Vol.2, No.6, 358-362 (2013) Case Reports in Clinical Medicine
Presentation of signet ring cell type at carcinoma
ventriculi of the patient aged 20 years old*
Afrim A vdaj1, Ugur Gozalan2, Nexhmi Hyseni3#, Hatim Baxhaku1, Sherif Krasniqi1,
Shpejtim Rramanaj1
1Division of Surgery, Regional Hospital “Primarius Daut Mustafa”, Prizren, Kosova;
avdajafrim@yahoo.com, hatimbaxhaku@hotmail.com, oni_pz@hotmail.com, shpejtim@libero.it
2American Hospital, Pristina, Kosovo; ugur.gozalan@spitliamerikan.com
3Department of Pediatric Surgery, University Clinical Center, Prishtina, Kosovo; #Corresponding Author: nexhmi_h@yahoo.com
Received 1 July 2013; revised 4 August 2013; accepted 11 August 2013
Copyright © 2013 Afrim Avdaj et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Diffuse variant of GC is composed
of gastric-type mucou s cells, which generally do
not form glands, but rather permit the mucosa
and wall as scattered individual cells or small
clusters in an “infiltrative” gro wth p attern. These
cells appear to arise from the middle layer of the
mucosa, and the presence of intestinal meta-
plasia is not a prerequisite. In this version,
mucin formation expands the malignant cells
and pushes the nucleus to the periphery, creat-
ing a “signet ring” conformation. If the signetr-
ing cells are more than 50% of the tumor, the
tumor is classified as signetring cell carcinoma
[1]. This case is important for reporting because
we encountered for the first time such a carci-
noma type, due to the new age and its atypical
presentation. Case Presentation: We report a
case of a 20 years Albanian old patient with
Signet Ring Cell Type of Gastric CA. The patient
was brought at the urgency with severe ab-
dominal pain, nausea and peritoneal irritation.
Clinical examination has been made in emer-
gency, where we conclude the signs of perito-
neal irritation, from native Ro no signs of pneu-
moperitoneum, while laboratory tests found a
slight anemia (erythrocytes 3.36, HCT 25, HGB
8.6). Two hours later we repeated the native RTG
and there were present the signs of pneumop-
eritoneum. It was indicated urgent surgical in-
tervention. Intraoperatively, we found Ulcer duo-
denal perforation and undertook the operation
procedures by Roscoe Graham technique. Con-
clusions: At this age, it is rare, and it is difficult
to detect in its early stages, because the signs
and symptoms are often non-existent, non-spe-
cific, or mimic as an ulcer. The most common
symptoms are early heartburn indigestion, ab-
dominal pain or discomfort, vomiting, constipa-
tion, diarrhea or to feel of filling after a small
meal, loss of appetite, weakness and fatigue.
Less common symptoms are anemia and weight
Keywords: Signet Ring Cell Type; Gastric
Adenenocarcinoma; Diffuse Variant of GC
Gastric Aden carcinoma is rare at young people, while
the risk increases significantly after age 50, and gastric
biopsies ambulatory ring cell carcinoma is rarely found
due to atypical clinical presentation [2]. GCs are pre-
sented in different histological characteristics, with a
positive family history, while genes regulate the sensi-
tivity of Helicobacter Pylori at different types of CG [3].
Histological confirmation is very important for deter-
mining the method of treatment [4]. Signet ring cell car-
cinoma is characterized by sub-mucosal infiltration of
different sizes and with distribution in distant lymph
node, and metastasis in the skin [5,6]. Here we report the
rare case of a 20-year-old girl presented with acute ab-
domen, because of the perforated duodenal ulcer, with
positive family history for GC and with Helicobacter
Pylori positive.
*Competing interests: The authors declare that they have no compet-
ing interests.
Contributions of authors: Our patient was admitted under the care o
SHK, with the contribution of HB, was treated. The main contributors
to this manuscript are all authors who have approved the final manu-
Copyright © 2013 SciRes. OPEN ACCESS
A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362 359
We report one case of 20 years old patient (Kosovo,
Albanian) with Signet Ring Cell Type of gastric CA. The
patient was brought in emergency with severe abdominal
pain, nausea, vomiting, pallor, and fatigue. The patient
had a position with curved knees towards the stomach,
hypertensive (TA: 100/60 mmHg), pulse speed (110/min)
and with superficial breathing. The clinical examination
took place in emergency centre, which concludes: diffuse
abdominal pain, irritation peritoneal signs. In X-ray na-
tive of abdomen are concluded signs of pneumoperito-
neumit while in laboratory analysis are concluded the
following values: RBC = 3.69; RDW% = 15.1; RDWA =
32.1; HCT = L 25.2; PLT = H 458; MPV = L 7.2; PDW =
9.7; PCT = 0.33; LPCR = 9.7; WBC = H 18.4; HGB = L
88HL; MCH = L 23.8; MCHC = 349; LYM = 0.9;
GRAN = H 16.4; MID = 1.1; LYM% = L 5.3; GRA% =
H 89.2; MID% = 5.5; Fe2+ = 4.31 µmol/L. Glucose = 8.2
µmol/L; Urea = 6.8 µmol/L; Creatinine 8.5 µmol/L; To-
tal Bilirubin = 7.5 µmol/L; Direct Bilirubin = 2.4 µmol/L;
Na+ = 134 µmol/L; K+ = 4.45 µmol/L; Cl = 103 µmol/L;
Ca++ = 1.23 µmol/L; Albumins = 43 g/L; CRP = 5.7
mg/L. Helicobacter Pylori IgG = positive (3.42) Blood
type = A RhD(+)poz. The patient was hospitalized
from emergency to the surgery department with diagno-
sis: acute abdomen, ulcer perforation. In the department
we placed the wide nasogastric probe, and the compen-
sation of the fluids parenteral were provided, blockers
H2 histaminic and antibiotics. It is indicated the Surgical
intervention, where the abdomen has been opened in lay-
ers through the median upper and middle laparotomy. In-
tra operative concludes: Serofibrinous fluid content and a
hole that has penetrated to the wall of the front duode-
num. It has been taken excision from the part of perfo-
rated duodenum for biopsy, and operation has been con-
ducted by Roscoe Graham with omentoplasty. Washers
of peritoneal space and drainage of the Douglas space.
Postoperative, the patient stays in intensive care.
Treated with intensive therapy: compensation of fluids,
antibiotics, analgesic blockers, H2 Histaminic. Nasogas-
tric tube and abdominal drain are removed in the fifth
day after operation. Wound with no leaks. The patient
has been recommended home care, in general stable
condition. With therapy: oral antibiotics and oral protein
pump inhibitors. The result of the biopsy of the excision
of perforated place in the duodenum results as chronic
peptic ulcer of the duodenum Figur e 1.
10 days after discharge from the hospital, patient came
back to Hospital In, while the patient continues to suffer
the pain in the epigastria region, fatigue, and anorexia.
The patient returns at home with therapy—analgesic as
needed and protein pump inhibitors. After two weeks, the
patient visited the surgeon again with the same symp-
toms (abdominal pain in the epigastria, nausea, vomiting,
anorexia, fatigue). The surgeon suggested the patient to
make the esophago gastro duodenoscopy, which resulted:
hyperemia and non confluent longitudinal erosion of the
bottom of stomach. In pre pyloric area of the stomach
mucosa is edematous, infiltrated, and vulnerable. Infil-
trate includes the pyloric canal which is narrow and is
inaccessible by the instrument. From the infiltrated pre
pyloric part is taken the biopsy in six parts for histopa-
thological examination. Biopsy results: gastric carcinoma
(Signet ring cell type)—infiltration into the pylorus with
evident stenosis and Reflux esophagitis gr. A. (Figure 2).
Six days after verification of the diagnosis with histo-
pathology, the patient was hospitalized at the American
hospital in Prishtina. In the day of admission is done the
CT of the abdomen and pelvic with application of in-
strument of the oral contrast and intravenous which re-
sulted: expansive process in the rear wall of the small
curvatures of the stomach and also pylorus have been
affected, with characteristics of mucinous carcinoma,
Figure 1. Histological report: ulcer peptic chronic duodenum (tissue granulation and peptic necrosis).
Copyright © 2013 SciRes. OPEN ACCESS
A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362
Figure 2. Histological report: ventricular carcinoma (signet ring cell type)—(fragments of gastric mucosa with solid islands malign-
nant stromal cells, polymorphous eccentric nuclei).
with gangrene of the gallblader.
On date: 23. 03. 2013 took place: op. Subtotal Gas-
trectomy D1 Lymph node disection, Gastroenterostomy,
where more than 2/3 of the stomach (pylorus, duodenum
initial part) was removed and was established gastroin-
testinal continuity by direct anastomosis between the rest
of the resected stomach and proximal anse of jejunum.
Where initially gastro colic ligament is cut within gas-
troepiploic arcade, curvature ventricle major is released
as long as the lower pole of the spleen is seen. Then re-
section duodenum is conducted about two cm. from py-
lorus after resection of duodenum and the mobilization
of the stomach. Stomach pulled above and now sinister
gastric artery and vein are released which present resec-
tion line of curvature ventricle minor. It is set Gastroin-
testinal continuity in two layers, then occurs entero-en-
tero-anastomosis according to Brown about 20 cm dis-
tally from gastrointestinal anastomosis with one layer.
During surgical intervention in gastric tissues were iden-
tified lymph nodes as following (according to the classi-
fication of the Japanese Research Association for the
classification of gastric cancer): Zone 1. (Right pericar-
dial): 0 lymph nodes, Zone 2. (left pericardial): 0 lym-
ph’s nodes, Zone 3. (Curvature minor): 0 lymph’s nodes,
Zone 4. (Curvature major): 4 lymph nodes’ measuring
0.2 - 0.6 cm in greatest diameter, Zone 5. (Supra pyloric):
0 lymph’s nodes, Zone 6. (Infra pyloric): 9 lymph nodes
measuring 0.2 - 1.2 cm in greatest diameter. Histological
report resulted: Adenocarcinoma type Diffuse. Zone 4
(curvature major): Metastatic tumor tissue is identified in
1 lymph node (1/4). Zone 6 (infra pyloric) Metastatic
tumor tissues is identified in 5 lymph nodes (5/9). Histo-
logical type: Adenocarcinoma-diffuse type. TNM patho-
logical classification: pT4b, pN2, pM1.
The postoperative is treated with antibiotic, analgesic,
4 doses blood and 3 plasma. On date 03. 04. 2013 rec-
ommended going home, and visit the oncologist for fur-
ther treatment. The patient has taken the therapy with
Gastric carcinoma (GC) is more common in develop-
ing countries, among black peoples and in countries with
poor socio-economic condition. Dietary factors and in-
fection with Helicobacter pylori (H. pylo ri) are main risk
factors for the development of such tumors [7]. H. py-
lori-stimulates cell polarity disorder that can be associ-
ated with the pathogenesis of carcinoma, at least in the
layers of the population infected with HP [8]. Recently
GC shows an EBV (+), in vitro EBV infection induces
extensive mutation of the (ADN) DNA gene repression
within 18 weeks, which can be considered another risk
factor for the emergence of GC [9]. Gastric carcinoma of
type (SRC) is known to have different characteristics and
biological microscopic compared to non-(SRC) [5]. Our
case has unusual clinical and histopathological manifes-
tation that responds to data from the literature. On the
basis of data protocol of our hospital was not evidenced
so far any case with such type of CG under the age of 30
years. GC is one of the most common causes of can-
cer-related deaths worldwide. The success of surgery
depends on the depth of penetration in layers, the extent
of lymph node and distant metastases, and it is possible
through diagnostic methods: MDCT (multi detector com-
puted tomography) and PET (positron emission tomo-
graphy). Multi detector computed tomography (MDCT)
has the ability to assess the depth of the tumor, the main
disease and metastasis so that preferred technique for
managing GC. Endoscopic ultrasound is the most accu-
rate assessment of the depth of wall invasion in early
cancers, but is limited in the evaluation of stenosis or
local advanced cancer and detection of distant metas-
Copyright © 2013 SciRes. OPEN ACCESS
A. Avdaj et al. / Case Reports in Clinical Medicine 2 (2 013) 358-362 361
tases. Magnetic resonance imaging (MRI) has not proved
to be effective. Positron emission tomography (PET) is
useful for detection and characterization of distant me-
tastases. Both MDCT and PET methods are useful for
evaluating the response to treatment after chemotherapy,
preoperative and detection of recurrence after surgical
removal [10]. in our case was not possible to use diag-
nostic methods mentioned above, and because of the
atypical clinical presentation, our case was diagnosed in
the late stages of distant metastases, which represents an
unfavorable prognostic factor. Rapid development of the
tumor in our case, atypical clinical presentation and the
increasing number of cancer in general, the experts sup-
pose the risk factor comes from the high level of de-
pleted uranium due to the recent war. SRC Ca, do not
have good prognosis and can be neglected during routine
pathological examination [11]. For patient survival is
important tumor localization, histopathological stages
and treatment [12]. The following factors are also im-
portant for the patient survival: the extent of tumor in
lymph nodes, depth of infiltration in layers and distant
metastases [13]. SRC Ca survival depends on tumor size,
histological cell differentiation level, the degree of pene-
tration in layers and metastasis. 5-year survival after ap-
plication of chemotherapy at patients with GC resectable
is less than 20% and therefore the effectiveness of che-
motherapy is disputed [14]. 5-year survival of the four
groups classified by differentiation and depth of penetra-
tion in layers is [T2/3 (differentiated type), T2/3 (undif-
ferentiated type), T4a (differentiated type), and T4a (un-
differentiated type)] were 98%, 92%, 80%, and 72%,
respectively (P < 0.01) [15]. Inhibitory effects on cell Ca
growth of the stomach have antioxidant substances like:
CFPS-2 containing: Glucosamin, glucose, Galactose, Fruc-
tose, protein and sulfate groups [16]. Our case is sent for
chemotherapy treatment after consular decision and con-
sultation with oncologist. Since about four months past
after the first surgery and about three months after the
second surgery, the general condition of the patient is
Gastric Aden carcinoma in such age is rare, and it is
difficult to detect it in its early stages, because the signs
and symptoms are often non-existent, non-specific, or
mimic as ulcer, therefore we recommends taking into
consideration all patients complaints regardless of age
and non-specific clinical data for malignant disease. The
most common symptoms at the beginning are indigestion
heartburn, abdominal pain or discomfort, vomiting, con-
stipation, diarrhea, or a feeling of fullness after a small
meal, loss of appetite, weakness and fatigue. Less com-
mon symptoms are anemia and weight loss. This case is
presented because it is very rare at this age, and clinic
atypical manifestation is in the form of perforated ulcers.
It is the first reported case of this type of tumor for us,
because of the very young age of the patient.
Patient Perspective: In order to provide data on the
case, I report my concerns about the disease.
I am a second year student, living in the village, I have
never been sick before. It has been about 3 months since
I started to feel occasional pain in the stomach but no
other concerns. At this time I used tablets to ease my
pain, and I visited a general practitioner. I have thought
the pain was coming from studies stress, but pain day by
day hardened, when at hospital admission day at a time I
felt severe abdominal unbearable pain, associated with
nausea which forced me to go to the hospital. It was the
first time that I had lay in the hospital, where I was un-
dergoing urgent surgical intervention. After the operation
I began to feel improvement and get sucked, even though
after a week I continued to feel pain. A week after leav-
ing the hospital I started the same concerns as before
surgery such as stomach pain, loss of appetite and lassi-
tude and I asked again for medical help from my surgeon
who suggested me doing endoscopy of the stomach. Af-
ter endoscopy my situation got worse and I have been
hospitalized, where after a few days by the suggestion of
doctors I have been transferred to American Hospital for
second surgical intervention. It has been about 5 days
since I left the hospital and I am waiting for further
treatment. With the help of God and the support of fam-
ily members, I want to fight for the life that I love it so
Written consent was obtained from our patient for the
presentation of this case. A copy of the written consent is
available for review by the editor of this magazine.
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