case_images: PMC7656275_01
case_images: Abdominopelvic CT scan with contrast is primarily nonrevealing for a malignant process.. Nonspecific gastric fold thickening in the fundus is observed (
  arrow). An incidental finding in the liver was noted by a small focal hypoattenuation in the middle segment of the left lobe of the liver adjacent to the fissure for ligamentum teres (
  arrowhead). This nodule was confirmed as PET-negative on later PET/CT studies.
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case_images: Abdominopelvic imaging was obtained by computerized tomography (CT) scans with contrast, which were primarily equivocal ( Figure 1).
case_images: EGD demonstrates esophagitis and an extensive ulcer involving the entire lesser curvature of the stomach.. (From proximal to distal.) (
  A) Esophagitis. (
  B) Gastro-esophageal junction. (
  C) More esophagitis, and a tongue of columnar mucosa. (
  D) Normal gastric cardia. (
  E) Normal gastric fundus. (
  F) Cavernous ulcer along the incisura (lesser curvature) with debris, food particles, and some central exudates (
  G) Continued ulcer description. At the 12 o'clock position the scope is originating from the gastric cardia and fundus region. At 3 o'clock is the expected location of the pylorus. However, due to size and extent of the ulcer typical anatomy and landmarks were considerably distorted making visualization of the fundus from that particular EGD position not possible. At 6 o'clock the ulcer is shown to extend along the incisura. At 9 o'clock food debris is seen along the greater curvature.
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case_images: An extensive, deep ulcer was noted to involve the entirety of the incisura and pre-pyloric area, as well as extended along the lesser curvature ( Figure 2).
case_images: Pathology demonstrates an invasive poorly differentiated adenocarcinoma.
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case_images: The malignant-appearing cells lacked immunoreactivity for synaptophysin, CD45, and HER2 ( Figure 3).
case_images: Pre-chemotherapy staging PET scan shows a locally advanced gastric cancer.. PET from skull to mid-thigh reveals extensive, diffuse hypermetabolism throughout the gastric wall compatible with a PET-avid infiltrating gastric neoplasm. Imaging revealed involvement of at least one hepatogastric lymph node. Thus, the patient was determined to have stage III disease (T3N1). Scattered areas of contrast uptake within the bowel are likely physiologic and limit evaluation for lesions. Contrast uptake within the brain and genitourinary system are physiologic.
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case_images: The PET scan showed a localized but advanced gastric neoplasm associated with regional PET-avid lymphadenopathy. ( Figure 4).
case_images: Case report timeline.. Presented according to CARE guidelines.
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case_images: Thus, she was diagnosed with Stage II gastric adenocarcinoma ( Figure 5). She was started on intravenous vitamin B12 and iron replacement (dose given in Figure 5). The patient initiated treatment with the FLOT regimen (oxaliplatin, leucovorin, docetaxel, fluorouracil) for her advanced, invasive poorly differentiated gastric adenocarcinoma ( Figure 5).