PMC3994611_01
Gastrofiberoscopic findings showed abrupt change in a year. (A) Normal gastric mucosal fold at midbody greater curvature side 1 year ago, (B) Diffuse thickening of the gastric mucosal folds and cent ral ulceration.
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F1
Hospital (Fig. 1A). However, diffuse engorged gastric folds with ulcerations at the mid body and greater curvature side of the stomach, suggesting a Borrmann-4 AGC were found during the current GFS (Fig. 1B).
Computed tomography shows diffuse gastric wall thickening suggesting Borrmann-4 gastric cancer.
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F2
A biopsy confirmed signet ring cell carcinoma. An abdominal computed tomography (CT) scan also showed diffuse gastric wall thickening, compatible with the GFS findings without definite regional lymphadenopathy (cT4aN0M0) (Fig. 2).
Positron emission tomography-computed tomography shows equivocal hypermetabolic lesion at the sacroiliac joint (arrow).
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F3
However, a mild hypermetabolic focus at the medial aspect of the left iliac bone was noted, which was equivocal to confirm the bone metastasis (Fig. 3).
(A) Computed tomography showed dilatation of roux-limb. (B) Upper Gastrografin gastrointestinal swallowing study showed near complete obstruction of the Roux-limb proximal to the jejunojejunostomy site.
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An abdominal CT scan and Gastrografin swallowing radiography showed a markedly dilated jejunal Roux-limb with an abrupt cutoff near the jejuno-jejunostomy site (Fig. 4).
(A) Laparoscopic findings during reoperation revealed whitish multifocal nodules at the left side of the diaphragm. (B) Histologic finding for peritoneal biopsy revealed signet ring cell type malignant cells infiltrated into muscle tissue.
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F5
However, we incidentally found some whitish peritoneal nodules on the left diaphragmatic surface that were not present at the initial operation (Fig. 5A). One of peritoneal nodules was excised for histologic examination, revealing a metastatic adenocarcinoma with signet ring cell features (Fig. 5B).