PMC6139993_01
Endoscopic findings at diagnosis.
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The patient underwent a biannual nationwide screening program regularly and the recent upper gastrointestinal endoscopy identified a 2.5 cm superficially depressed early gastric cancer lesion at the antrum and greater curvature of his stomach (Fig. 1).
Computed tomography (CT) findings of the abdomen and chest. Multiple enlarged lymph nodes are noted (A) at the right cervical, (B) & (C) along the celiac axis, and (D) the cardiophrenic areas.
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An abdominal CT scan showed multiple enlarged lymph nodes with or without calcification in the perigastric, para-esophageal, pericardial, and anterior diaphragmatic areas with a maximum size of approximately 2 cm A chest CT scan showed enlarged non-calcified lymph nodes at the right lower cervical, paratracheal, subcarinal, and cardiophrenic areas, as well as around the inferior vena cava, with a strong likelihood of metastatic nodes considering their nature (Fig. 2).
Preoperative positron emission tomography findings. Multiple hypermetabolic lymph nodes highly suspicious of metastasis are visible at the perigastric, retrocaval, mediastinal, hilar, and right cervical areas.
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The patient was evaluated with additional 18F-FDG PET-CT; the results demonstrated mild uptake in the greater curvature of the stomach, where the primary gastric cancer was located, along with the multiple hypermetabolic lymph nodes at the perigastric, retrocaval, mediastinal, hilar, and right cervical areas; the lymph nodes were highly suspicious of metastatic nodes (Fig. 3).
Gross findings. (A) Gross examination of the resected stomach showed a superficial depressed mass measuring 2.8 x 2.0 cm, consistent with type 0-IIc early gastric cancer, in the greater curvature of antrum. (B) Dark-pigmented lymph nodes retrieved at the celiac axis.
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Surgical exploration discovered numerous dark-pigmented lymph nodes along the celiac axis; the most prominent one was retrieved and sent for intraoperative pathologic examination (Fig. 4).
Representative scan view of enlarged lymph node composed of extensive necrosis, calcification, fibrosis, and inflammation (taken at 0.4x objective). When magnifying square, aggregates of epithelioid histiocytes were intermingled with other inflammatory cells and pigments of brown to black color surrounding the extensive necrotic region (taken at 10x objective).
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The enlarged two lymph nodes out of 47 perigastric lymph nodes were composed of chronic granulomatous inflammation with extensive caseous-like necrosis, admixed with anthracotic pigment, fibrosis, and calcification (Fig. 5).