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+A 70-year-old man was referred to our hospital for gastric cancer that was detected during screening by esophagogastroduodenoscopy (EGD).
+No significant medical history was identified, except dysuria caused by bladder contraction.
+Initial laboratory data showed a serum level of AFP of 32.3 ng/mL (normal range: 0-15 ng/mL), but no other abnormality, which included other tumor markers, such as, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9).
+EGD revealed a 5-cm ulcerofungating mass that was comprised of three septate ulcers in the greater curvature of the gastric antrum.
+A pathological examination of endoscopic biopsy tissues confirmed the presence of moderately differentiated tubular adenocarcinoma.
+Subsequent abdominopelvic computed tomography visualized a gastric mass with deep ulceration in the gastric antrum with perigastric lymph node enlargement.
+No metastatic lesions were observed in the liver, lung or peritoneum, and chest radiography showed no significant findings.
+Radical subtotal gastrectomy with D2 lymph node dissection and Billroth II gastrojejunostomy were performed.
+Grossly, the resected specimen contained double lesions: the first was a 5.8 cm × 3.2 cm ulcerofungating mass in the antrum, with extensive hemorrhage and light gray fibrosis; and the second was a nearby 2.5 cm × 2.0 cm ulcerative lesion (Figure ​1).
+Microscopically, massive numbers of pleomorphic, bizarre tumor cells with hemorrhage (syncytiotrophoblasts and cytotrophoblasts) were observed in the first lesion.
+Hematoxylin and eosin (HE)-stained tissues revealed a bubbly purple cytoplasm and giant nuclei at a magnification of 40 × (Figure ​2A) and 100 × (Figure ​2B).
+The tumor involved the proper muscle layer (T2a) and metastasis was found in four of 56 regional lymph nodes (N1).
+Immunohistochemical staining showed positive immunoreactivity for β-human chorionic gonadotropin (HCG) (Figure ​3A) and focal positivity for AFP (Figure ​3B).
+These findings confirmed the presence of gastric choriocarcinoma that contained small foci of an AFP-producing adenocarcinoma.
+The second lesion was moderately differentiated tubular adenocarcinoma, which extended to the submucosal layer (T1b).
+It was close to, but distinct from the first lesion, which was negative by immunohistochemical staining for β-HCG and AFP.
+The patient had an uneventful postoperative course and was discharged on postoperative day 9.
+Two weeks later, his HCG level was 176 mIU/mL (normal range: 0-10 mIU/mL) and his AFP level was 10.0 ng/mL.
+Six cycles of adjuvant chemotherapy with capecitabine (Xeloda; Hoffmann-La Roche Inc., Nutley, NJ, USA) was started at 2500 mg/m2 per day for 14 d/cycle.
+After two cycles, his β-HCG level had declined to < 3 mIU/mL, and has since remained at this level.
+No recurrence or distant metastasis had occurred at his 4-year postoperative follow-up.