A 73-year-old man visited an outpatient clinic for further evaluation due to incidentally found gastric cancer without symptoms. The patient underwent a biannual nationwide screening program regularly and the recent upper gastrointestinal endoscopy identified a 2.5 cm superficially depressed early gastric cancer lesion at the antrum and greater curvature of his stomach (Fig. 1). The endoscopic biopsy finding was well-differentiated adenocarcinoma. An abdominal CT scan showed multiple enlarged lymph nodes with or without calcification in the perigastric, para-esophageal, pericardial, and anterior diaphragmatic areas with a maximum size of approximately 2 cm A chest CT scan showed enlarged non-calcified lymph nodes at the right lower cervical, paratracheal, subcarinal, and cardiophrenic areas, as well as around the inferior vena cava, with a strong likelihood of metastatic nodes considering their nature (Fig. 2). The patient was evaluated with additional 18F-FDG PET-CT; the results demonstrated mild uptake in the greater curvature of the stomach, where the primary gastric cancer was located, along with the multiple hypermetabolic lymph nodes at the perigastric, retrocaval, mediastinal, hilar, and right cervical areas; the lymph nodes were highly suspicious of metastatic nodes (Fig. 3). Based upon these test results, the patient was tentatively diagnosed with stage IV gastric cancer with distant lymph node metastasis according to the 7th edition of the American Joint Committee on Cancer
The patient was recommended to undergo neck node biopsy to facilitate differential diagnosis between metastatic gastric cancer versus localized gastric cancer with concurrent lymphoma or other lymphoproliferative disease and to determine the therapeutic strategy. The patient underwent repeated ultrasonography-guided fine-needle aspiration for the enlarged right supraclavicular lymph node. Histologic analysis, however, failed to attain a confirmative diagnosis, instead demonstrating aggregation of polymorphous lymphoid cells without evidence of malignancy.
After discussion with the oncologists, we decided to conduct exploratory surgery for diagnostic purposes and simultaneous curative gastrectomy, if possible. Surgical exploration discovered numerous dark-pigmented lymph nodes along the celiac axis; the most prominent one was retrieved and sent for intraoperative pathologic examination (Fig. 4). Frozen sectioning revealed that the lymph node contained numerous histiocytic infiltrations without evidence of malignancy. Therefore, we proceeded with standard distal gastrectomy with D2 lymphadenectomy, as intended.
The resected stomach showed a well-differentiated adenocarcinoma confined in the muscularis mucosa of the stomach. The enlarged two lymph nodes out of 47 perigastric lymph nodes were composed of chronic granulomatous inflammation with extensive caseous-like necrosis, admixed with anthracotic pigment, fibrosis, and calcification (Fig. 5). To differentiate tuberculosis, polymerase chain reaction (PCR) for Mycobacterium tuberculosis was performed on DNA samples extracted from a formalin-fixed paraffin-embedded lymph node tissue block and was proven negative. Notably, it was considered that lymph node enlargement was attributable to anthracosilicosis. The patient was finally diagnosed with stage IA (T1N0M0) gastric cancer according to the 8th edition of the American Joint Committee on Cancer staging system and planned for regular follow-up without further treatment. The detailed occupational information of the patient taken in detail after the pathologic report revealed that he had worked as a supervisor in the construction field for a long time.