A 72-year-old man presented with heartburn and epigastric pain at the emergency department. On presentation, physical examination was contributory for an upper quadrant pain on abdominal palpation. Subsequently, biopsies of the ulcer edges were done. After two days, he was admitted to the emergency department with acute epigastric pain. A computed-enhanced tomodensitometry of the abdomen showed the presence of free air in the peritoneal cavity. Exploration of the cavity revealed a perforated gastric ulcer. The histopathological analysis revealed the presence of solid structures with tumoral aspect, containing small tumor cells with a high mitotic index. Immunohistochemical work-up showed the presence of TTF-1, CK 7, synaptophysin, NSE receptors but negative for CK 20, and it was consistent for small cell carcinoma. A thoracic CT showed an anthraco-silicotic pseudotumoral mass in the right lung and a four-centimeter lung nodule superior to the left hilum compatible with a primary lung tumor. An additional abdominal CT was remarkable for left gastric artery infracentimetric nodes and 3 other lesions highly suspected of metastases: one located in the left adrenal gland, one in the splenic hilum, and one in the right bottom in the subcutaneous tissue.
A Positron Emission Tomography (PET) with radiolabeled [18F]-2-fluoro-deoxy-d-glucose (FDG) showed an increased metabolic activity to the head of the pancreas as well as multiple hypermetabolic lesions in the two pulmonary fields and the mediastinum. The patient received chemotherapy (Cisplatine-VP 16) with no response after 6 cures. The patient was eligible for a second line of chemotherapy.