Correspondence

The Response of Early Gastric Cancer to Proton-Pump Inhibitors

N Engl J Med 1998; 338:1924-1925June 25, 1998

Article

To the Editor:

Early diagnosis is paramount in the successful treatment of gastric cancer.1 We have found that empirical treatment with a proton-pump inhibitor can delay the diagnosis as occurred in the first patient described below, and we have also observed, by serendipity, the effect of a short course of a proton-pump inhibitor on the symptoms and endoscopic signs of early gastric cancer in another patient.

The first patient was a 41-year-old woman who was referred with a biopsy-confirmed diagnosis of gastric cancer. Four years earlier, a 1-cm gastric ulcer was seen on endoscopy, and a biopsy reportedly showed no evidence of malignancy. Endoscopy was repeated six months later, and since the ulcer had healed after treatment with a proton-pump inhibitor, the patient was discharged. A few weeks later, symptoms of epigastric pain returned. The proton-pump inhibitor was given again, with complete resolution of symptoms. Treatment was continued until weight loss, early satiety, and epigastric pain developed. These symptoms prompted another endoscopy, which led to the diagnosis of an extensive cancer involving most of the lesser curvature of the stomach. Reexamination of the sections from the original biopsy revealed findings consistent with the presence of intramucosal cancer. The patient underwent a total gastrectomy but died 18 months later with recurrence in the gastric bed.

The second patient was a 69-year-old woman who presented with a one-month history of epigastric discomfort. She was given a 10-day course of omeprazole and referred for open-access endoscopy. On endoscopy three weeks later, she was asymptomatic. Endoscopic examination revealed an ulcer 5 cm in diameter in the gastric antrum that appeared to have an epithelial lining over the crater (Figure 1AFigure 1Endoscopic Photograph of a Malignant Gastric Ulcer.). A biopsy was performed. The patient was advised to continue taking 20 mg of omeprazole twice a day pending the results of histologic analysis. Histologic examination of the biopsy specimen was suggestive of a malignant condition. Endoscopy was repeated four weeks later, at which time the patient was still asymptomatic, and revealed complete resolution of the ulcer (Figure 1B). Multiple repeated biopsies of the area showed intramucosal adenocarcinoma. The patient underwent a subtotal gastrectomy for lymph-node–negative intramucosal early gastric cancer.

Two patients similar to Patient 1 and six patients similar to Patient 2 have been seen at this center in the past two years. In all of them, symptoms attributable to gastric cancer were masked and endoscopic signs obscured. Crucially, the response to proton-pump inhibitors can be sustained long enough for early gastric cancer to become advanced, with a resulting change in the prognosis from a probability of cure to the likelihood of incurable disease.

John Wayman, M.B., F.R.C.S.
Nick Hayes, M.B., F.R.C.S.
S. Michael Griffin, M.D., F.R.C.S.
Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom

1 References

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Citing Articles (13)

Citing Articles

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   Jong Pil Im, Sang Gyun Kim, Joo Sung Kim, Hyun Chae Jung, In Sung Song. (2009) Time-dependent morphologic change in depressed-type early gastric cancer. Surgical Endoscopy 23:11, 2509-2514
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   David A. Edelman, Krupa R. Patel, James G. Tyburski, Lisa G. Hall Zimmerman. (2008) Intravenous pantoprazole utilization in a level 1 trauma center. Surgical Endoscopy 22:4, 967-973
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   M. Naunton, G. M. Peterson, M. D. Bleasel. (2008) Overuse of proton pump inhibitors. Journal of Clinical Pharmacy and Therapeutics 25:5, 333
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   Yih K. Tan, John W.L. Fielding. (2006) Early diagnosis of early gastric cancer. European Journal of Gastroenterology & Hepatology 18:8, 821-829
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   Hitoshi Katai, Takeshi Sano. (2005) Early gastric cancer: concepts, diagnosis, and management. International Journal of Clinical Oncology 10:6, 375-383
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   Annmarie Lassen, Jesper Hallas, Ove B. Schaffalitzky de Muckadell. (2005) The Risk of Missed Gastroesophageal Cancer Diagnoses in Users and Nonusers of Antisecretory Medication. Gastroenterology 129:4, 1179-1186
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   X. Calvet. (2005) Tratamiento erradicador de Helicobacter pylori en la enfermedad no ulcerosa. Gastroenterología y Hepatología 28:1, 40-46
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   S. J. Panter, H. O'Flanagan, M. G. Bramble, A. P. S. Hungin. (2004) Empirical use of antisecretory drug therapy delays diagnosis of upper gastrointestinal adenocarcinoma but does not effect outcome. Alimentary Pharmacology and Therapeutics 19:9, 981-988
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   C La Vecchia, A Tavani. (2002) A review of epidemiological studies on cancer in relation to the use of anti-ulcer drugs. European Journal of Cancer Prevention 11:2, 117-123
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    Gianni Testino, Matteo Cornaggia. (2002) Gastric Epithelial Dysplasia and Gastric Cancer in Young Dyspeptic Patients Treated With Proton Pump Inhibitors. Journal of Clinical Gastroenterology 34:3, 282-283
    CrossRef

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    M. Naunton, G. M. Peterson, M. D. Bleasel. (2000) Overuse of proton pump inhibitors. Journal of Clinical Pharmacy and Therapeutics 25:5, 333-340
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    T Sano. (2000) The management of early gastric cancer. Surgical Oncology 9:1, 17-22
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    Gianni Testino, Alessandro Sumberaz, Delehaye Emilio, Maurizio Valentini, Matteo Cornaggia. (1999) Gastric high-grade dysplasia. Gastroenterology 117:1, 285-286
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