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case_images: Brain MRI with Gadolinium enhancement. (1A) No visible bright signal intensity in the posterior pituitary gland. (1B) Multiple small round lesions with surrounding brain edema in the entire cerebral hemisphere.
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case_images: A brain MRI was performed to demonstrate abnormal findings in the posterior pituitary gland, but it showed multiple enhanced nodules with surrounding edema in the entirety of the cerebral hemisphere, suggesting brain metastases (Figure 1).
case_images: Two round-shaped elevated lesions with central umblications were noticed on the antrum (2A) and low body (2B) of the stomach by gastroscopy
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case_images: There was no abnormal finding detected by mammography. Two round-shaped, elevated lesions with central umblications were noticed on the antrum and low body of the stomach (Figure 2).
case_images: Photograph of the biopsied specimen of the gastric carcinoma. H&E (3A) Stomach : The tumor is mainly located in the submucosa and infiltrates the gastric mucosa. The tumor cells are large, polygonal in shape and show pleomorphic nuclei with frequent mitoses(H&E, x100). (3B) Adrenal: The large and polygonal tumor cells have abundant eosinophillic cytoplasm and pleomorphic nuclei, which is similar to the gastric tumor (cell block, H&E, x200).
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case_images: Histologic examinations of both the gastric tissue and right adrenal mass showed malignant tumors composed of anaplastic cells (Figure 3).
case_images: Photograph of the electron microscopy (EM x 15,000) of the gastric tissue Tumor cells are occasionally joined by desmosomes(arrow). However, there is no evidence of steroidogenic cells in the adrenal cortical carcinoma including in the well developed SER and mitochondria with tubular cisternae.
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case_images: The ultrastructural findings of the tumor cells were compatible with anaplastic carcinoma, including sarcomatoid carcinoma, rather than cortical carcinoma (Figure 4).Therefore, the metastatic lesions of the brain and right adrenal gland were assumed to have originated from gastric carcinoma.