case_images: PMC3960811_01
case_images: CT Chest: Bilateral effusion, left more than right. Note diffuse soft tissue edema in the anterior aspect of left hemithorax
case_images: LI-31-47-g001.jpg
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case_images: F1
case_images: A computed tomogram (CT scan) of the chest showed moderate lymphangitis in the left lung, left-sided pleural effusion, minimal right-sided pleural effusion and minimal ascites [Figure 1].
case_images: CT Neck: Diffuse soft tissue edema and multiple enlarged lymph nodes on the left side. The jugular veins are shown by the thick arrows
case_images: LI-31-47-g002.jpg
case_images: PMC3960811_01_LI-31-47-g002.jpg
case_images: F2
case_images: A CT scan of the neck region revealed multiple enlarged left submandibular, posterior triangle and supraclavicular lymph nodes, the largest measuring 2.2 cm x 1.3 cm [Figure 2].
case_images: FNAC of cervical lymph node: Smear shows cluster of cells with irregular nucleus exhibiting moderate pleomorphism and moderate amount of vacuolated cytoplasm - consistent with metastatic adenocarcinoma
case_images: LI-31-47-g003.jpg
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case_images: F3
case_images: Ultrasound-guided fine needle aspiration of the neck lymph node was suggestive of adenocarcinoma [Figure 3].
case_images: Gastroendoscopy: Ulcer in the gastric antrum
case_images: LI-31-47-g004.jpg
case_images: PMC3960811_01_LI-31-47-g004.jpg
case_images: F4
case_images: Upper gastrointestinal endoscopy showed an ulcerated growth with everted margins measuring 2 cm x 2 cm in the posterior part of the stomach [Figure 4].
case_images: Gastric ulcer biopsy: Section shows fragments of gastric mucosa. The lamina propria shows moderate increase in the inflammatory cell content composed of lymphocytes and plasma cells. One of the fragments show sheets and clusters of neoplastic cells with high N:C, peripherally pushed pleomorphic and hyperchromatic nucleus with abundant eosinophilic granular cytoplasm. These cells are infiltrating the muscularis mucosa. Stomach biopsy consistent with moderately differentiated adenocarcinoma with signet ring cells
case_images: LI-31-47-g005.jpg
case_images: PMC3960811_01_LI-31-47-g005.jpg
case_images: F5
case_images: Biopsy of the ulcer confirmed it to be signet ring cell adenocarcinoma [Figure 5].