PMC3764693_01
Non-contrast computed tomography (a) and dual phase contrast enhanced computed tomography (b and c) images of abdomen showing multiple hypodense lesions in an enlarged liver with significant marginal contrast enhancement and rapid washout on the venous phase suggestive of hypervascular metastasis. Thickening along the greater curvature of the stomach is also evident (arrow)
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F1
A preliminary high-resolution dual phase computed tomography (CT) revealed a grossly enlarged liver with multiple enhancing hypodense lesions suggestive of hypervascular secondaries and thickening of the greater curvature of the stomach [Figure 1].
(a) 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) images showing multiple focal areas of increased radiotracer uptake in both lobes of the liver, implicating metabolically active lesions. No significant tracer uptake was noted in the greater curvature of the stomach (arrow) (b) 68Ga-DOTA-NOC PET/CT showing increased radiotracer uptake in the mass at the greater curvature (arrow) while the liver lesions show only minimal radiotracer uptake
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F2
18F-FDG PET/CT revealed multiple hypodense lesions in liver with focally increased radiotracer uptake, suggestive of poorly differentiated secondaries with high metabolic activity, which was earlier proven on FNAC from a liver SOL [Figure 2a] while foci of increased tracer uptake in a soft-tissue mass at the greater curvature of the stomach was seen on a 68Ga-DOTA-NOC PET/CT scan suggesting a well-differentiated primary somatostatin receptor expressing NET in addition to regional lymph node involvement while the liver lesions showed no tracer uptake [Figure 2b].
Gastric biopsy showing superficial mucosal fragments with tumor cells arranged as nests and as acini (H and E, x200) had a small rim of cytoplasm and had a stippled nuclear chromatin (a). They were strongly immunopositive for chromogranin and synaptophysin, two of the common markers used for detection and demonstration of neuroendocrine differentiation (b and c) FNAC from the liver mass (d) showed sheets and fragments of tumor cells with cells having moderately pleomorphic nuclei and coarse chromatin (Papanicolaou, x200). The tumor was more poorly differentiated as compared to the gastric primary
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F3
A gastric biopsy later confirmed this finding (well-differentiated NET; Ki-67 index-2%) [Figure 3].
Six months after, chemotherapy (A) 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) showing normal physiological distribution the radiotracer. The multiple liver lesions, which previously had intense tracer uptake, have disappeared (b) 68Ga-DOTA-NOC PET/CT showing that the greater curvature of the stomach has normalized and no lesion is visible on the post-therapy image
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F4
Based on a combination of these findings the patient was deferred from surgery and instead underwent chemotherapy protocol with etoposide and cisplatin, following which he went into a near total clinical and radiological remission [Figure 4].