Aggressive Gastric Carcinoma Producing Alpha-Fetoprotein: A Case Report and Review of the Literature
In September 2011, a 65-year-old Caucasian man was admitted to our hospital after a 1-month history of epigastric pain, dyspepsia, and anorexia. He had been treated with a proton-pump inhibitor for 2 months. He had a history of type 2 diabetes mellitus, arterial hypertension, and dyslipidemia. At physical examination, intense abdominal pain in the upper abdominal quadrants was noted. Laboratory tests showed elevated aspartate transaminase 107 U/l (reference range 10–40 U/l), alanine transaminase 89 U/l (reference range 10–40 U/l), gamma-glutamyl transpeptidase 627 U/l (reference range 10–40 U/l) and alkaline phosphatase 309 U/l (reference range 40–130 U/l); total bilirubin was 1.07 mg/dl (reference range 0.3–1.0 mg/dl). Ultrasonography showed a remarkable and irregular enlargement of the liver with multiple and diffuse nodules in the right hepatic lobe (the largest measured 5 cm in diameter) and a unique large mass (15 × 9 cm) in the left lobe. Abdomen computer tomography scans showed multiple nodules in the liver, suspected to be metastatic lesions, portal vein thrombosis, multiple adenopathies along the lesser curvature of the stomach, the mesenteric root and the lombo-aortic region as well as a thickening of the gastric lesser curvature wall (fig. a, b). Tumor markers were: alpha-fetoprotein (AFP) 209093 U/ml (reference range 0–10 U/ml), Ca 19.9 170,5 U/ml (reference range 0–39 U/ml), and Ca 125 52,2 U/ml (reference range 035 U/ml); other markers were found to be in a normal range, in particular CEA and Ca 72.4. Markers for hepatitis B and C were negative (HBsAg, HBV-DNA and HCV IgG). An esophagogastroduodenoscopy showed a 4 cm ulcer on the lesser curvature of the stomach (fig. ). At the pathologic examination, the biopsy revealed a gastric adenocarcinoma. The biopsy of one of the hepatic nodules showed a poorly differentiated adenocarcinoma, similar to that of a gastric biopsy. Immunohistochemical findings showed a positivity for CAM 5.2, CDX 2 CK 20 and a negativity for CD10, TTF1, sinaptophysin and chromogranin A, therefore supporting a diagnosis of metastasis of gastric adenocarcinoma (fig. ). One week later, the patient's condition quickly worsened (Performance Status 3 in accordance with the European Cooperative Oncology Group scale). He presented jaundice, abdominal pain and, at palpation, the appearance of a solid mass in the left upper quadrant of the abdomen and liver enlargement. Levels of transaminases, gamma-glutamyl transpeptidase and alkaline-phosphatase increased; total bilirubin was 19.6 mg/dl and the conjugated one was 12.8 mg/dl. Abdominal ultrasonography showed, with respect to the previous one, an increased number and size of the hepatic nodules as well as a biliary tract dilatation. Tumor markers were found to be increased further: AFP 470396 U/ml, Ca 19.9 354.0 U/ml, and Ca 125 113.7 U/ml. A chemotherapeutic approach was excluded due to the patient's poor condition, his performance status and the altered liver function tests. The patient was discharged and received the best possible supportive care. He died 15 days later.