An Alpha Fetoprotein Producing Gastric Tumor with Yolk Sac, Hepatoid and Papillary Adenocarcinoma Components

Abstract

A 75-year-old male presented with history of abdominal pain and generalised weakness for about three months. Clinically he was anaemic and per abdomen examination was unremarkable. Oesophagogastroduodenoscopy revealed an ulceroproliferative polypoidal growth involving the gastric antrum [Table/ Fig-1] and few scattered small sessile nodules in the body and antrum of stomach. Colonoscopy revealed a polyp in the rectum. The gastric antral lesion was biopsied and rectal polyp was excised and sent for histopathological examination. The patient also had an enlarged left supraclavicular lymph node which was also biopsied. Gastric antral lesion was reported as a moderately differentiated adenocarcinoma with papillary pattern and the rectal polyp was reported as ganglioneuroma [Table/ Fig-2]. The supraclavicular lymphnode showed a necrotising granulomatous inflammation, however the special stains such as Zeihl-Neelsen and Periodic Acid Schiff (PAS) for tuberculosis and fungi were negative.A radical subtotal gastrectomy with D2 lymphadenectomy and Billroth I anastomosis with feeding jejunostomy was done. Specimen was fixed in 10% neutral buffered formalin and representative sections were taken. Grossly, there was a raised ulcerated lesion involving the gastric antrum along the greater curvature measuring 5.0 x 3.0 AbSTRACTAlpha Fetoprotein (AFP) producing gastric carcinomas are very rare and have unique clinicopathological features and an extremely poor prognosis. Here, we report a case of AFP producing gastric carcinoma with three distinct histomorphologic patterns such as yolk sac like, hepatoid, tubular and papillary adenocarcinoma components. The uniqueness of this case is absence of metastases and associated findings such as fundic gland polyposis with varying degrees of dysplasia, gastric and duodenal well differentiated neuroendocrine tumour and rectal ganglioneuroma. The patient is symptom free as of two and half year's postoperative period.

Both the serum AFP test and AFP/GPC3/SALL4 immunohistochemistry are beneficial for predicting the prognosis of gastric adenocarcinoma

“…In 1970, Bourreille et al proposed the concept of hepatoid adenocarcinoma (HAC) based on morphology and found that this subtype was often accompanied by elevated sAFP and more likely to have liver metastases [4,5]. Subsequent studies also found that gastric adenocarcinoma with enteroblastic differentiation (GAED) and yolk-sac tumor-like carcinoma had similar characteristics [6,7]. Successive studies concluded that regardless of whether there was a special pathological morphology, cases of positive AFP immunohistochemistry or elevated sAFP had a suggestive risk of progression, collectively referred to as "AFP-producing gastric adenocarcinoma" [8,9].…”

Α-fetoprotein producing hepatoid gastric adenocarcinoma with neuroendocrine differentiation

“…[ 1 , 9 ] And in some AFP producing cases, the component of the tumor is not unique. [ 10 ] According to the literature, the incidence of AFP producing gastric cancer is 1.3% to 15%. [ 10 ] Above all, there is some clinical experience.…”

“…[ 10 ] According to the literature, the incidence of AFP producing gastric cancer is 1.3% to 15%. [ 10 ] Above all, there is some clinical experience. On one hand, gastric cancer without AFP producing cannot exclude the possibility of hepatoid adenocarcinoma.…”