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case_images: (A) Gastroscopy showed that irregular giant ulcers in the cardia with a peripheral dike, which was covered with dirty moss on the surface. (B) Hematoxylin and eosin staining suggested adenocarcinoma. (C) Computed tomography (CT) of the upper abdomen showed thickening of the gastric wall in the cardia and the lesser curvature of the stomach, enlargement of lymph nodes in the lesser omentum and space occupying lesions of liver.
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case_images: She underwent gastroscopy, which revealed irregular giant ulcers in the cardia with a peripheral dike covered with dirty moss on the surface ( Figure 1A ). The histology report indicated adenocarcinoma in the cardia ( Figure 1B ). The upper abdominal CT scan revealed the thickening of the gastric wall in the cardia and lesser curvature of the stomach, enlarged lymph nodes in the lesser omentum, and liver with space-occupying lesions (See  Figure 1C ).
case_images: Positron emission tomography/computed tomography (PET/CT) images. Arrows indicate tumors. (D) PET/CT scan showed intense accumulation of the (18) F-fluorodeoxyglucose (FDG) metabolism at the cardia and the lesser curvature of the stomach, the gastric lesser omental lymph nodes, both lungs, liver and left parietal occipital lobe at the time of initial diagnosis. (E) After the HYPERLINK "javascript:;" treatment of pembrolizumab plus chemotherapy and pembrolizumab monotherapy, PET/CT scan showed that the lesions in the cardia and the lesser curvature of the stomach and the gastric lesser omental lymph nodes were significantly reduced and the metabolic activity was reduced. The lesions in both lungs, liver and left parietal occipital lobe disappeared.
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case_images: The PET/CT illustrated high accumulations of (18)F-fluorodeoxyglucose (FDG) metabolism in the cardia and lesser curvature of the stomach, gastric lesser omental lymph nodes, both lungs, liver and left parietal occipital lobe ( Figure 2D ). Lesions in the lungs, liver and left parietal occipital lobe disappeared ( Figure 2E ).
case_images: (F) Brain magnetic resonance imaging (MRI) showed a lesion in the left frontal lobe. (G) Hematoxylin and eosin staining suggested metastatic poorly differentiated neuroendocrine carcinoma. (H) Brain MRI showed enhanced edge and adjacent meninges after brain tumor surgery.
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case_images: Magnetic resonance imaging (MRI) of the brain showed a lesion in the left frontal lobe ( Figure 3F ). Histology revealed metastatic poorly differentiated neuroendocrine carcinoma in the left frontal lobe ( Figure 3G ). Brain MRI in April 2022 showed enhancement of the rim and adjacent meninges after brain tumor surgery ( Figure 3H ).
case_images: Treatment process flow chart for this case. MDT, multidisciplinary team; PD, progressive disease; SRT, stereotactic radiation therapy; WBRT, whole brain radiation therapy.
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case_images: A flow chart of the treatment process is shown in  Figure 4 .