case_images: PMC10768574_01
case_images: (a) Computed tomography (CT) scan of the abdomen and pelvis: Liver enlargement and multiple heterogeneous hypodense masses depicted with arrows (largest 11 cm). (b) CT scan of the chest: Multifocal left lower lobe pulmonary nodules depicted with arrow (largest 1.6 x 1.4 cm) and pulmonary emboli.
case_images: 10.1177_2050313X231223469-fig1.jpg
case_images: PMC10768574_01_10.1177_2050313X231223469-fig1.jpg
case_images: fig1-2050313X231223469
case_images: Computed tomography (CT) of the abdomen and pelvis with contrast revealed hepatomegaly with multiple heterogeneous hypodense masses, measuring up to 11 cm and concerning for metastasis (Figure 1(a)). Native chest CT showed multiple pulmonary nodules, with the largest measuring 1.6 cm, and pulmonary emboli (Figure 1(b)).
case_images: Liver mass biopsy. (a) H&E staining indicative of poorly differentiated carcinoma. (b) Positive CDX2 staining. (c) Positive Glypican 3 staining. (d) Positive Sal-like protein 4 staining.
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case_images: PMC10768574_01_10.1177_2050313X231223469-fig2.jpg
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case_images: Immunohistochemistry (IHC) was positive for Sal-like protein 4 (SALL4), Glypican3 (GPC3), cytokeratin AE1/AE3 (AE1/3), caudal-type homeobox transcription factor 2 (CDX2), and alpha-fetoprotein (AFP) (Figure 2) favoring yolk sac tumor.   The following markers displayed negative staining: Oct4, Arginase1, HepPar1, Chromogranin, Napsin A, NKX3.1, TTF-1, CK5/6, EMA, P63, SOX10, and PAX8.
case_images: Gastroesophageal junction mass biopsy. (a) H&E staining indicative of poorly differentiated carcinoma. (b) Positive Arginase staining. (c) Rare positivity for Hepar1 staining. (d) Positive Sal-like protein 4 staining.
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case_images: PMC10768574_01_10.1177_2050313X231223469-fig3.jpg
case_images: fig3-2050313X231223469
case_images: HCC with GEJ metastasis versus GEJHA (Figure 3). Given the clinical response to VIP chemotherapy, the patient was continued on the same regimen and completed four cycles of treatment. His AFP subsequently reached a plateau in the 18,000 ng/ml range, while restaging CT scans showed a partial treatment response (Time +14w).
case_images: CT scan of chest, abdomen, and pelvis. Hepatic and pulmonary metastatic lesions response to treatment. (a) Multiple liver masses at the time of diagnosis. (b) Liver lesions following four cycles of etoposide + ifosfamide + cisplatin (VIP regimen). (c) Liver lesions following two cycles of FLOT (5-FU, leucovorin, oxaliplatin, docetaxel) plus pembrolizumab. (d) Multiple left lower lobe pulmonary nodules (largest indicated with arrow) at the time of diagnosis. (e) Lung nodules following four cycles of VIP regimen. (f) Lung nodules following two cycles of FLOT plus pembrolizumab.
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case_images: PMC10768574_01_10.1177_2050313X231223469-fig4.jpg
case_images: fig4-2050313X231223469
case_images: Restaging CT scans showed further decrease in hepatic and lung lesions and no new sites of disease (Figure 4) (Time +22w).