Unusual Manifestation of Gastric Adenocarcinoma presenting with Lymphedema, Chylothorax, and Chylous ascites: A Case Report

Abstract

Abstract Background: Gastric cancer is one of most common cancers worldwide with a high mortality rate. Lymphedema and chyle leakage are unusual presentations of metastatic gastric carcinoma. We present a rare case of advanced stage gastric carcinoma presenting with lower limb lymphedema, bilateral chylothorax, and chylous ascites caused by metastatic infiltration of the lymphatics. Case presentation: A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal (GI) symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies, however treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient’s skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis. Conclusion: The differential diagnosis of uncertain causes of lymphedema and chyle leakage should include metastatic gastric cancer, regardless of GI symptoms. Early upper GI endoscopy is a crucial diagnostic tool, as imaging alone may be insufficient to detect the primary lesion. Nutritional interventions form an integral component of chyle leakage management as it may help to reduce chyle flow, minimise nutrient loss, and improve patients’ nutritional status, leading to better survival and quality of life.