Gastric hepatoid adenocarcinoma resulting in a spontaneous gastric perforation: a case report and review of the literature

Abstract

Background: Gastric hepatoid adenocarcinoma (GHAC) is an atypical form of gastric cancer (GC) that has similar tissue morphology to hepatocellular carcinoma and frequently produces alpha-fetoprotein. We present an exceedingly rare case of GHAC resulting in a spontaneous gastric perforation.

Case presentation: A 61-year-old man presented at our institution complaining of abdominal and back pain. A computed tomography scan revealed a spontaneous gastric perforation with a solitary liver tumor and lymph node swelling. Following a diagnosis of advanced-stage GC with a gastric perforation, perforative peritonitis, multiple lymph node metastases, and a solitary metastasis of the lateral segment of the liver, the patient underwent distal gastrectomy. Histopathology of the resected specimen revealed that the tumor cells were arranged in a hepatoid pattern. On immunohistochemical staining, the tumor cells were positive for alpha-fetoprotein and Sal-like protein 4. Thus, the patient was diagnosed with GHAC. Hepatic resection of the solitary liver metastasis was performed. However, recurrence occurred and the patient achieved complete response following tegafur/gimeracil/oteracil-based chemotherapy.

Conclusions: GHAC is a highly malignant histological subtype of GC. We reported on an extremely rare case of GHAC resulting in a spontaneous gastric perforation and reviewed the literature, including epidemiological data, treatment regimens, and the association between GHAC and alpha-fetoprotein-producing GC.

Keywords: Alpha-fetoprotein; Case report; Gastric cancer; Gastric perforation; Hepatoid adenocarcinoma.

Fig. 1

Imaging findings. Abdominal contrast-enhanced computed tomography revealed disruption and thickening of the anterior wall of the gastric antrum with free air (a) and a low enhanced lesion (30 mm in diameter) on the lateral segment of the liver (b)

Fig. 2

Intraoperative findings. A 7-mm perforation of the anterior wall of the gastric antrum with serous exposure of bulky tumors and opacity ascites

Fig. 3

Gross findings. Ulcerative and infiltrative (type 3) tumor of the gastric antrum (approximately 100 × 50 mm) with an infiltrative serosal surface and central perforation of the gastric cancer

Fig. 4

Histopathological findings. Hematoxylin and eosin staining of proliferating tumor cells with solid or thick-trabecular patterns mimicking hepatocellular carcinoma. The scale bars in (a) and (b) indicate 200 μm and 50 μm, respectively

Fig. 5

Immunohistochemical analysis. Tumor cells stained positive for (a) alpha-fetoprotein and (b) Sal-like protein 4, but were negative for (c) carcinoembryonic antigen, (d) synaptophysin, (e) chromogranin A, and (f) neural cell adhesion molecule. The scale bar indicates 50 μm