PMC7244962_01
EGD photograph:an ulcerated mass 40 cm from incisors is shown, with stigmata of recent bleeding involving the gastric cardia, extending to the gastroesophageal junction.
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The primary care provider's workup included upper endoscopy (Figure 1) which revealed a mass 40 cm from the incisors, arising from the gastric cardia, with extension to the gastroesophageal junction.
EUS:a hypoechoic mass involving two-thirds of the gastric circumference measured 4.8 x 1.9 cm, with serosal invasion and two malignant-appearing lymph nodes (one shown in field-of-view) in the paracardial region (level 16), T3N1MX by endosonographic criteria.
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Staging endoscopic ultrasound (Figure 2) demonstrated a well-circumscribed hypoechoic mass measuring up to 4.8 cm with sonographic evidence of serosal invasion.
Initial axial fused PET/CT image (a) showing robust hypermetabolism of the gastric cardia (max SUV 10.4) with subsequent axial fused PET/CT image (b.) following neoadjuvant therapy with reduced size and uptake (SUV 4.3), consistent with 60% reduction in FDG concentration.
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A restaging PET/CT (Figure 3) showed reduction in both tumor bulk and FDG avidity by approximately 60%, with CEA level decreased to 2.3 (initially 5.6).
Axial postcontrast CT performed in the postoperative period showed leaked contrast concentrated at the tip of the surgical drain (black arrow). Contrast level is also present within Jackson-Pratt drain reservoir (white arrow).
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Antipyretic and empiric antibiotics were started, and a CT was performed for further investigation (Figure 4).
Coronal (a) and sagittal (b) overlays with isodense lines of planned external beam radiotherapy (XRT) with coverage of the surgical bed.
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A regimen of salvage chemoradiation was initiated, which included capectabine, as well as 1.8 Gy fractions divided over 25 sessions, for a total dose of 45 Gy focused on the surgical bed (Figure 5).
Coronal noncontrast (a) and postcontrast (b) CT reconstructions demonstrating a new vascular nodule (black arrow) in close proximity to the drain tract with the residual barium demarcating tract (white arrow).
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Two months later, a near-tripling in CEA (6.4 from 2.3) was concurrent with a new CT finding of a 1.1 cm hypervascular lesion embedded within the right abdominal wall subcutaneous fat (Figure 6) in close proximity to the previous JP surgical drain.
Doppler ultrasound confirming the subcutaneous nodule with internal vascularity and distortion of associated subcutaneous tissue planes, performed concurrent with image-guided biopsy.
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An ultrasound was performed (Figure 7) to facilitate targeted biopsy.
Hematoxylin and eosin-stained histology slides of primary gastric adenocarcinoma at 4x magnification, moderately-differentiated with solid nests and glandular architecture (a). Identical pattern found after biopsy of the abdominal wall mass (b) at 1x magnification.
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Pathology from core biopsy (Figure 8) showed an identical histological pattern as the original gastric adenocarcinoma.