Fiberoptic bronchoscopy was performed demonstrating left apical segment stenosis by

mucosal thickening. Transbronchial and deep submucosal biopsies documented adenocarcinoma since cancer cells were intensely positive for cytokeratin 7 (CK7) and thyroid-transcription factor-1 (TTF-1). Figure 1 Chest x-ray showing bilateral multiple nodular opacities with associated hilar lymphadenopathy Additional work-up using abdominal CT detected secondary lesions in the left liver lobe. Brain CT was negative. Therefore, the clinical stage of the tumor was defined as stage IV(T4N3M1b). During Inhibitors,research,lifescience,medical hospitalization period, the patient developed bilateral swelling and tenderness at both lower extremities as well as two episodes of melena with associated considerable decrease in hematocrit value (Ht: 28%), albeit complete blood count was normal on admission day. Triplex Transferase activity ultrasonography of the lower extremities showed the presence Inhibitors,research,lifescience,medical of deep vein thrombus. Gastroduodenoscopy was then performed revealing an ulcerative lesion with coagulum on the posterior wall and greater curvature of the stomach (Figure 2). Biopsies from the lesion were obtained and pathological Inhibitors,research,lifescience,medical examination of specimens demonstrated adenocarcinoma (Figure 2A). To examine

whether the gastric tumor was a primary cancer or a metastasis from the lung adenocarcinoma, immunohistochemistry was performed showing positive immunoreactivity for the markers TTF-1 and CK/7 and negative staining for CK/20 (Figure 3). Therefore, the diagnosis of gastric Inhibitors,research,lifescience,medical metastasis from lung adenocarcinoma was made. Figure 2 (A, B). Gastroduodenoscopy revealing an ulcerative lesion with coagulum on the posterior wall and greater curvature of the stomach (black arrows) Figure 3 A. Hematoxylin and eosin (×400) staining of the specimen from the gastric lesion showed adenocarcinoma cells infiltrating the gastric Inhibitors,research,lifescience,medical mucosa; B. Thyroid transcription factor-1 positive staining in gastric cancerous lesion (×400) Blood transfusion and intravenous omeprazole

were given to the patient leading to complete response of the hematologic parameters and bleeding cessation. After hematocrit restoration, fondaparinux was administered subcutaneously for DVT treatment followed by combination chemotherapy including carboplatin, paclitaxel and bevacizumab. Shortly Phosphatidylinositol diacylglycerol-lyase after three courses of chemotherapy (three months after diagnosis of single gastric metastasis), several metastatic lesions to brain and bones were detected by using contrast-enhanced brain CT and bone scitntigraphy. The patient’s general condition was deteriorated accordingly. Chemotherapy regimen was subsequently discontinued and palliative radiotherapy was applied. Because of his poor overall performance status, supportive care management was recommended without any supplementary therapeutic modality administration.