PMC7402956_01
Chest radiography at the initial visit.
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CRP (0.9 mg/dL) (Table 1). Chest radiography showed mild heart enlargement and enhancement in pulmonary vascular shadow (Fig. 1).
High-resolution chest tomography at the initial visit. (a) The mediastinal window showed a small amount of pleural and pericardial fluid retention. (b) (c) (d) The lung window showed bronchial vascular bundle thickening, centrilobular nodules, and interlobular septal thickening on both sides.
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Uneven ground-glass opacity was present mainly on the right side; in addition, there was pleural effusion on both sides as well as pericardial effusion (Fig. 2).
The TBLB specimen showed vascular endothelial thickening and adenocarcinoma cells in small vessels (yellow arrows). (a) Hematoxylin and Eosin staining. (b) EVG staining. EVG: Verhoeff-Van Gieson, HE: Hematoxylin and Eosin staining, TBLB: transbronchial lung biopsy
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In a pathological image of the TBLB specimen, phloem-like or clumping adenocarcinoma cells were noted in the thick interstitial vessels and vessels of the alveolar wall but not in the lymphatic vessels (Fig. 3).
Immunostaining of the TBLB specimen showed CA19-9 (+), Mac5-AC (+), D2-40 (-) and TTF-1 (-). CA19-9: carbohydrate antigen 19-9, TBLB: transbronchial lung biopsy, TTF-1: thyroid transcription factor-1
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Immunostaining showed carbohydrate antigen 19-9(+), Mac5-AC(+), D2-40(-), and thyroid transcription factor-1(-) (Fig. 4).
High-resolution chest tomography at the emergency hospitalization. The lung window showed increased pleural effusion and worsening of interlobular separation wall thickening.
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HRCT showed increased pleural effusion and worse interlobular separation wall thickening on both sides than had been noted in the HRCT findings acquired previously (Fig. 5).
Upper gastrointestinal endoscopy showed ulcerative lesions in the posterior wall of the stomach (yellow arrows).
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Ulcerative lesions were noted in the posterior wall of the stomach (Fig. 6).
A biopsy of the stomach showed moderately to poorly differentiated adenocarcinoma and signet-ring cell carcinoma.
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The biopsy result indicated moderately to poorly differentiated adenocarcinoma and signet-ring cell carcinoma, which was in agreement with the finding of adenocarcinoma cells on the TBLB (Fig. 7).
Contrast-enhanced CT performed at the initiation of chemotherapy.
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Contrast-enhanced CT was performed to rule out pulmonary thromboembolism, but no thrombi were observed in the pulmonary artery (Fig. 8).