case_images: PMC9500356_01
case_images: (A) Gastroscopy (April 1, 2020): gastric antrum ulcer. (B) CT (April 1, 2020): (a) Gastric antrum tumor; (b) Abnormal low density of left lateral lobe of the liver, considering metastasis. (C) Results of endoscopic biopsy: (a) HE staining; (b) AFP staining. (Gastric antrum) Moderately to poorly differentiated hepatoid adenocarcinoma. Immunopathology: AFP(+), HER-2(+), Ki-67(40%), PD-L1(22C3)(-), PD-1(-), CD4(+), CD8(+), MLH1(+), PMS2(+), MSH6(+), MSH2(+). (D) PET-CT examination: The masses of gastric antrum and left liver were hypermetabolic.
case_images: fsurg-09-968891-g001.jpg
case_images: PMC9500356_01_fsurg-09-968891-g001.jpg
case_images: F1
case_images: Gastroscopy and computed tomography (CT) examinations revealed an irregular surface ulcer on the wall of the gastric antrum (Figure 1A) and a mass of 2.0 cm in diameter was found in the liver (Figure 1B). The pathological diagnosis from endoscopic biopsy was consistent with a moderately to poorly differentiated hepatoid adenocarcinoma (Figure 1C). PET-CT examination was then performed, and this showed that the stomach and liver masses were hypermetabolic (Figure 1D).
case_images: Ct examination: (A) April 1, 2020. (B) June 17, 2020. The mass of the left liver was more advanced than before.
case_images: fsurg-09-968891-g002.jpg
case_images: PMC9500356_01_fsurg-09-968891-g002.jpg
case_images: F2
case_images: After three cycles of chemotherapy, CT revealed progression of liver metastasis (Figure 2).
case_images: Postoperative pathology: (A) HE staining; (B) AFP staining; (C) CK staining; (D) PD-L1 staining. Routine pathology: (Stomach) Moderately to poorly differentiated adenocarcinoma, focal features of hepatoid adenocarcinoma, small necrosis, tumor invasion, tumor thrombus in the vessel; (Right liver nodule S5) cancer metastasis; (Left lateral liver) cancer metastasis, with massive necrosis, bleeding, no cancer accumulation in the liver resection margin, while the liver lesions were about 10% of hepatoid adenocarcinoma and 90% were choriocarcinoma. Immunopathology: (Stomach): CK(+), AFP(+), Glypican-3(+), MSH2(+), MSH6(+), MLH1(+), PMS2(+), MSS, Her-2(1+), Ki-67(+, 95%), PD-L1(22C3) (tumor cell: 1%-5%; microenvironment immune cells: +, 20%-30%), CD117(+), Hepa-1(-), CK7(-), CK5/6(-), P40(-), PD-1(-), CD5(-), Vimentin(-), EVB(-); (Liver): CK7(+), Her-2(2+), Ki67(+, 95%), PD-L1(22C3)(+, >50%), MLH1(+), MSH2(+), MSH6(+), PMS2(+), MSS, AFP(-), Hepa-1(-), CD5(-), and EBV(-).
case_images: fsurg-09-968891-g003.jpg
case_images: PMC9500356_01_fsurg-09-968891-g003.jpg
case_images: F3
case_images: Postoperative pathology (Figure 3) showed that the stomach mass was hepatoid adenocarcinoma, while the mass in the liver was approximately 10% hepatoid adenocarcinoma and 90% choriocarcinoma, with lymphatic metastasis (7/26).
case_images: (A) CT examination (July 28, 2020): many slightly low-density lesions in the liver, considering metastasis. (B) CT examination (September 14, 2020): Right pulmonary nodule, considering metastasis. (C) CT examination (November 19, 2020): (a) Multiple low-density liver metastases (more and larger than before). (b) The metastatic nodules in the lower lobe of the right lung were larger than before. (D) MR examination (March 18, 2021): Brain metastasis.
case_images: fsurg-09-968891-g004.jpg
case_images: PMC9500356_01_fsurg-09-968891-g004.jpg
case_images: F4
case_images: CT imaging revealed liver metastasis and recurrence (Figure 4A). Considering the poor effect of the original chemotherapy regimen, we chose the DS chemotherapy regimen, which consisted of paclitaxel, gimeracil, and oteracil potassium capsules. After two cycles of the chemotherapy regimen, on September 14, 2020, CT reexamination showed that liver and lung metastases occurred (Figure 4B). Two months later, CT examination showed that the liver and lung metastases were more and larger than before (Figure 4C). On March 18, 2021, the magnetic resonance (MR) scan showed that the patient had developed brain metastases (Figure 4D).