PMC5627014_01
(A) Computed tomography (CT) of the abdomen showing the right hepatic lobe occupied by a large hypodense mass and left lobe contains a smaller scattered solid nodule (black arrows). In addition, enlarged lymph nodes at porta hepatica are seen (red arrow). (B) Vertical computed tomography showing heterogenously enhancing hepatic masses (black arrows) with circumferential infiltrative gastric wall thickening (red arrow). (C) CT scan of the abdomen showing no changes in liver metastasis with significant clearing of gastric wall thickening.
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F1
In addition, enlarged lymph nodes at the porta hepatica were seen (Figure 1A). A total body vertical computed tomography was done (Figure 1B) and showed tiny subcentimetric cervical lymph nodes, minimal bilateral pleural thickening, atelectatic band of left lung base, and hepatomegaly with multiple heterogenous masses of the right and left lobes the largest measuring 12 cm. Minimal pelvic free fluid was noted as well (Figure 1B). A follow up CT was performed and showed partial response of gastric wall thickening and the liver metastasis with less prominent enhancement suggestive of central necrosis (Figure 1C).
Comparable Hematoxylin and Eosin (H&E) staining and immunostaining for alpha fetoprotein (AFP), CDX2, and cytokeratin AE1/AE3 (CK AE1/3) expressions (brown color refers to positively stained cells) between (A) stomach biopsy tumor tissue sections (consisting mainly of hepatoid cells) on the left side and (B) liver fine needle aspirate tumor tissue sections (showing infiltrate of neoplastic hepatoid cells) on the right side.
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F2
Fine needle aspirate of the liver masses was performed and revealed pathological features in favor of hepatocellular carcinoma diagnosis (Figure 2B). A liver biopsy done outside our institution (Figure 2B) and a gastric biopsy at our institution (Figure 2A) were examined and underwent IHC markers evaluation all supporting the diagnosis of HAS (Table 1).
PMC5627014_02
Timeline organizing main events of the case.
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F3
This case report (Figure 3) was conducted and reported in accordance with CAse REports (CARE) guidelines for reporting case reports.