Alpha-Fetoprotein-Producing Nonmetastatic Gastric Adenocarcinoma: A Rare Entity

Alpha-fetoprotein (AFP) is a plasma protein that is produced by the liver and the yolk sac during fetal development. In adults, an elevation in this protein can be exclusive to specific malignancies such as hepatocellular carcinoma, yolk sac tumors, and metastatic disease to the liver. In the clinical setting, an elevated AFP level and a liver mass (masses) translate to a diagnosis of hepatocellular carcinoma. Gastric adenocarcinoma is an aggressive malignancy that has a poor prognosis and has a potential for early metastatic spread [ 1 ]. There have been some case reports in the literature that have described elevated AFP levels in gastric adenocarcinoma with metastasis to the liver and hepatoid adenocarcinoma of the stomach. Here, we report an unusual case of nonmetastatic gastric adenocarcinoma with local compression on the liver and elevated AFP levels in a previously healthy woman. A 33-year-old woman from Saint Vincent Island presented to the emergency department with complaints of 6-month history of epigastric mass and pain, 15-lb weight loss, and poor appetite. She stated that she was evaluated by the local physician in the Caribbean and was told that she has a cyst. No other further work-up was done. She denied fevers, chills, change in the color of the urine or stool, nausea, or vomiting. She was an ex-smoker and quit 10 years ago. She denied alcohol intake, any prescribed or illicit drug use, drug allergy, or any significant family history. Vital signs revealed a pulse of 82 beats/min, blood pressure of 101/62 mmHg, respiratory rate of 20 respirations/min, and normal temperature. On physical exam, the patient appeared cachectic. Rest of the physical exam was significant for jaundice, scleral icterus, and a 14 × 16 cm non-tender epigastric mass. Laboratory tests revealed the following: white blood count of 16,000/μL, hemoglobin of 9.9 g/dL, platelet count of 882,000/μL, total bilirubin of 8.7 mg/dL, alkaline phosphatase of 590 units/L, albumin of 2.2 g/dL, LDH of 374 units/L, INR of 1.5, and normal glucose, electrolytes, renal function, amylase, lipase, and rest of the liver function tests. Tests of tumor markers revealed an AFP level of 1,451 ng/dL and normal carcinoembryonic antigen, CA 19-9, and βHCG. CT scan of the abdomen with oral and intravenous contrast revealed a heterogeneous upper abdominal mass measuring 12.6 × 11.7 × 11.4 cm inseparable from the lesser curvature of the stomach, compressing the liver hilum, periportal vessels and causing mild to moderate intrahepatic biliary ductal dilatation (Fig. 1 ). Ultrasound of the abdomen also confirmed these findings. Esophagogastroduodenoscopy revealed candidal esophagitis and a large smooth intramural or extrinsic mass arising from the lesser curvature of the stomach. Histopathological examination of the biopsy of the gastric mass was inconclusive. Histopathological examination and immunohistochemistry of CT-guided fine-needle aspiration of the abdominal mass revealed CK7 rare positivity, CK20 , villin , CDX-2 , and negative for CA 19-9 and CA 125. AFP stain was negative. These findings were consistent with upper gastrointestinal, pancreatobiliary, or bladder neoplasm. Ultrasound of the pelvis did not reveal any masses. Serology for Helicobacter pylori was positive, and treatment was initiated. She was also treated for candidal esophagitis. Further testing revealed sequential elevations in the total bilirubin, direct bilirubin, and the alkaline phosphatase levels. The patient became more cachectic and could not maintain adequate oral intake. Parenteral nutrition was started. She also underwent a laparoscopy and core biopsy of the abdominal mass, and the histopathological examination and immunohistochemistry revealed adenocarcinoma with extensive necrosis most consistent with upper gastrointestinal primary neoplasm. An independent external pathology laboratory also confirmed the same findings. Jejunostomy tube was also placed for feeding, and parenteral nutrition was discontinued. Due the rising bilirubin levels, a transhepatic cholangiogram was performed with placement of an internal/external biliary catheter for drainage. The bilirubin levels decreased to a nadir of 12.5 mg/dL after the placement of the biliary drainage catheter. Due to the abnormal bilirubin, the patient was not a candidate for the conventional gastric adenocarcinoma chemotherapy regimens, and the plan was to start chemotherapy consisting of weekly gemcitabine at a reduced dose to adjust for the bilirubin levels. She received gemcitabine at the reduced dose of 800 mg/m . Pain control was achieved with intravenous hydromorphone via the patient-controlled analgesia pump. Soon after the administration of chemotherapy, there was an improvement in the clinical and laboratory parameters. However, after a few days, there was deterioration in the patient’s mental and respiratory status. CT scan of the head and the chest did not reveal metastasis or pulmonary embolism. Ammonia level was elevated, and lactulose was administered. She was not able to receive any further chemotherapy, and efforts were made to keep her on comfort care. Eventually, the patient was discharged in stable condition as per the family’s wishes to the Saint Vincent Island. Image presentation of heterogeneous upper abdominal mass