Hala Abdelwahab, MD, Omar Tageldin, MD, Stephen Hasak, MD, Hwa Jeong Lee, MD Albany Medical Center, Albany, NY
Introduction: Alpha fetoprotein (AFP) is an oncogenic glycoprotein which is normally expressed during gestation. AFP can be secreted during the prenatal period by yolk sac, fetal liver, and some gastrointestinal cells. AFP is used as a biomarker for yolk sac tumor, tumors of gonadal origin, hepatocellular carcinoma (HCC), and certain gastric carcinomas (GCs). Extrahepatic AFP-producing carcinomas are relatively rare. 1.3-15% of GC is classified as AFP-producing GC (AFPPGC). AFPPGC is an aggressive, usually advanced tumor with higher incidence of metastasis and poor prognosis. We present a case of metastatic AFPPGC which initially was thought to be a metastatic pancreatic adenocarcinoma based on imaging.
Case Description/Methods: A 54-year-old otherwise healthy male presented with three weeks of dry, persistent cough associated with diffuse abdominal pain and distension, decreased oral intake and unintentional weight loss. Beside generalized abdominal distension and tenderness, the physical exam was unremarkable. Laboratory studies revealed elevated LFTs, AFP of 16916 ng/mL (reference range 10-20 ng/mL) and beta HCG of 2399 mIU/mL (reference range < 2 mIU/mL). Testicular ultrasound was unremarkable. CT scan of abdomen and pelvis and subsequent MRCP showed innumerable masses in the liver, extensive upper abdominal lymphadenopathy, and a large mass arising from the head of the pancreas, likely representing primary pancreatic tumor. He underwent endoscopic ultrasound (EUS) which revealed a large gastric ulcer and numerous malignantappearing peripancreatic lymph node (LN), but no pancreatic mass was seen. LN and gastric ulcer biopsy confirmed AFPPGC [Figure 1]. Patient’s clinical condition deteriorated quickly, and he opted for non-aggressive treatment. Eventually, he was discharged to inpatient hospice and died within one month.
Discussion: AFPPGC is one of the most aggressive gastric tumors due to its high incidence of early liver and LN metastasis with poor prognosis compared with other GCs. The poor prognosis is attributed to the AFP effect as a growth promoter. Our patient not only had elevated AFP but also had elevated beta HCG which is extremely rare. Tissue biopsy with immunohistochemical staining is helpful in arriving at the diagnosis and differentiating it from metastatic HCC. Although there is no current standardized treatment for AFPPGC, surgical resection and chemotherapy have been reported. Clinicians should be aware of this rare tumor due to its rapid progression and early metastasis.
Figure: H&E section (10x magnification) shows a focus of carcinoma (solid arrow) with fetal enteric type differentiation and clear cytoplasm in a background of gastric mucosa with intestinal metaplasia (hollow arrow) .
Disclosures: Hala Abdelwahab indicated no relevant financial relationships. Omar Tageldin indicated no relevant financial relationships. Stephen Hasak indicated no relevant financial relationships. Hwa Jeong Lee indicated no relevant financial relationships.
Hala Abdelwahab, MD, Omar Tageldin, MD, Stephen Hasak, MD, Hwa Jeong Lee, MD. P1030 - A Rare Case of Metastatic AFP and Beta HCG-Producing Gastric Carcinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.