PMC9278084_01
According to an abdominal contrast-enhanced computed tomography (CT) scan, there were a malignant gastric mass and seven low-density shadows in the liver recognized as liver metastases (A). After eight cycles of SOX, contrast-enhanced CT scan showed no recurrence of the primary tumor, but liver metastases did not show any obvious changes (B). After surgery and chemotherapy for gastric cancer, the stomach was absent, and the lower esophagus and jejunum were anastomosed. A high-density metal anastomotic line shadow (indicated by the arrow) can be seen at the anastomotic stoma, and a small patch of slightly increased radiation uptake shadow can be seen locally. A small nodular low-density shadow with a size of about 0.5 cm can be seen in the right lobe of the liver (S8 segment). The density and radioactivity distribution in other parts of the liver were not abnormal. A small nodule-calcified shadow can be seen under the capsule of the right lobe of the liver (S6 segment). According to the positron emission tomography (PET) scan, the red arrows pointed out the tumor foci (C-E), the image (F) showed the image of coronal plane.
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The pathological examination ( Supplementary Figure 1 ) of the specimen proved to be poorly differentiated adenocarcinoma with Helicobacter pylori (+). According to an abdominal contrast-enhanced computed tomography (CT) scan, there were a malignant gastric mass and seven low-density shadows in the liver recognized as liver metastases ( Figure 1A ). S-1 (40 mg twice a day on days 1-14) plus oxaliplatin (130 mg/m2 once on day 1) (SOX) as first-line chemotherapy for eight cycles (3 weeks per cycle) due to his liver metastases. Subsequently, a contrast-enhanced CT scan demonstrated that there was no recurrence in the primary tumor, but the liver metastases did not show any obvious changes ( Figure 1B ). A positron emission tomography (PET) scan was performed after the eighth cycle of SOX and showed a resectable liver metastasis and no recurrence of the primary tumor in the stomach ( Figures 1C-F ).
A surgical intervention was implemented to remove the calcified liver metastasis (E) when pneumonia resolved, and PET (A-D) and CT scans (F) demonstrated that liver metastasis disappeared.
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IV GC. Immunohistochemistry (IHC) demonstrated the following ( Supplementary Figure 2 ): CK (+), CK7 (+), HER-2 (-), Ki67 approximately 95% (+), CD45 (-), SYN (-), and EBER (-). The pathology confirmed that there were extensive lymphocytes aggregated without tumor cells in the resected tissue, and then PET and CT scan showed that liver metastasis disappeared ( Figures 2A-F ). The timeline and the dynamic changes in tumor markers are displayed in  Figure 3  and  Supplementary Figure 2 .
The course timeline showed that shortly after the diagnosis of advanced gastric cancer, the patient underwent total gastrectomy for acute gastric bleeding, followed by eight cycles of SOX and then eight cycles of SOX + nivolumab treatment. Subsequently, immune pneumonia occurred and was treated with methylprednisolone. After the patient became stable, the suspected calcified metastasis of the liver was removed, and all medications were stopped. The patient has achieved disease-free survival until now.
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The timeline and the dynamic changes in tumor markers are displayed in  Figure 3  and  Supplementary Figure 2 .