in september 2011 , a 65-year - old caucasian man was admitted to our hospital after a 1-month history of epigastric pain , dyspepsia , and anorexia .
he had a history of type 2 diabetes mellitus , arterial hypertension , and dyslipidemia . at physical examination , intense abdominal pain in the upper abdominal quadrants
laboratory tests showed elevated aspartate transaminase 107 u / l ( reference range 1040 u / l ) , alanine transaminase 89 u / l ( reference range 1040 u / l ) , gamma - glutamyl transpeptidase 627 u / l ( reference range 1040 u / l ) and alkaline phosphatase 309 u / l ( reference range 40130 u / l ) ; total bilirubin was 1.07 mg / dl ( reference range 0.31.0 mg / dl ) .
ultrasonography showed a remarkable and irregular enlargement of the liver with multiple and diffuse nodules in the right hepatic lobe ( the largest measured 5 cm in diameter ) and a unique large mass ( 15  9 cm ) in the left lobe .
abdomen computer tomography scans showed multiple nodules in the liver , suspected to be metastatic lesions , portal vein thrombosis , multiple adenopathies along the lesser curvature of the stomach , the mesenteric root and the lombo - aortic region as well as a thickening of the gastric lesser curvature wall ( fig .
tumor markers were : alpha - fetoprotein ( afp ) 209093 u / ml ( reference range 010 u / ml ) , ca 19.9 170,5 u / ml ( reference range 039 u / ml ) , and ca 125 52,2 u / ml ( reference range 035 u / ml ) ; other markers were found to be in a normal range , in particular cea and ca 72.4 .
markers for hepatitis b and c were negative ( hbsag , hbv - dna and hcv igg ) .
an esophagogastroduodenoscopy showed a 4 cm ulcer on the lesser curvature of the stomach ( fig .
the biopsy of one of the hepatic nodules showed a poorly differentiated adenocarcinoma , similar to that of a gastric biopsy .
immunohistochemical findings showed a positivity for cam 5.2 , cdx 2 ck 20 and a negativity for cd10 , ttf1 , sinaptophysin and chromogranin a , therefore supporting a diagnosis of metastasis of gastric adenocarcinoma ( fig .
one week later , the patient 's condition quickly worsened ( performance status 3 in accordance with the european cooperative oncology group scale ) .
he presented jaundice , abdominal pain and , at palpation , the appearance of a solid mass in the left upper quadrant of the abdomen and liver enlargement .
levels of transaminases , gamma - glutamyl transpeptidase and alkaline - phosphatase increased ; total bilirubin was 19.6 mg / dl and the conjugated one was 12.8 mg / dl .
abdominal ultrasonography showed , with respect to the previous one , an increased number and size of the hepatic nodules as well as a biliary tract dilatation .
tumor markers were found to be increased further : afp 470396 u / ml , ca 19.9 354.0 u / ml , and ca 125 113.7 u / ml . a chemotherapeutic approach was excluded due to the patient 's poor condition , his performance status and the altered liver function tests .
gastric adenocarcinoma is a neoplasm with a frequent association to various tumor markers such as ca 72.4 , cea and ca 19.9 . in our case report ,
elevated serum afp levels were present in a patient with gastric adenocarcinoma and liver metastases .
afp is a well - known embryonic serum protein , produced by fetal liver cells , yolk sac cells and some fetal gastrointestinal cells .
the elevation of serum afp , in conjunction with the hepatic lesions , may be associated with hepatocellular carcinoma or germ - cell tumors .
however , afp can be produced exceptionally by gastrointestinal tract organs , the lung , the bladder   and by renal cancers . for diseases such as chronic hepatitis , liver cirrhosis and hepatocellular carcinoma
, the level of afp is a good predictor of disease progression and outcome , as it is directly correlated to disease progression [ 5 , 6 ] . gastric cancer with the capability of releasing afp
is called afp - producing gastric carcinoma , first described by boureille et al .   in 1970 .
only a few cases have been reported with an incidence rate of 2.78.0% of all gastric malignant tumors .
our case is one of the few european cases of afp - producing gastric carcinomas .
however , the serum afp level does not necessarily correlate with tumor size , stage or prognosis [ 6 , 8 , 10 ] . in our case ,
elevated serum levels of afp and his quick increase were associated with a rapid disease progression and a fatal outcome .
cases of afp - producing gastric cancers are characterized by a poor prognosis , a high incidence of venous invasion , by lymph node and liver metastases and even t1 tumors ( according to the tnm staging system ) .
possible causes of liver metastases have been hypothesized in the hepatic capability to develop a suitable environment for the cancer cells growth and to promote an early vascular invasion .
afp - producing gastric cancers are a small subgroup of gastric cancers , with a high likelihood of rapid hepatic metastasization .
we think that further studies , especially on a cellular and molecular level , are necessary to explain the highly aggressive biological behavior of afp - producing gastric cancers in order to develop an effective multimodal and targeted therapy .
the authors declare that there are no conflicts of interest regarding the publication of this paper .
 a 65-year - old man presented to our hospital with abdominal pain , dyspepsia and anorexia . 
 laboratory tests showed an altered liver function and abdomen ultrasonography revealed multiple liver nodules , suspected to be metastatic lesions . 
 serous tumor markers were elevated and a very high level of alpha - fetoprotein was found . 
 computer tomography confirmed the hepatic lesions and disclosed a thickening of the lesser curvature of the gastric wall . 
 a subsequent endoscopy showed an ulcer on the lesser curvature . 
 biopsies taken from the gastric ulcer and the liver nodule revealed an adenocarcinoma , both of gastric origin . shortly after the diagnosis , the patient 's condition worsened and he died only 15 days later . 
 this case report illustrates how alpha - fetoprotein - producing gastric adenocarcinomas have a high incidence of venous and lymphatic invasion and a rapid hepatic spread with a very poor prognosis . 
Case Presentation
Discussion
Conclusions
Disclosure Statement