,"origin":"","legend":"\u003cp\u003eFig 1.2: surgical removal of the distal part of the stomach, including the tumor,\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6159490/v1/c7d08fba8f865f49d51b70e6.png"},{"id":82888481,"identity":"eb9d26e0-f09a-464e-b5b0-917e6a195edf","added_by":"auto","created_at":"2025-05-16 12:02:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":191207,"visible":true,"origin":"","legend":"\u003cp\u003eFig 1.3: Postoperative Surgical Incision and Radical Distal Gastrectomy\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6159490/v1/1a20d7e8df0b7c7b8b0a9a43.png"},{"id":87194430,"identity":"b126d8b4-e6ab-4456-9d49-2040367831c8","added_by":"auto","created_at":"2025-07-21 12:01:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":738461,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6159490/v1/687a5b43-bc4a-4db7-8867-a3efe2ab5cd6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case report on Signet ring cell carcinoma in the distal stomach with a history of CABG and a known case of diabetes mellitus (DM) and hypertension (HTN)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSignet ring cell carcinoma (SRCC) is a rare and aggressive form of gastric cancer, often found in the distal stomach. It is characterized by the presence of signet ring cells, which are tumor cells that have a distinctive appearance with a large mucin-filled vacuole pushing the nucleus to the periphery, resembling a signet ring. SRCC is typically diagnosed at an advanced stage, as it tends to grow in a diffuse manner, making it harder to detect early.\u003c/p\u003e\n\u003cp\u003eGastric cancer (GC) is a significant global health issue. In 2012, there were 951,000 new cases, making up 6.8% of all new cancer diagnoses. That same year, 723,000 people died from gastric cancer, which accounted for 8.8% of all cancer-related deaths.(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eGastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer deaths worldwide. While overall gastric cancer rates have decreased in recent years, the incidence of signet-ring cell carcinoma (SRCC) is rising. In recent studies, SRCC accounts for 35\u0026ndash;45% of gastric adenocarcinoma cases in regions like Asia, the United States, and Europe.(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eSignet-ring cell carcinoma (SRCC) is a type of adenocarcinoma, defined by the World Health Organization (WHO) as a cancer where more than 50% of the tumor cells are signet-ring cells. These cells contain a large amount of mucin that pushes the nucleus to the edge of the cell, giving them a distinctive ring-like appearance.(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eSignet-ring cell carcinoma (SRCC) is characterized by cells with abundant intracellular mucin production, leading to distinguishing cellular morphology resembling that of a signet ring.(\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eSignet-ring cell carcinoma (SRCC) is a rare and aggressive type of gastric cancer, characterized by tumor cells with a large mucin-filled vacuole pushing the nucleus to the edge. It often presents at an advanced stage, has a poor prognosis, and is resistant to treatment. SRCC is increasing in incidence worldwide and is typically treated with surgery and chemotherapy. However, survival rates remain low due to its aggressive nature and early metastasis.\u003c/p\u003e\n"},{"header":"Case Presentation","content":"\u003cp\u003eA 70-year-old male patient presented with complaints of nausea, vomiting, and black-colored stools, raising suspicion of an upper gastrointestinal pathology. The patient had a known medical history of diabetes mellitus, hypertension, and ischemic heart disease, for which he underwent coronary artery bypass grafting (CABG) in 2018. On clinical examination and evaluation, the findings were suggestive of a potential gastrointestinal malignancy. Further diagnostic investigations, including a digital PET scan(Fig. 1.1), revealed asymmetric hypermetabolic malignant wall thickening localized to the mid and distal body, as well as the pyloric region of the stomach. Subcentimeter regional lymph nodes were noted with insignificant metabolic activity, and no evidence of distant metastasis was identified.\u003c/p\u003e\n\u003cp\u003eA gastric growth biopsy was performed for histopathological examination, which confirmed the presence of moderately differentiated signet ring cell carcinoma. Microscopic evaluation showed tumor infiltration into the gastric mucosa, with sections demonstrating extracellular mucin production, a hallmark feature of this type of malignancy. These findings corroborated the diagnosis of gastric cancer with signet ring cell morphology.\u003c/p\u003e\n\u003cp\u003eOn evaluation, the patient was found to have symptoms suggestive of gastrointestinal malignancy. Investigations, including a digital PET scan, revealed asymmetric hypermetabolic malignant wall thickening in the mid and distal body as well as the pyloric region of the stomach. Subcentimeter regional lymph nodes were noted, but with insignificant metabolic activity. There was no definite evidence of distant metastasis.\u003c/p\u003e\n\u003cp\u003eSubsequent histopathological examination of a gastric growth biopsy confirmed the diagnosis of moderately differentiated signet ring cell carcinoma. Microscopic examination revealed tumor infiltration into the gastric mucosa, with sections showing extracellular mucin.\u003c/p\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003eFollowing the confirmation of moderately differentiated signet ring cell carcinoma through histopathological examination, the patient was planned for surgical intervention as the primary treatment modality. Preoperative optimization was conducted to manage the patient's comorbid conditions, including diabetes mellitus, hypertension, and ischemic heart disease, to reduce perioperative risks.\u003c/p\u003e \u003cp\u003eThe patient underwent an exploratory laparotomy to assess the extent of the tumor and surrounding tissue involvement. Based on intraoperative findings, a radical distal gastrectomy was performed. This procedure involved the surgical removal of the distal part of the stomach, including the tumor, with an adequate margin of normal tissue to ensure complete resection of the malignancy. Additionally, lymphadenectomy was performed to remove potentially affected regional lymph nodes and to prevent disease progression. Reconstruction of the gastrointestinal tract was achieved via gastrojejunostomy to restore digestive continuity.\u003c/p\u003e \u003cp\u003ePostoperatively, the patient was closely monitored in the surgical unit for any complications. Pain management, nutritional support, and early mobilization were prioritized to promote recovery. Laboratory tests and imaging were conducted to ensure there were no signs of infection, anastomotic leakage, or residual disease. The patient was started on a soft diet as tolerated and gradually transitioned to a regular diet.\u003c/p\u003e \u003cp\u003eThe histopathological examination of the resected specimen confirmed complete tumor removal with clear margins. The patient showed a good postoperative recovery and was discharged in stable condition. Follow-up plans were established, including regular clinical examinations, imaging studies, and, if necessary, adjuvant therapy to monitor for recurrence or metastasis.\u003c/p\u003e \u003cp\u003eOverall, the surgical intervention proved successful, and the patient is currently in remission, with no immediate postoperative complications or signs of residual disease.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePostoperative Outcome\u003c/strong\u003e \u003cp\u003eThe patient underwent successful exploratory laparotomy with radical distal gastrectomy and gastrojejunostomy. Postoperative recovery has been smooth, with no immediate complications such as infection, bleeding, or anastomotic leakage. The surgical wound is healing well, as observed during follow-up assessments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe patient has resumed a soft diet and is tolerating oral intake without nausea, vomiting, or dysphagia. Pain management has been effectively controlled, and mobility is progressively improving. Regular physiotherapy and nutritional counseling have been initiated to optimize recovery.\u003c/p\u003e \u003cp\u003eHistopathological analysis of the excised specimen confirmed the complete removal of the tumor with negative margins, suggesting a favorable oncological outcome. Subcentimeter regional lymph nodes with insignificant metabolic activity on the preoperative PET scan correlate with the absence of nodal metastasis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSignet ring cell carcinoma is a rare and aggressive form of gastric cancer, often presenting with nonspecific gastrointestinal symptoms. Early detection and intervention, as seen in this case, are critical for improving outcomes. The patient's management involved a multidisciplinary approach, including oncologists, surgeons, and physicians, to address his complex comorbid conditions alongside the malignancy.\u003c/p\u003e \u003cp\u003eSignet-ring cell carcinoma (SRCC) is a rare tumor, most commonly found in the stomach, compared to other parts of the digestive tract. Recent studies show that SRCC makes up 35\u0026ndash;45% of all gastric adenocarcinoma cases.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMost cases of signet-ring cell carcinoma (SRCC) in the duodenum arise in the ampulla. Only four cases have been reported in other parts of the duodenum in English literature.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIntestinal-type adenocarcinomas in the duodenum are similar to colorectal adenocarcinomas and are often linked to adenomas. Studies suggest that duodenal adenocarcinomas may develop from these preexisting adenomas, following a sequence similar to colorectal cancer. Intestinal-type histology is associated with a better prognosis in both ampullary and non-ampullary adenocarcinomas.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe exact origin of signet-ring cells is still unclear. One theory suggests they come from ectopic gastric mucosa in the duodenum, while another proposes they arise from gastric-type metaplastic cells. These metaplastic changes are seen as a protective response to acid production and are often found in the duodenal bulb.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSignet-ring cell carcinoma (SRCC) is a rare and highly aggressive form of gastric cancer, known for its distinct histological appearance, where tumor cells contain large mucin-filled vacuoles that displace the nucleus to the periphery, resembling a signet ring. The exact origin of SRCC is still not fully understood, though two primary theories have been proposed. One suggests that SRCC may originate from ectopic gastric mucosa found in the duodenum, while the other theory posits that it arises from gastric-type metaplastic epithelia, typically seen in the duodenal bulb as a protective response to acid production.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the critical importance of early detection and timely intervention in managing gastric malignancies, particularly in patients with comorbidities that may complicate treatment and recovery. Gastric cancer, including signet-ring cell carcinoma (SRCC), often presents at advanced stages, making effective surgical management essential for improving prognosis. The patient's positive outcome following radical distal gastrectomy highlights the potential for recovery when appropriate surgical intervention is combined with careful postoperative care. However, it also emphasizes the need for continuous monitoring, as SRCC has a tendency to recur and metastasize. The case further reinforces the need for individualized treatment strategies, taking into account the patient's overall health, stage of the cancer, and response to therapy. Additionally, it serves as a reminder of the necessity for ongoing research into better diagnostic techniques, novel therapeutic options, and preventive measures to improve survival rates and quality of life for gastric cancer patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo financial support was indicated for this case report\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was conducted in accordance with ethical guidelines and principles, ensuring respect for patient confidentiality and autonomy. The patient\u0026rsquo;s identity has been protected, and all personal information has been anonymized to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for participation in this case report. The patient was fully informed about the nature of the report, the voluntary nature of participation, and the use of their medical information for educational and research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient has provided written consent for the publication of this case report, including any anonymized images and medical information. The patient understands that the case details may be published in a medical journal and used for educational purposes.\u003c/p\u003e\n\u003cp\u003eI, the corresponding Author declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e : \u0026nbsp;All the data relevant to this case is already incorporated\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015 Mar 1;136(5):E359-386. \u003c/li\u003e\n\u003cli\u003eBamboat ZM, Tang LH, Vinuela E, Kuk D, Gonen M, Shah MA, et al. Stage-stratified prognosis of signet ring cell histology in patients undergoing curative resection for gastric adenocarcinoma. Ann Surg Oncol. 2014 May;21(5):1678\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eFl\u0026eacute;jou JF. [WHO Classification of digestive tumors: the fourth edition]. Ann Pathol. 2011 Nov;31(5 Suppl):S27-31. \u003c/li\u003e\n\u003cli\u003eNguyen MD, Plasil B, Wen P, Frankel WL. Mucin profiles in signet-ring cell carcinoma. Arch Pathol Lab Med. 2006 Jun;130(6):799\u0026ndash;804. \u003c/li\u003e\n\u003cli\u003eTaghavi S, Jayarajan SN, Davey A, Willis AI. Prognostic significance of signet ring gastric cancer. J Clin Oncol. 2012 Oct 1;30(28):3493\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMochizuki K, Kondo T, Tahara I, Inoue T, Kasai K, Oishi N, et al. Signet ring cell carcinoma of the non-ampullary duodenum: A case report. Pathol Res Pract. 2015 Oct;211(10):801\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eWestgaard A, Tafjord S, Farstad IN, Cvancarova M, Eide TJ, Mathisen O, et al. Pancreatobiliary versus intestinal histologic type of differentiation is an independent prognostic factor in resected periampullary adenocarcinoma. BMC Cancer. 2008 Jun 11;8:170. \u003c/li\u003e\n\u003cli\u003eHoedemaeker PJ. Heterotopic gastric mucosa in the duodenum. Digestion. 1970;3(3):165\u0026ndash;73. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Signet ring cell carcinoma, distal stomach cancer, radical distal gastrectomy, gastric malignancy, coronary artery bypass grafting (CABG), gastrointestinal oncology, surgical management","lastPublishedDoi":"10.21203/rs.3.rs-6159490/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6159490/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 70-year-old male patient who presented with complaints of nausea, vomiting, and black-colored stools. The patient is a known case of diabetes mellitus (DM), hypertension (HTN), and ischemic heart disease (IHD), with a history of coronary artery bypass grafting (CABG) performed in 2018. All investigations are done, including a digital PET scan, shows asymmetric hypermetabolic thickening in the distal stomach and pyloric region, shows of malignancy. A gastric biopsy confirmed moderately differentiated signet ring cell carcinoma. The patient underwent radical distal gastrectomy with gastrojejunostomy, under preoperative treatment.\u003c/p\u003e","manuscriptTitle":"Case report on Signet ring cell carcinoma in the distal stomach with a history of CABG and a known case of diabetes mellitus (DM) and hypertension (HTN)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 12:02:39","doi":"10.21203/rs.3.rs-6159490/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"deb7c63f-d3d3-4c36-ba61-06772507983e","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-21T11:53:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 12:02:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6159490","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6159490","identity":"rs-6159490","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}