case_images: PMC7244962_01
case_images: EGD photograph:an ulcerated mass 40 cm from incisors is shown, with stigmata of recent bleeding involving the gastric cardia, extending to the gastroesophageal junction.
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case_images: fig1
case_images: The primary care provider's workup included upper endoscopy (Figure 1) which revealed a mass 40 cm from the incisors, arising from the gastric cardia, with extension to the gastroesophageal junction.
case_images: EUS:a hypoechoic mass involving two-thirds of the gastric circumference measured 4.8 x 1.9 cm, with serosal invasion and two malignant-appearing lymph nodes (one shown in field-of-view) in the paracardial region (level 16), T3N1MX by endosonographic criteria.
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case_images: fig2
case_images: Staging endoscopic ultrasound (Figure 2) demonstrated a well-circumscribed hypoechoic mass measuring up to 4.8 cm with sonographic evidence of serosal invasion.
case_images: Initial axial fused PET/CT image (a) showing robust hypermetabolism of the gastric cardia (max SUV 10.4) with subsequent axial fused PET/CT image (b.) following neoadjuvant therapy with reduced size and uptake (SUV 4.3), consistent with 60% reduction in FDG concentration.
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case_images: PMC7244962_01_CRIONM2020-3738798.003.jpg
case_images: fig3
case_images: A restaging PET/CT (Figure 3) showed reduction in both tumor bulk and FDG avidity by approximately 60%, with CEA level decreased to 2.3 (initially 5.6).
case_images: Axial postcontrast CT performed in the postoperative period showed leaked contrast concentrated at the tip of the surgical drain (black arrow). Contrast level is also present within Jackson-Pratt drain reservoir (white arrow).
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case_images: PMC7244962_01_CRIONM2020-3738798.004.jpg
case_images: fig4
case_images: Antipyretic and empiric antibiotics were started, and a CT was performed for further investigation (Figure 4).
case_images: Coronal (a) and sagittal (b) overlays with isodense lines of planned external beam radiotherapy (XRT) with coverage of the surgical bed.
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case_images: fig5
case_images: A regimen of salvage chemoradiation was initiated, which included capectabine, as well as 1.8 Gy fractions divided over 25 sessions, for a total dose of 45 Gy focused on the surgical bed (Figure 5).
case_images: Coronal noncontrast (a) and postcontrast (b) CT reconstructions demonstrating a new vascular nodule (black arrow) in close proximity to the drain tract with the residual barium demarcating tract (white arrow).
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case_images: fig6
case_images: Two months later, a near-tripling in CEA (6.4 from 2.3) was concurrent with a new CT finding of a 1.1 cm hypervascular lesion embedded within the right abdominal wall subcutaneous fat (Figure 6) in close proximity to the previous JP surgical drain.
case_images: Doppler ultrasound confirming the subcutaneous nodule with internal vascularity and distortion of associated subcutaneous tissue planes, performed concurrent with image-guided biopsy.
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case_images: fig7
case_images: An ultrasound was performed (Figure 7) to facilitate targeted biopsy.
case_images: Hematoxylin and eosin-stained histology slides of primary gastric adenocarcinoma at 4x magnification, moderately-differentiated with solid nests and glandular architecture (a). Identical pattern found after biopsy of the abdominal wall mass (b) at 1x magnification.
case_images: CRIONM2020-3738798.008.jpg
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case_images: fig8
case_images: Pathology from core biopsy (Figure 8) showed an identical histological pattern as the original gastric adenocarcinoma.