PMC4448069_01
CT on admission and 25 months after chemotherapy. Enhanced CT on admission revealed ring enhancement around the periphery of the tumors and heterogeneous enhancement within the tumors (a). CT also revealed multiple hepatic tumors with heterogeneous enhancement, and a swollen lymph node surrounding the lesser curve of the stomach (b, arrowhead). Thickening of the stomach wall was indicative of a gastric tumor that was thought to have invaded the muscularis propria (c, arrowheads). MRI on admission showed enhancement at the periphery of the tumors and heterogeneous enhancement within the tumors in the arterial phase (d), but there was no enhancement during the delayed phase (e). CT finding 25 months after chemotherapy showed a remarkable reduction in the size of the metastatic liver tumors without enhancement (f).
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F1
CT using contrast agent showed that the tumors had peripheral ring enhancement and a heterogeneous interior (fig. 1a, b). CT also revealed a swollen lymph node surrounding the lesser curve of the stomach (fig. 1b, arrowhead) and a thickening of the stomach wall (fig. 1c, arrowheads). The hepatic tumors had a low intensity on diffusion-weighted magnetic resonance imaging (MRI), and enhanced MRI with contrast agent showed that the periphery of the hepatic tumors was enhanced in the arterial phase (fig. 1d), but the hepatic tumors were not enhanced in the hepatobiliary phase (fig. 1e). EGD performed 25 months after chemotherapy revealed a more remarkable reduction in the size of the tumor, which appeared as a small elevated lesion with scar (fig. 2d), and CT findings at the same time showed a remarkable reduction in the size of the metastatic liver tumors defined as partial response according to the revised response evaluation criteria in solid tumors (RECIST) guideline (version 1.1; fig. 1f).
Endoscopic findings before chemotherapy and 25 months after chemotherapy. EGD before chemotherapy revealed a Bormann type 3 advanced tumor about 30 mm in diameter in the lower part of the stomach (a). Closer view of the gastric tumor (b). EGD performed 8 months after chemotherapy showed a remarkable reduction in the size of the tumor, which had the appearance of an excavated lesion with marginal protrusion (c). EGD performed 25 months after chemotherapy revealed an even greater reduction in the size of the tumor, which had the appearance of an extremely small elevated lesion with a scar (d).
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F2
An esophagogastroduodenoscopy (EGD) revealed a Bormann type 3 advanced tumor about 30 mm in diameter in the lower part of the stomach (fig. 2a, b). EGD performed 8 months after chemotherapy showed a remarkable reduction in the size of the tumor, which appeared as an excavated lesion with marginal protrusion (fig. 2c). EGD performed 25 months after chemotherapy revealed a more remarkable reduction in the size of the tumor, which appeared as a small elevated lesion with scar (fig. 2d), and CT findings at the same time showed a remarkable reduction in the size of the metastatic liver tumors defined as partial response according to the revised response evaluation criteria in solid tumors (RECIST) guideline (version 1.1; fig. 1f).
Hematoxylin and eosin (HE) staining and immunohistochemical findings of the gastric tumor biopsy specimen. HE staining revealed that the tumor was a poorly differentiated adenocarcinoma (a). Immunohistochemical evaluation of a tumor biopsy specimen revealed that the tumor cells were positive for AFP (b), PIVKA-II (c), and HER2 (d). Original magnification x400 (a-d).
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F3
A biopsy specimen showed that the tumor was a poorly differentiated adenocarcinoma (fig. 3a), corresponding with the specimen obtained from the fine needle aspiration biopsy of the hepatic tumors. Immunohistochemical evaluation of a tumor biopsy specimen revealed that the tumor cells were positive for AFP (fig. 3b) and PIVKA-II (fig. 3c), as well as human epidermal growth factor receptor 2 (HER2; fig. 3d).